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7. Hand and Wrist MCQs

Practice Set 150 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 2981

Topic: 7. Hand and Wrist

A 30-year-old heavy laborer presents with central dorsal wrist pain. Radiographs demonstrate sclerosis of the lunate with no evidence of collapse or fragmentation. He has an ulnar variance of -3 mm. MRI confirms decreased T1 signal intensity throughout the entire lunate. What is the most appropriate surgical treatment?

. Proximal row carpectomy
. Scaphoid-trapezium-trapezoid (STT) fusion
. Lunate excision and silastic replacement
. Radial shortening osteotomy
. Total wrist arthrodesis

Correct Answer & Explanation

. Proximal row carpectomy

Explanation

This patient has Lichtman Stage II Kienböck's disease, characterized by sclerosis of the lunate on plain radiographs without lunate collapse. In the presence of ulnar negative variance, joint leveling procedures, such as a radial shortening osteotomy, are the treatment of choice. This mechanically unloads the radiolunate joint, decreasing the stress on the lunate and potentially allowing for revascularization and halting disease progression. Proximal row carpectomy or fusions are salvage procedures reserved for more advanced stages (Stage III or IV) with carpal collapse or secondary osteoarthritis.

Question 2982

Topic: 7. Hand and Wrist

A 68-year-old woman is treated nonoperatively in a cast for a non-displaced distal radius fracture. Four weeks later, she suddenly becomes unable to actively extend her thumb interphalangeal joint. Rupture of which of the following tendons is the most likely cause, and at which anatomical pulley does this occur?

. Extensor pollicis longus; Lister's tubercle
. Extensor pollicis brevis; First dorsal compartment
. Abductor pollicis longus; First dorsal compartment
. Extensor indicis proprius; Fourth dorsal compartment
. Flexor pollicis longus; Carpal tunnel

Correct Answer & Explanation

. Extensor pollicis longus; Lister's tubercle

Explanation

Extensor pollicis longus (EPL) tendon rupture is a well-known complication of distal radius fractures, occurring most frequently in non-displaced fractures treated nonoperatively. The EPL tendon travels through the third dorsal compartment and takes a sharp 45-degree angle turn around Lister's tubercle, creating a mechanical fulcrum. Swelling within the intact extensor retinaculum or callus formation can lead to vascular compromise (watershed area), attrition, and subsequent rupture of the tendon. Treatment typically involves an Extensor Indicis Proprius (EIP) to EPL tendon transfer.

Question 2983

Topic: Nerve & Tendon

During surgical decompression of the ulnar nerve for cubital tunnel syndrome, multiple potential sites of compression must be evaluated. Which of the following anatomical structures represents the most common site of ulnar nerve entrapment in this region?

. The arcade of Struthers
. The medial intermuscular septum
. Osborne's ligament
. The deep flexor-pronator aponeurosis
. The anconeus epitrochlearis

Correct Answer & Explanation

. The arcade of Struthers

Explanation

Cubital tunnel syndrome is the second most common compression neuropathy of the upper extremity. The ulnar nerve can be compressed at multiple sites around the elbow. The most frequent site of compression is between the two heads of the flexor carpi ulnaris (FCU), which are connected by the arcuate ligament of Osborne (Osborne's fascia). Other potential compression sites include the arcade of Struthers (hiatus in the medial intermuscular septum), the medial epicondyle, and the deep flexor-pronator aponeurosis, all of which should be assessed during a thorough decompression or transposition.

Question 2984

Topic: 7. Hand and Wrist

A 30-year-old male presents with chronic dorsal wrist pain after a fall six months ago. Posteroanterior radiographs demonstrate a widened scapholunate interval (Terry Thomas sign) and a cortical 'ring sign' of the scaphoid. On the lateral radiographic view, what is the expected carpal alignment?

