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7. Hand and Wrist MCQs

Practice Set 151 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 3001

Topic: Nerve & Tendon

A 40-year-old carpenter presents with 6 months of persistent numbness in his small and ring fingers, and subjective clumsiness in his right hand. Examination shows a positive Tinel's sign at the cubital tunnel, weak pinch strength, and a positive Froment's sign. Electrodiagnostic studies confirm severe ulnar neuropathy at the elbow with active denervation in the first dorsal interosseous muscle. Notably, his right elbow demonstrates a 15-degree cubitus valgus deformity from a malunited pediatric supracondylar fracture. What is the most appropriate surgical intervention?

. In situ ulnar nerve decompression
. Ulnar nerve anterior transposition
. Medial epicondylectomy
. Cubital tunnel release and carpal tunnel release
. Ulnar motor nerve branch transfer

Correct Answer & Explanation

. In situ ulnar nerve decompression

Explanation

While in situ decompression of the ulnar nerve is highly effective and widely utilized for primary, idiopathic cubital tunnel syndrome, an anterior transposition (whether subcutaneous, intramuscular, or submuscular) is specifically indicated when there is tension on the nerve, subluxation of the nerve over the medial epicondyle during flexion, or a significant valgus deformity of the elbow (cubitus valgus leading to tardy ulnar nerve palsy). In a patient with a malunited pediatric fracture and cubitus valgus, in situ decompression fails to address the underlying traction neuritis, making anterior transposition the procedure of choice.

Question 3002

Topic: 7. Hand and Wrist

A 25-year-old man presents with chronic wrist pain 1 year after falling on an outstretched hand. Imaging reveals a scaphoid nonunion with a humpback deformity and avascular necrosis (AVN) of the proximal pole. There is no significant radiocarpal arthritis. Which of the following vascularized bone grafts is most appropriate for addressing this specific injury?

. 1,2 intercompartmental supraretinacular artery (1,2-ICSRA) pedicled graft
. Medial femoral condyle free vascularized bone graft
. Volar carpal artery pedicled graft
. Pronator quadratus pedicled bone graft
. Free fibular vascularized bone graft

Correct Answer & Explanation

. 1,2 intercompartmental supraretinacular artery (1,2-ICSRA) pedicled graft

Explanation

For a scaphoid proximal pole nonunion complicated by avascular necrosis (AVN) and structural collapse (humpback deformity), a structural vascularized bone graft is required. The medial femoral condyle (MFC) free vascularized bone graft is the treatment of choice, as it provides robust blood supply and the structural integrity needed to correct the deformity. The 1,2-ICSRA graft often fails in the setting of true AVN with structural collapse.

Question 3003

Topic: 7. Hand and Wrist

A 30-year-old man sustains a hyperextension wrist injury, resulting in a volar perilunate dislocation. During surgical reconstruction via a combined dorsal and volar approach, which of the following ligaments must be repaired to restore the primary stabilizer of the proximal carpal row and prevent a dorsal intercalated segment instability (DISI) deformity?

. Volar radiocarpal ligament
. Lunotriquetral interosseous ligament
. Scapholunate interosseous ligament
. Dorsal intercarpal ligament
. Radioscaphocapitate ligament

Correct Answer & Explanation

. Volar radiocarpal ligament

Explanation

The scapholunate interosseous ligament (SLIL), specifically its dorsal band, is the primary stabilizer of the scapholunate articulation. Failure to appropriately repair the SLIL during perilunate dislocation reconstruction will reliably lead to a dorsal intercalated segment instability (DISI) deformity and eventual Scapholunate Advanced Collapse (SLAC) arthritis.

Question 3004

Topic: Nerve & Tendon

A 45-year-old avid cyclist complains of numbness and tingling in his right ring and small fingers, along with weakness in gripping. Examination reveals clawing of the small and ring fingers, a positive Froment's sign, but normal sensation over the dorso-ulnar aspect of the hand. Where is the most likely site of ulnar nerve compression?

