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7. Hand and Wrist MCQs

Practice Set 159 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 3161

Topic: 7. Hand and Wrist
A 32-year-old carpenter presents with a 6-month history of central dorsal wrist pain and decreased grip strength. Radiographs reveal sclerosis and early fragmentation of the lunate, but no carpal collapse is noted. Radiographic measurements demonstrate a negative ulnar variance of 3 mm. Which of the following surgical interventions is most appropriate to halt disease progression?
. Proximal row carpectomy
. Ulnar lengthening osteotomy
. Radial shortening osteotomy
. Scaphoid-trapezium-trapezoid (STT) arthrodesis
. Total wrist fusion

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

The patient has Kienböck's disease (avascular necrosis of the lunate) Lichtman Stage II or early IIIa (fragmentation but no carpal collapse) associated with negative ulnar variance. Negative ulnar variance increases compressive load transmission across the radiolunate joint. For patients with negative ulnar variance and no advanced carpal collapse, joint-leveling procedures such as a radial shortening osteotomy are indicated. This decreases the mechanical stress on the lunate, potentially allowing for revascularization and halting collapse. While ulnar lengthening achieves the same biomechanical goal, radial shortening osteotomy is technically preferred due to higher union rates and fewer complications.

Question 3162

Topic: Nerve & Tendon

A 42-year-old male construction worker presents with chronic numbness in his small and ring fingers and weakness in grip strength. Exam reveals a positive Froment's sign and intrinsic muscle atrophy. Intraoperatively, during decompression, the ulnar nerve is found to subluxate anteriorly over the medial epicondyle upon elbow flexion. What is the most appropriate surgical management?

. In situ decompression of the ulnar nerve alone.
. Ulnar nerve anterior transposition or medial epicondylectomy.
. Guyon's canal decompression.
. Endoscopic in situ decompression.
. Medial ulnar collateral ligament reconstruction.

Correct Answer & Explanation

. Ulnar nerve anterior transposition or medial epicondylectomy.

Explanation

In patients with ulnar nerve subluxation or instability at the elbow during flexion, an in situ decompression alone is contraindicated. Decompressing without stabilizing the nerve can lead to continued or worsened subluxation, causing a severe friction neuritis over the medial epicondyle. An anterior transposition (subcutaneous, intramuscular, or submuscular) or a medial epicondylectomy is recommended to address both the compression and the dynamic instability.

Question 3163

Topic: 7. Hand and Wrist
A 30-year-old male presents with chronic radial-sided wrist pain following a remote injury. Radiographs demonstrate a scaphoid nonunion with radioscaphoid and capitolunate arthritis. The radiolunate joint is radiographically preserved. What is the most appropriate surgical intervention for this stage of Scaphoid Nonunion Advanced Collapse (SNAC)?
. Radial styloidectomy and scaphoid open reduction internal fixation.
. Proximal row carpectomy (PRC).
. Four-corner arthrodesis with scaphoid excision.
. Scaphoid excision and partial wrist denervation.
. Total wrist arthrodesis.

Correct Answer & Explanation

. Four-corner arthrodesis with scaphoid excision.

Explanation

The scenario describes SNAC Stage III, characterized by capitolunate arthritis with a spared radiolunate joint. A proximal row carpectomy (PRC) requires a pristine capitate head and lunate fossa to function as the new articulation; therefore, capitolunate arthritis is a contraindication to PRC. Four-corner arthrodesis (capitate, hamate, lunate, triquetrum) with scaphoid excision is the most appropriate motion-preserving salvage procedure for SNAC Stage III, as it relies on the preserved radiolunate joint.

Question 3164

Topic: Nerve & Tendon

A 48-year-old weightlifter feels a 'pop' in his anterior elbow during a heavy deadlift, followed by ecchymosis and weakness in supination. MRI confirms a complete distal biceps tendon avulsion. He opts for surgical repair using a single-incision anterior approach. Which nerve is at greatest risk of iatrogenic injury during the superficial dissection of this specific surgical approach?

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

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve (LABCN)

Explanation

The single-incision anterior approach for distal biceps tendon repair primarily places the lateral antebrachial cutaneous nerve (LABCN) at risk during the superficial exposure. The LABCN exits the deep fascia lateral to the biceps tendon and must be identified and protected. While the posterior interosseous nerve (PIN) is at risk during deep retractor placement or drilling of the posterior radius cortex, the LABCN is statistically the most commonly injured nerve overall in the single-incision anterior approach.