. Volar tilt of the lunate, leading to a Volar Intercalated Segment Instability (VISI)
. Dorsal tilt of the lunate, leading to a Dorsal Intercalated Segment Instability (DISI)
. Volar tilt of the scaphoid with concomitant dorsal tilt of the capitate
. Dorsal subluxation of the entire carpus relative to the radius
. Normal carpal alignment without any segment instability

Correct Answer & Explanation

. Volar tilt of the lunate, leading to a Volar Intercalated Segment Instability (VISI)

Explanation

A widened scapholunate interval and a scaphoid 'ring sign' (representing an abnormally flexed scaphoid viewed end-on) are indicative of a scapholunate ligament tear. Biomechanically, the scaphoid inherently tends to flex, while the triquetrum inherently tends to extend. The lunate is caught in between. When the primary constraint (the scapholunate interosseous ligament) is disrupted, the scaphoid flexes volarly, while the lunate extends dorsally alongside the triquetrum (since the lunotriquetral ligament remains intact). This resultant dorsal tilting of the lunate relative to the capitate and radius is known as a Dorsal Intercalated Segment Instability (DISI) deformity.

Question 2985

Topic: Hand Trauma & Infection

A 28-year-old avid skier catches his thumb in a ski pole strap, sustaining a severe hyperabduction injury to the metacarpophalangeal (MCP) joint of the thumb. Physical examination reveals gross instability to valgus stress. Which of the following anatomical findings defines a Stener lesion, an absolute indication for operative repair?

. Interposition of the extensor pollicis brevis tendon between the torn UCL and its insertion
. Interposition of the adductor pollicis aponeurosis between the torn UCL and its insertion
. Interposition of the abductor pollicis longus tendon between the torn UCL and its insertion
. An avulsion fracture of the base of the proximal phalanx with greater than 2 mm of displacement
. Complete rupture of the radial collateral ligament associated with a UCL tear

Correct Answer & Explanation

. Interposition of the extensor pollicis brevis tendon between the torn UCL and its insertion

Explanation

A Stener lesion occurs when the ulnar collateral ligament (UCL) of the thumb MCP joint completely ruptures (usually from its distal insertion on the proximal phalanx) and the proximal stump of the torn ligament displaces superficial to the adductor pollicis aponeurosis. Consequently, the aponeurosis becomes interposed between the torn UCL and its anatomical insertion site. Because the ligament is physically blocked from reaching its insertion, natural healing is prevented, making a Stener lesion a definitive indication for surgical repair of the UCL (Gamekeeper's or Skier's thumb).

Question 2986

Topic: Wrist & Carpus

A 62-year-old female presents to the clinic complaining of an inability to actively flex the tip of her thumb. Nine months ago, she underwent open reduction and internal fixation of a distal radius fracture with a volar locking plate. On physical examination, she has a full passive range of motion of the thumb interphalangeal (IP) joint but lacks active flexion. Radiographs demonstrate the volar plate is positioned distal to the watershed line. Which of the following is the most appropriate definitive management for her current condition?

. Plate removal and primary end-to-end repair of the flexor pollicis longus (FPL)
. Plate removal and FPL reconstruction with a palmaris longus autograft
. Plate removal and extensor indicis proprius (EIP) to FPL tendon transfer
. Plate removal and brachioradialis to FPL tendon transfer
. Plate removal and flexor digitorum superficialis (FDS) of the ring finger to FPL tendon transfer

Correct Answer & Explanation

. Plate removal and primary end-to-end repair of the flexor pollicis longus (FPL)

Explanation

The patient has sustained an attritional rupture of the flexor pollicis longus (FPL) tendon secondary to prominent hardware placed distal to the watershed line. Because this is a delayed presentation and an attritional rupture, the tendon ends are typically severely frayed and retracted, making primary repair impossible or highly prone to failure. The gold standard for reconstructing an FPL rupture in this setting is a tendon transfer utilizing the flexor digitorum superficialis (FDS) of the ring or middle finger. This provides an expendable, vascularized, and synergistic motor unit. EIP transfer is typically utilized for extensor pollicis longus (EPL) ruptures.

Question 2987

Topic: 7. Hand and Wrist

A 58-year-old female presents with chronic, severe base of thumb pain. Radiographs demonstrate Eaton-Littler Stage III trapeziometacarpal (CMC) arthritis. Physical examination reveals a flexible hyperextension deformity of the metacarpophalangeal (MCP) joint of 45 degrees. She is scheduled to undergo a trapezium excision and ligament reconstruction and tendon interposition (LRTI). Which of the following concomitant procedures must be performed to optimize her outcome?