. Cubital tunnel
. Zone 1 of Guyon's canal
. Zone 2 of Guyon's canal
. Zone 3 of Guyon's canal
. Arcade of Struthers

Correct Answer & Explanation

. Cubital tunnel

Explanation

The patient has both motor (weakness, clawing, positive Froment's sign) and sensory (volar ring and small finger numbness) deficits of the ulnar nerve, but spared dorsal sensation. The dorsal ulnar cutaneous nerve branches proximal to the wrist; its sparing rules out a lesion at the elbow (cubital tunnel). Within Guyon's canal, Zone 1 is located proximal to the bifurcation and contains both motor and sensory fibers. Therefore, compression in Zone 1 causes mixed symptoms.

Question 3005

Topic: 7. Hand and Wrist

A 55-year-old manual laborer presents with progressive wrist pain and stiffness. Radiographs show severe joint space narrowing between the scaphoid and the radial styloid, as well as between the lunate and capitate. The radiolunate joint space is completely preserved. This radiographic appearance is most consistent with which stage of Scapholunate Advanced Collapse (SLAC)?

. Stage I
. Stage II
. Stage III
. Stage IV
. Stage V

Correct Answer & Explanation

. Stage I

Explanation

SLAC wrist follows a predictable pattern of progressive arthritis. Stage I involves the radial styloid and distal scaphoid. Stage II involves the entire radioscaphoid fossa. Stage III progresses to involve the capitolunate joint. A hallmark of SLAC wrist is the sparing of the radiolunate joint, due to its congruent spherical articulation and lack of cartilage defect, differentiating it from generalized wrist osteoarthritis.

Question 3006

Topic: Wrist & Carpus

A 65-year-old woman presents to the emergency department after falling on an outstretched hand. Radiographs demonstrate a displaced volar shear fracture of the distal radius (volar Barton's fracture).

Which of the following is the most appropriate surgical approach and fixation strategy to prevent displacement?

. Closed reduction and percutaneous pinning
. Volar approach with a volar buttress plate
. Dorsal approach with a dorsal spanning plate
. Application of a bridging external fixator
. Fragment-specific fixation via a dedicated dorsal approach

Correct Answer & Explanation

. Closed reduction and percutaneous pinning

Explanation

Volar shear fractures of the distal radius (volar Barton's fractures) are highly unstable due to the deforming forces of the robust radiocarpal ligaments and flexor tendons pulling the carpus and volar rim proximally. The most biomechanically sound method of fixation is a volar approach utilizing a volar buttress plate to counteract these shearing forces. External fixation or dorsal plating does not adequately buttress the volar articular fragment and risks subluxation.

Question 3007

Topic: 7. Hand and Wrist

A 45-year-old construction worker presents with chronic wrist pain and limited range of motion. Radiographs demonstrate a long-standing scaphoid nonunion with arthritic changes at the radioscaphoid and capitolunate joints, while the radiolunate articulation remains preserved.

What is the most appropriate definitive surgical management?

. Proximal row carpectomy (PRC)
. Scaphoid excision and four-corner fusion
. Scaphoid open reduction internal fixation with vascularized bone graft
. Radial styloidectomy
. Total wrist arthrodesis

Correct Answer & Explanation

. Proximal row carpectomy (PRC)

Explanation

The patient has Scaphoid Nonunion Advanced Collapse (SNAC) Stage III, characterized by arthrosis extending to the capitolunate joint but sparing the radiolunate joint. Because the capitate head is arthritic, a proximal row carpectomy (PRC) is contraindicated (as the capitate must articulate smoothly with the lunate fossa). Therefore, scaphoid excision combined with a four-corner fusion (capitate, lunate, triquetrum, and hamate) is the most appropriate motion-preserving salvage procedure.