Question 3165

Topic: 7. Hand and Wrist
A 24-year-old female gymnast presents with progressive dorsal wrist pain. Radiographs reveal sclerosis of the lunate with no carpal collapse (Lichtman Stage II). Ulnar variance is determined to be negative 3 mm. MRI confirms Kienböck's disease. Which of the following is the most appropriate surgical treatment?
. Lunate excision and silastic replacement.
. Radial shortening osteotomy.
. Proximal row carpectomy.
. Scaphoid-trapezium-trapezoid (STT) arthrodesis.
. Total wrist arthrodesis.

Correct Answer & Explanation

. Radial shortening osteotomy.

Explanation

Kienböck's disease is avascular necrosis of the lunate. In the early stages (Lichtman Stage II or IIIa - sclerosis or mild collapse without carpal instability) in a patient with negative ulnar variance, a joint-leveling procedure such as a radial shortening osteotomy is indicated. This unloads the radiolunate joint, decreasing the forces transmitted through the lunate, and has a high success rate in halting disease progression. Salvage procedures like PRC or STT arthrodesis are reserved for more advanced stages with carpal collapse.

Question 3166

Topic: Wrist & Carpus
A 28-year-old tennis player complains of chronic ulnar-sided wrist pain. MRI confirms a central articular disc tear of the triangular fibrocartilage complex (TFCC) (Palmer Type 1A). Radiographs reveal a positive ulnar variance of 4 mm. Conservative management has failed. What is the most appropriate surgical management?
. Arthroscopic debridement of the TFCC only.
. Open TFCC repair to the fovea.
. Arthroscopic TFCC debridement combined with an ulnar shortening osteotomy.
. Darrach procedure (distal ulna resection).
. Sauvé-Kapandji procedure.

Correct Answer & Explanation

. Arthroscopic TFCC debridement combined with an ulnar shortening osteotomy.

Explanation

The patient has a Palmer Type 1A TFCC tear (central, avascular portion of the articular disc) associated with significant positive ulnar variance, indicative of ulnocarpal impaction syndrome. Central tears lack blood supply and are generally treated with arthroscopic debridement rather than repair. However, addressing the underlying ulnocarpal impaction with an ulnar shortening osteotomy (USO) is crucial to relieve the excessive mechanical load on the ulnar carpus. Debridement alone without joint leveling would lead to persistent symptoms.

Question 3167

Topic: Wrist & Carpus

A 65-year-old woman is 6 months status-post open reduction and internal fixation of a distal radius fracture with a volar locking plate. She presents with a sudden inability to actively flex the interphalangeal joint of her thumb. Which of the following surgical errors is most commonly associated with this complication?

. Placement of the plate too proximal to the watershed line
. Prominence of screws penetrating the dorsal cortex
. Placement of the plate distal to the watershed line
. Failure to repair the pronator quadratus
. Use of locking screws instead of non-locking screws

Correct Answer & Explanation

. Placement of the plate distal to the watershed line

Explanation

Flexor pollicis longus (FPL) tendon rupture is a well-known complication of volar plating of distal radius fractures. It is most commonly caused by placement of the plate distal to the watershed line, resulting in prominence of the distal edge of the plate and subsequent attrition and rupture of the FPL tendon. Prominent dorsal screws typically cause extensor tendon irritation or rupture (e.g., extensor pollicis longus).

Question 3168

Topic: 7. Hand and Wrist

A 21-year-old male fell on an outstretched hand 3 months ago and was treated conservatively for a 'sprained wrist.' He now presents with persistent radial-sided wrist pain. Radiographs reveal a scaphoid waist fracture with cystic changes and 2 mm of displacement. What is the primary blood supply to the proximal pole of the scaphoid, which places it at high risk for avascular necrosis in this fracture pattern?