. Metacarpal extension osteotomy
. MCP joint arthrodesis or volar capsulodesis
. Flexor pollicis longus (FPL) tendon lengthening
. Abductor pollicis longus (APL) to extensor pollicis brevis (EPB) transfer
. Extensor pollicis longus (EPL) rerouting

Correct Answer & Explanation

. Metacarpal extension osteotomy

Explanation

In the setting of advanced CMC arthritis, a secondary hyperextension deformity of the thumb MCP joint frequently develops as a compensatory mechanism for CMC adduction contracture. If an MCP hyperextension deformity >30 degrees is present, it must be addressed at the time of CMC arthroplasty. Failure to correct this deformity alters the mechanics of the thumb ray, leading to continued pain, pinch weakness, and a high risk of failure or dorsal subluxation of the CMC reconstruction. Options for correction include EPB transfer or volar capsulodesis for flexible deformities <40 degrees, and MCP joint arthrodesis for fixed deformities or those >40 degrees.

Question 2988

Topic: 7. Hand and Wrist

A 35-year-old man presents with hand weakness. He reports that three weeks ago, he experienced the sudden onset of severe, unrelenting shoulder and proximal forearm pain that lasted for two weeks. As the pain subsided, he noticed difficulty using his thumb and index finger. On examination, he is unable to make an 'OK' sign, instead demonstrating a flattened pinch between the thumb and index finger. Sensation is intact globally. What is the most likely diagnosis?

. Cubital tunnel syndrome
. Pronator syndrome
. Anterior interosseous nerve (AIN) syndrome secondary to Parsonage-Turner syndrome
. Carpal tunnel syndrome
. Posterior interosseous nerve (PIN) syndrome

Correct Answer & Explanation

. Cubital tunnel syndrome

Explanation

The clinical presentation is classic for Parsonage-Turner syndrome (neuralgic amyotrophy), which is characterized by the acute onset of severe shoulder or arm pain lasting days to weeks, followed by muscle weakness (amyotrophy) in a specific nerve distribution as the pain resolves. The anterior interosseous nerve (AIN) is commonly affected. AIN syndrome manifests as weakness of the flexor pollicis longus (FPL) and the flexor digitorum profundus (FDP) to the index finger, leading to an inability to flex the thumb IP joint and index DIP joint (resulting in a 'flat pinch' instead of a normal 'OK' sign). It is a pure motor nerve, so sensation remains intact. Pronator syndrome and Carpal tunnel syndrome would present with sensory deficits in the median nerve distribution.

Question 2989

Topic: 7. Hand and Wrist

A 48-year-old manual laborer complains of a 5-year history of progressive, aching right wrist pain. Radiographs reveal a scaphoid nonunion with advanced collapse (SNAC). There is prominent arthritic change at the radioscaphoid joint and the capitolunate joint, but the radiolunate articulation is completely spared. Which of the following is the most appropriate surgical treatment?

. Proximal row carpectomy (PRC)
. Scaphoid excision and four-corner fusion (capitate, lunate, hamate, triquetrum)
. Total wrist arthrodesis
. Radial styloidectomy
. Scaphoid open reduction and internal fixation with vascularized bone grafting

Correct Answer & Explanation

. Proximal row carpectomy (PRC)

Explanation

The patient has Stage III SNAC wrist, characterized by radioscaphoid and midcarpal (capitolunate) arthritis, with preservation of the radiolunate joint. Proximal row carpectomy (PRC) is contraindicated because the capitate head is arthritic and would articulate with the lunate fossa, leading to rapid failure. Scaphoid excision with a four-corner fusion removes the arthritic radioscaphoid joint and fuses the arthritic capitolunate joint while preserving some wrist motion through the pristine radiolunate joint. Total wrist arthrodesis is reserved for pan-carpal arthritis (Stage IV).

Question 2990

Topic: Wrist & Carpus

Six weeks after nonoperative management of a nondisplaced distal radius fracture, a 62-year-old woman presents with the sudden inability to actively extend the interphalangeal joint of her thumb. An extensor indicis proprius (EIP) to extensor pollicis longus (EPL) tendon transfer is planned. At the level of the metacarpophalangeal joint of the index finger, where is the EIP tendon located relative to the extensor digitorum communis (EDC) tendon?