Question 3008

Topic: Nerve & Tendon

A 50-year-old man presents with persistent ulnar neuropathy 14 months after undergoing an in situ cubital tunnel release. He reports progressive intrinsic weakness. Dynamic ultrasound reveals the ulnar nerve is encased in thick scar tissue and subluxates over the medial epicondyle during elbow flexion. What is the most appropriate surgical intervention?

. Repeat in situ decompression with neurolysis
. Medial epicondylectomy
. Anterior submuscular transposition of the ulnar nerve
. Anterior subcutaneous transposition of the ulnar nerve
. Ulnar nerve wrapping with a processed vein conduit

Correct Answer & Explanation

. Repeat in situ decompression with neurolysis

Explanation

In the revision setting for recurrent or persistent cubital tunnel syndrome, especially when the nerve is subluxating or encased in heavy scar tissue, an anterior submuscular transposition is the preferred technique. It places the nerve in a healthy, well-vascularized muscular bed away from the scarred bed and eliminates the dynamic friction over the medial epicondyle. Subcutaneous transpositions have a higher failure rate in revision scenarios due to the poor quality of the subcutaneous tissue bed.

Question 3009

Topic: 7. Hand and Wrist

A 28-year-old carpenter presents with worsening dorsal wrist pain. Radiographs demonstrate sclerosis and early fragmentation of the lunate, without carpal collapse. Ulnar variance is measured at -3 mm. What is the most appropriate surgical treatment to halt disease progression?

. Radial shortening osteotomy
. Proximal row carpectomy
. Total wrist arthrodesis
. Scaphoid-trapezium-trapezoid (STT) fusion
. Lunate excision without replacement

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

The patient has Lichtman Stage IIIa Kienböck's disease (fragmentation of the lunate, normal carpal height/alignment) with negative ulnar variance. A joint-leveling procedure is the treatment of choice to decrease compressive loads across the radiolunate joint. Radial shortening osteotomy is technically preferred over ulnar lengthening due to lower rates of nonunion and hardware complications, effectively offloading the lunate.

Question 3010

Topic: 7. Hand and Wrist

A 42-year-old right-hand-dominant carpenter presents with chronic wrist pain 6 years after an untreated fall on his outstretched hand. Radiographs reveal a scaphoid nonunion with arthritic changes involving the radioscaphoid joint and the capitolunate joint. The radiolunate articulation is entirely spared. Based on this Scaphoid Nonunion Advanced Collapse (SNAC) pattern, which of the following is the most appropriate surgical intervention?

. Proximal row carpectomy (PRC)
. Scaphoid open reduction and internal fixation with vascularized bone grafting
. Radial styloidectomy
. Four-corner arthrodesis with scaphoid excision
. Total wrist arthrodesis

Correct Answer & Explanation

. Proximal row carpectomy (PRC)

Explanation

The patient has Stage III Scaphoid Nonunion Advanced Collapse (SNAC), which is characterized by arthritis involving the radioscaphoid and capitolunate joints, while sparing the radiolunate joint. Proximal row carpectomy (PRC) is contraindicated in SNAC III because it relies on a pristine capitate head to articulate with the lunate fossa; here, the capitolunate joint is already arthritic. Therefore, a four-corner arthrodesis (capitate, hamate, lunate, triquetrum) with scaphoid excision is the motion-preserving procedure of choice.

Question 3011

Topic: Nerve & Tendon

A 48-year-old man presents with severe recurrence of right ulnar neuropathy symptoms 18 months after an in situ ulnar nerve decompression at the cubital tunnel. Electrodiagnostic studies confirm a conduction block at the elbow. Intraoperatively, the ulnar nerve is found to be encased in thick perineural scar tissue within the postcondylar groove. What is the most appropriate management for this revision procedure?

. Repeat in situ neurolysis
. Anterior subcutaneous transposition
. Anterior submuscular transposition
. Medial epicondylectomy
. Ulnar nerve wrapping with a vein graft

Correct Answer & Explanation

. Repeat in situ neurolysis

Explanation

In the setting of revision cubital tunnel surgery where the nerve bed is heavily scarred, leaving the nerve in the same scarred bed (in situ or epicondylectomy) is generally avoided. An anterior submuscular transposition is widely considered the gold standard for revision procedures with a scarred bed, as it places the ulnar nerve in a well-vascularized, healthy muscular environment free from the prior scar tissue.