. Ulnar and volar to the EDC tendon of the index finger
. Radial and dorsal to the EDC tendon of the index finger
. Ulnar and dorsal to the EDC tendon of the index finger
. Radial and volar to the EDC tendon of the index finger
. Directly dorsal to the EDC tendon of the index finger

Correct Answer & Explanation

. Ulnar and volar to the EDC tendon of the index finger

Explanation

EPL rupture is a known complication of nondisplaced distal radius fractures, often secondary to ischemia or attrition over a bony spike at Lister's tubercle. The standard treatment is an EIP to EPL tendon transfer. To harvest the EIP correctly, the surgeon must remember the anatomic relationship: at the level of the metacarpophalangeal joint, the EIP tendon consistently lies ulnar and volar to the EDC tendon of the index finger.

Question 2991

Topic: 7. Hand and Wrist

A 27-year-old woman complains of progressive dorsal wrist pain. Radiographs demonstrate sclerosis, fragmentation, and flattening of the lunate without carpal collapse. Her ulnar variance is determined to be -3 mm. Based on the most likely diagnosis, what is the preferred initial surgical intervention?

. Radial shortening osteotomy
. Proximal row carpectomy
. Lunate excision and silastic replacement
. Scaphotrapeziotrapezoid (STT) fusion
. Ulnar lengthening osteotomy

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

The clinical picture describes Kienböck's disease (avascular necrosis of the lunate), Lichtman Stage II or IIIA (fragmentation/flattening without fixed carpal collapse). In a patient with negative ulnar variance, a joint-leveling procedure such as a radial shortening osteotomy is the treatment of choice. It unloads the lunate by shifting compressive forces to the radioulnar joint and the scaphoid. Ulnar lengthening is theoretically similar but associated with higher complication rates (nonunion). Proximal row carpectomy is reserved for advanced stages (Stage IIIB or IV).

Question 2992

Topic: Nerve & Tendon

A 52-year-old man with severe, electromyographically confirmed cubital tunnel syndrome is undergoing an anterior subcutaneous transposition of the ulnar nerve. During the transposition, a specific structural band extending from the medial epicondyle to the medial humerus must be resected to prevent secondary kinking of the nerve as it is moved anteriorly. What is this structure?

. Arcade of Frohse
. Ligament of Struthers
. Medial intermuscular septum
. Lacertus fibrosus
. Arcade of Struthers

Correct Answer & Explanation

. Arcade of Frohse

Explanation

When performing an anterior transposition of the ulnar nerve, the medial intermuscular septum must be excised. If left intact, the ulnar nerve can tether or kink sharply over the edge of the septum as it routes anteriorly, leading to persistent or worsened iatrogenic compression. The Arcade of Struthers is a proximal site of primary compression but kinking during transposition is classic for the medial intermuscular septum. The Arcade of Frohse relates to the posterior interosseous nerve (PIN).

Question 2993

Topic: Wrist & Carpus

A 38-year-old man falls from a height of 10 feet, sustaining a severely comminuted, unsalvageable radial head fracture. The surgeon performs an isolated radial head excision. Six months later, the patient develops severe, progressive ulnar-sided wrist pain. Radiographs reveal 5 mm of positive ulnar variance. What concurrent injury was missed at the time of the initial trauma?

. Triangular fibrocartilage complex (TFCC) tear without instability
. Longitudinal disruption of the interosseous membrane and distal radioulnar joint
. Scapholunate interosseous ligament tear
. Lunotriquetral interosseous ligament tear
. Ulnar collateral ligament tear of the elbow

Correct Answer & Explanation

. Triangular fibrocartilage complex (TFCC) tear without instability

Explanation

The scenario describes an Essex-Lopresti lesion, which consists of a radial head fracture, rupture of the forearm interosseous membrane (IOM), and disruption of the distal radioulnar joint (DRUJ). If the radial head is simply excised without recognizing the IOM injury, there is no proximal block to radius migration. The radius migrates proximally, causing dynamic positive ulnar variance, severe ulnar impaction syndrome, and wrist pain. In these injuries, the radial head must be replaced with an arthroplasty to maintain radial length.

Question 2994

Topic: Wrist & Carpus

A 55-year-old woman sustained a distal radius fracture treated with a volar locking plate. Three months postoperatively, she presents with inability to actively flex the interphalangeal joint of her thumb. Radiographs show plate placement distal to the watershed line. Which tendon is most commonly ruptured in this scenario?

. Flexor pollicis longus (FPL)
. Flexor digitorum profundus to the index finger
. Extensor pollicis longus (EPL)
. Flexor carpi radialis (FCR)
. Abductor pollicis longus (APL)

Correct Answer & Explanation

. Flexor pollicis longus (FPL)

Explanation

Volar plating of distal radius fractures is associated with flexor tendon rupture if the plate is placed distal to the watershed line. The flexor pollicis longus (FPL) tendon is most commonly affected due to its direct proximity to the volar margin of the radius and the plate edge. Extensor pollicis longus (EPL) ruptures are more frequently associated with dorsal screw prominence or nonoperative management of nondisplaced fractures.

Question 2995

Topic: 7. Hand and Wrist

A 50-year-old manual worker presents with dorsal wrist pain and decreased range of motion. Radiographs demonstrate advanced narrowing of the radioscaphoid joint and midcarpal (capitolunate) joint, while the radiolunate joint is perfectly preserved. Which of the following procedures is strictly contraindicated in this patient?

. Proximal row carpectomy (PRC)
. Scaphoid excision and four-corner fusion
. Total wrist arthrodesis
. Denervation of the wrist
. Radial styloidectomy

Correct Answer & Explanation

. Proximal row carpectomy (PRC)

Explanation

The patient has a stage III Scapholunate Advanced Collapse (SLAC) wrist (radioscaphoid and midcarpal arthritis, capitate migration). Proximal row carpectomy (PRC) involves excising the scaphoid, lunate, and triquetrum, which leaves the capitate to articulate with the lunate fossa of the radius. Therefore, PRC requires a preserved capitate head and lunate fossa. In stage III SLAC wrist, the capitate head is arthritic, making PRC contraindicated. Four-corner fusion is the preferred motion-preserving salvage procedure.

Question 2996

Topic: 7. Hand and Wrist

A 32-year-old carpenter presents with insidious onset of dorsal wrist pain. Radiographs demonstrate sclerosis and fragmentation of the lunate, but carpal height is maintained, and there is no fixed scaphoid rotation. The patient has negative ulnar variance. Which of the following surgical interventions is most appropriate?

. Radial shortening osteotomy
. Proximal row carpectomy
. Scaphoid excision and four-corner fusion
. Capitate shortening osteotomy
. Total wrist arthroplasty

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

The patient has Lichtman Stage IIIa Kienböck's disease (lunate collapse/fragmentation, but normal carpal height and no fixed scaphoid rotation). For early and intermediate stages (I, II, and IIIa) in patients with negative ulnar variance, a joint-leveling procedure such as a radial shortening osteotomy is the treatment of choice to decrease radiolunate contact stresses and offload the lunate. Salvage procedures are reserved for stage IIIb or IV.

Question 2997

Topic: 7. Hand and Wrist

A 45-year-old heavy laborer undergoes a single-incision anterior approach for the repair of a retracted acute distal biceps tendon rupture. Two weeks postoperatively, he complains of numbness over the lateral aspect of his forearm. His motor function in the hand and wrist is completely intact. Which of the following structures was most likely injured during the procedure?

. Posterior interosseous nerve
. Lateral antebrachial cutaneous nerve
. Superficial radial nerve
. Median nerve
. Ulnar nerve

Correct Answer & Explanation

. Posterior interosseous nerve

Explanation

The lateral antebrachial cutaneous (LABC) nerve is the most commonly injured nerve during a single-incision anterior repair of the distal biceps tendon. It courses between the biceps and brachialis muscles before piercing the fascia lateral to the biceps tendon. Injury results in sensory deficits (numbness or paresthesia) over the lateral forearm. The posterior interosseous nerve (PIN) injury is a devastating potential complication more commonly associated with two-incision approaches or over-retraction laterally, but it would present with motor deficits in wrist and finger extension.