Question 3012

Topic: 7. Hand and Wrist

A 28-year-old male athlete presents with dorsal wrist pain 3 weeks after falling on a hyperextended wrist. Imaging confirms an isolated, complete rupture of the scapholunate interosseous ligament (SLIL). Anatomically, which component of the SLIL is the thickest, strongest, and acts as the primary restraint to palmar flexion of the scaphoid?

. Volar band
. Proximal membranous band
. Dorsal band
. Radioscaphocapitate ligament
. Scaphotrapezial ligament

Correct Answer & Explanation

. Volar band

Explanation

The scapholunate interosseous ligament (SLIL) is a C-shaped ligament divided into three anatomic regions: dorsal, proximal (membranous), and volar. The dorsal band is the thickest and strongest portion, providing the primary mechanical restraint to translation and palmar flexion of the scaphoid relative to the lunate. The volar band provides secondary restraint, while the proximal membranous portion has negligible biomechanical strength but prevents fluid leakage between the radiocarpal and midcarpal joints.

Question 3013

Topic: Wrist & Carpus

A 55-year-old woman was treated nonoperatively in a short-arm cast for a nondisplaced distal radius fracture. Eight weeks post-injury, she returns to the clinic reporting a sudden inability to actively lift her thumb off a flat table. Physical examination demonstrates intact IP joint flexion but absent active IP joint extension of the thumb. Which of the following is the most appropriate surgical treatment?

. Primary end-to-end repair of the ruptured tendon
. Extensor indicis proprius (EIP) to extensor pollicis longus (EPL) tendon transfer
. Palmaris longus interposition tendon grafting
. Flexor carpi radialis (FCR) to extensor pollicis longus (EPL) tendon transfer
. Tenolysis of the first dorsal compartment

Correct Answer & Explanation

. Primary end-to-end repair of the ruptured tendon

Explanation

The patient has sustained a delayed rupture of the extensor pollicis longus (EPL) tendon, a known complication of nondisplaced distal radius fractures due to vascular watershed ischemia and mechanical attrition at the Lister tubercle. Because the tendon ends are typically frayed and retracted, primary repair is almost always impossible. The gold standard treatment is an extensor indicis proprius (EIP) to EPL tendon transfer, which restores independent thumb extension with predictable outcomes and minimal donor site morbidity.

Question 3014

Topic: 7. Hand and Wrist

A 30-year-old rock climber presents with acute pain and swelling at the volar base of his right ring finger after hearing a 'pop' while using a crimp grip. Ultrasound confirms bowstringing of the flexor tendons over the proximal phalanx. Which pulley has been ruptured, and what is its precise anatomical origin?

. A1 pulley; originating from the volar plate of the MCP joint
. A2 pulley; originating directly from the periosteum of the proximal phalanx
. A3 pulley; originating from the volar plate of the PIP joint
. A4 pulley; originating directly from the periosteum of the middle phalanx
. A5 pulley; originating from the volar plate of the DIP joint

Correct Answer & Explanation

. A1 pulley; originating from the volar plate of the MCP joint

Explanation

Bowstringing over the proximal phalanx indicates rupture of the A2 pulley, which is the most commonly injured pulley in rock climbers. The flexor tendon sheath consists of annular and cruciate pulleys. The A2 and A4 pulleys are the critical biomechanical restraints to bowstringing and arise directly from the periosteum of the proximal and middle phalanges, respectively. In contrast, the A1, A3, and A5 pulleys originate from the volar plates of the MCP, PIP, and DIP joints.

Question 3015

Topic: Nerve & Tendon

A 40-year-old avid cyclist presents with intrinsic muscle weakness in his right hand. He reports numbness on the volar aspect of his small finger and the ulnar half of his ring finger. Sensation on the dorsum of his right hand is completely normal. Tinel's sign is positive at the wrist but negative at the cubital tunnel. Compression of the ulnar nerve is most likely occurring at which anatomical location?

. Zone 1 of Guyon's canal
. Zone 2 of Guyon's canal
. Zone 3 of Guyon's canal
. The arcade of Struthers
. The two heads of the flexor carpi ulnaris (FCU)

Correct Answer & Explanation

. Zone 1 of Guyon's canal

Explanation

The clinical presentation is consistent with ulnar nerve compression at Guyon's canal. Guyon's canal is divided into three zones. Zone 1 is proximal to the nerve bifurcation; compression here causes mixed motor (intrinsic weakness) and sensory (volar ring/small fingers) deficits. Sensation to the dorsal ulnar hand is preserved because the dorsal ulnar cutaneous nerve branches off approximately 5-8 cm proximal to the wrist. Zone 2 compression is purely motor (deep branch), and Zone 3 compression is purely sensory (superficial branch).

Question 3016

Topic: 7. Hand and Wrist

A 28-year-old man presents with chronic radial-sided wrist pain 18 months after a fall onto an outstretched hand. Radiographs reveal a scaphoid proximal pole nonunion with a humpback deformity, but no evidence of radiocarpal arthritis. An MRI confirms avascular necrosis (AVN) of the proximal pole. Which of the following is the most appropriate surgical treatment?

. Nonvascularized iliac crest bone graft with K-wire fixation
. 1,2 Intercompartmental supraretinacular artery (ICSRA) pedicled bone graft
. Free vascularized medial femoral condyle bone graft with screw fixation
. Proximal row carpectomy
. Scaphoid excision and four-corner fusion

Correct Answer & Explanation

. Nonvascularized iliac crest bone graft with K-wire fixation

Explanation

In the setting of a scaphoid nonunion with avascular necrosis (AVN) of the proximal pole and a humpback deformity (carpal collapse), a free vascularized bone graft, such as the medial femoral condyle (MFC) free flap, is the treatment of choice. The MFC provides structural support capable of correcting the humpback deformity while delivering a robust vascular supply to heal the AVN. The 1,2 ICSRA pedicled graft is an option for proximal pole AVN without collapse, but it is typically inadequate for correcting a structural humpback deformity and has higher failure rates in the presence of AVN. Salvage procedures (PRC or four-corner fusion) are reserved for cases with established scaphoid nonunion advanced collapse (SNAC) arthritis, which this patient does not have.

Question 3017

Topic: Wrist & Carpus

A 62-year-old woman sustained a nondisplaced distal radius fracture treated nonoperatively with a short arm cast for 6 weeks. Two weeks after cast removal, she reports a sudden, painless inability to actively extend her thumb interphalangeal joint. Radiographs confirm a healed distal radius fracture in anatomic alignment. Which of the following is the most appropriate surgical treatment for this specific complication?

. Primary end-to-end repair of the extensor pollicis longus (EPL) tendon
. Extensor indicis proprius (EIP) to EPL tendon transfer
. Extensor carpi radialis longus (ECRL) to EPL tendon transfer
. Free tendon graft using the palmaris longus
. Tenodesis of the EPL to the extensor pollicis brevis (EPB)

Correct Answer & Explanation

. Primary end-to-end repair of the extensor pollicis longus (EPL) tendon

Explanation

This patient has experienced an extensor pollicis longus (EPL) tendon rupture, a known complication of nondisplaced or minimally displaced distal radius fractures. The rupture is typically secondary to mechanical attrition over the fracture callus or ischemic watershed necrosis within the third extensor compartment. Because the tendon ends are usually degenerated and retracted, primary end-to-end repair is rarely possible. The gold standard surgical treatment is an extensor indicis proprius (EIP) to EPL tendon transfer, which provides excellent function and appropriately matches the required excursion.