Question 2998

Topic: Wrist & Carpus

A 28-year-old male falls from a height and sustains a highly comminuted radial head fracture, diffuse forearm tenderness, and distal radioulnar joint (DRUJ) instability, consistent with an Essex-Lopresti injury. He undergoes prompt radial head replacement to restore length. Intraoperatively, following the radial head replacement, the DRUJ remains grossly unstable in neutral rotation. What is the next best step in management?

. Open repair of the interosseous membrane
. Open reduction and internal fixation of the ulnar styloid
. Pinning of the DRUJ in supination
. Resection of the distal ulna (Darrach procedure)
. Casting the forearm in pronation for 6 weeks

Correct Answer & Explanation

. Open repair of the interosseous membrane

Explanation

An Essex-Lopresti injury involves a radial head fracture, disruption of the central band of the interosseous membrane (IOM), and DRUJ instability. The primary treatment in the acute setting involves restoring the radiocapitellar contact and length with rigid radial head fixation or arthroplasty. If the DRUJ remains unstable after restoring the radial column, it should be closed reduced and pinned with K-wires in a stable position (typically supination) for 4 to 6 weeks to allow the IOM and DRUJ ligaments to heal. Acute open repair of the IOM is rarely performed, and distal ulna resection is contraindicated as it will result in proximal migration of the radius.

Question 2999

Topic: 7. Hand and Wrist

A 45-year-old male presents with chronic, progressive wrist pain. Radiographs reveal a scaphoid nonunion with advanced radioscaphoid arthritis and capitolunate arthritis. The radiolunate joint is well-preserved. This is consistent with a Stage III Scaphoid Nonunion Advanced Collapse (SNAC). Which of the following is the most appropriate motion-preserving surgical treatment?

. Radial styloidectomy and scaphoid ORIF
. Proximal row carpectomy (PRC)
. Scaphoid excision and 4-corner fusion
. Total wrist arthrodesis
. Scaphoid ORIF with vascularized bone graft

Correct Answer & Explanation

. Radial styloidectomy and scaphoid ORIF

Explanation

SNAC stage III involves degenerative arthritis of both the radioscaphoid and capitolunate joints, with preservation of the radiolunate joint. Proximal row carpectomy (PRC) is contraindicated in this stage because it relies on placing the head of the capitate into the lunate fossa; since the proximal capitate is arthritic, a PRC would result in a painful articulation. The most appropriate motion-preserving salvage procedure is scaphoid excision and a four-corner fusion (capitate, lunate, triquetrum, hamate), which preserves the healthy radiolunate articulation. Radial styloidectomy is reserved for SNAC I.

Question 3000

Topic: 7. Hand and Wrist

A 25-year-old man complains of persistent dorsal wrist pain and a clicking sensation 3 months after falling on an extended, ulnar-deviated wrist. Physical examination reveals focal tenderness over the dorsal scapholunate interval and a positive Watson scaphoid shift test. Radiographs show a scapholunate gap of 4 mm and a cortical 'ring sign' of the scaphoid. The radiolunate angle measures 20 degrees of dorsal tilt. Based on these radiographic findings, what carpal instability pattern has developed?

. Volar intercalated segment instability (VISI)
. Dorsal intercalated segment instability (DISI)
. Ulnar translocation
. Midcarpal instability
. Perilunate dislocation

Correct Answer & Explanation

. Volar intercalated segment instability (VISI)

Explanation

Scapholunate dissociation disrupts the scapholunate interosseous ligament. Left unchecked, the scaphoid naturally flexes volarly (creating the 'signet ring' sign on PA radiographs as the scaphoid is viewed end-on). Conversely, the lunate falls into extension dorsally, dragged by the intact lunotriquetral ligament and the natural tendency of the triquetrum. This uncoupling creates a Dorsal Intercalated Segment Instability (DISI) deformity. Radiographically, a DISI is confirmed by a radiolunate angle of >15 degrees of dorsal tilt (extension) and a scapholunate angle >60 degrees.

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