Question 3018

Topic: 7. Hand and Wrist

A 21-year-old rugby player sustained an injury to his right ring finger when he grasped an opponent's jersey. Physical examination reveals an inability to actively flex the distal interphalangeal (DIP) joint. A lateral radiograph demonstrates a small bony avulsion fragment located volar to the proximal interphalangeal (PIP) joint. According to the Leddy and Packer classification, what type of injury is this, and what is its blood supply status?

. Type I; avascular and requires repair within 7-10 days
. Type II; blood supply preserved via the vinculum longum, requires repair within 6 weeks
. Type III; blood supply preserved, large bony fragment limits retraction past the A4 pulley
. Type IV; associated with an avulsion fracture of the distal phalanx and simultaneous avulsion of the tendon off the fracture fragment
. Type V; avulsion with a concomitant fracture of the middle phalanx

Correct Answer & Explanation

. Type I; avascular and requires repair within 7-10 days

Explanation

This is a flexor digitorum profundus (FDP) avulsion ('jersey finger'). According to the Leddy and Packer classification: Type I injuries involve retraction of the tendon into the palm, rupturing the vincula, rendering it avascular (must be repaired <7-10 days). Type II injuries involve retraction to the level of the PIP joint; a small cortical fragment may be present, and the tendon is held by an intact vinculum longum, preserving blood supply (can be repaired up to 6 weeks). Type III injuries feature a large bony avulsion fragment that catches at the A4 pulley, keeping the tendon at the DIP joint level. Because the fragment is at the PIP joint, this is a Type II injury.

Question 3019

Topic: Wrist & Carpus

Six months after undergoing volar locking plate fixation for a distal radius fracture, a 58-year-old woman reports the sudden inability to actively flex the interphalangeal joint of her right thumb. Radiographs confirm that the fracture is fully healed, but the plate is noted to be placed prominent and distal to the watershed line. Which of the following is the most likely cause of her current symptoms?

. Extensor pollicis longus attrition rupture
. Anterior interosseous nerve syndrome
. Flexor pollicis longus attrition rupture
. Stenosing tenosynovitis (Trigger thumb)
. Intra-articular screw penetration

Correct Answer & Explanation

. Extensor pollicis longus attrition rupture

Explanation

Flexor pollicis longus (FPL) tendon rupture is a well-documented complication of volar plating of distal radius fractures, particularly when the plate is positioned distal to the watershed line (the distal margin of the pronator fossa). The prominent hardware causes frictional attrition and subsequent rupture of the FPL tendon. Extensor pollicis longus (EPL) rupture is more commonly associated with nonoperative management of distal radius fractures or dorsally prominent screws. AIN syndrome could cause a lack of FPL function, but it typically presents as a neuropathy earlier in the clinical course, lacking the sudden 'snapping' history typical of an attrition rupture at 6 months.

Question 3020

Topic: 7. Hand and Wrist

A 48-year-old manual laborer presents with chronic right wrist pain. Radiographs reveal advanced degenerative changes at the radioscaphoid and capitolunate articulations, while the radiolunate joint is completely spared. Based on these findings, which of the following surgical interventions is most appropriate?

. Scapholunate ligament reconstruction
. Proximal row carpectomy (PRC)
. Total wrist arthroplasty
. Scaphoid excision and four-corner fusion
. Radial styloidectomy alone

Correct Answer & Explanation

. Scapholunate ligament reconstruction

Explanation

The patient's radiographic findings describe Stage III Scapholunate Advanced Collapse (SLAC), characterized by osteoarthritis involving the radioscaphoid and capitolunate joints with preservation of the radiolunate joint. Scaphoid excision and four-corner fusion (capitate-lunate-triquetrum-hamate) is the treatment of choice. Proximal row carpectomy (PRC) is contraindicated in Stage III SLAC because PRC relies on a pristine capitate head and lunate fossa to form a functional new articulation. In Stage III SLAC, the capitate head is already arthritic.

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