. Palmar carpal branch of the radial artery
. Superficial palmar arch
. Dorsal carpal branch of the radial artery
. Anterior interosseous artery
. Ulnar artery via the deep palmar arch

Correct Answer & Explanation

. Dorsal carpal branch of the radial artery

Explanation

The primary blood supply to the scaphoid is retrograde. The dorsal carpal branch of the radial artery enters the scaphoid at the dorsal ridge (distal to the waist) and supplies the proximal 80% of the bone via intraosseous retrograde flow. A fracture at the scaphoid waist disrupts this blood supply to the proximal pole, placing it at high risk for avascular necrosis (AVN) and nonunion. The palmar carpal branch supplies only the distal 20%.

Question 3169

Topic: Wrist & Carpus

A 28-year-old male sustains a diaphyseal fracture of the middle third of the radius with an associated disruption of the distal radioulnar joint (DRUJ) after a fall. Intraoperatively, after rigid open reduction and internal fixation of the radius, the DRUJ is found to reduce anatomically and is stable in supination, but it readily subluxates when the forearm is placed in pronation. What is the most appropriate management of the DRUJ?

. Pinning of the DRUJ with Kirschner wires in pronation for 6 weeks
. Immobilization in a long arm cast in supination for 4 to 6 weeks
. Open repair of the triangular fibrocartilage complex (TFCC)
. Darrach procedure
. Immobilization in a short arm cast in pronation for 4 weeks

Correct Answer & Explanation

. Immobilization in a long arm cast in supination for 4 to 6 weeks

Explanation

This describes a Galeazzi fracture-dislocation. Following rigid internal fixation of the radial shaft, the stability of the DRUJ must be assessed. If the DRUJ is reducible and stable in supination (the position that tightens the palmar radioulnar ligaments and stabilizes dorsal dislocations), the recommended management is immobilization in a long arm splint or cast in supination for 4 to 6 weeks. If the DRUJ remains unstable in all positions or cannot be reduced, open reduction and TFCC repair or percutaneous pinning of the DRUJ is indicated.

Question 3170

Topic: 7. Hand and Wrist
A 34-year-old carpenter presents with an 8-month history of insidious onset, progressive dorsal wrist pain and limited extension. Radiographs show sclerosis and partial fragmentation of the lunate, with no evidence of carpal collapse or secondary osteoarthritis (Lichtman Stage IIIA). His ulnar variance is negative (-3 mm). Which of the following is the most appropriate surgical intervention?
. Proximal row carpectomy
. Scaphoid-trapezium-trapezoid (STT) fusion
. Radial shortening osteotomy
. Ulnar shortening osteotomy
. Total wrist arthrodesis

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

The patient has Kienböck's disease (avascular necrosis of the lunate) stage IIIA (lunate sclerosis and fragmentation, but normal carpal height) with negative ulnar variance. The goal of surgery in early stages with negative ulnar variance is to unload the lunate by leveling the distal radioulnar joint. A radial shortening osteotomy (or ulnar lengthening osteotomy) decreases the compressive forces on the lunate and is the procedure of choice. Proximal row carpectomy or intercarpal fusions are typically reserved for advanced stages (IIIB or IV) where carpal collapse or arthritis has occurred.

Question 3171

Topic: Wrist & Carpus

A 55-year-old woman sustained a non-displaced distal radius fracture treated non-operatively in a short arm cast. Eight weeks post-injury, she reports a sudden, painless inability to extend her thumb interphalangeal joint. On examination, she is unable to lift her thumb off the table when the palm is laid flat. What is the most appropriate surgical management to restore thumb kinematics?

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

Correct Answer & Explanation

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

Explanation

The patient has experienced an extensor pollicis longus (EPL) tendon rupture, a known complication of distal radius fractures, particularly non-displaced fractures due to localized ischemia and attrition at Lister's tubercle. Because the ruptured tendon ends are typically severely frayed, degenerated, and retracted, primary repair is usually impossible. An EIP to EPL tendon transfer is the standard of care, providing appropriately matched excursion and vector pull without significant donor site morbidity.

Question 3172

Topic: 7. Hand and Wrist

During an open carpal tunnel release, the surgeon carefully dissects the transverse carpal ligament and identifies the recurrent motor branch of the median nerve piercing directly through the substance of the ligament. According to the Lanz classification of median nerve variations, which subtype does this represent?

. Transligamentous
. Extraligamentous
. Subligamentous
. Pre-ligamentous
. Ulnar-sided

Correct Answer & Explanation

. Transligamentous

Explanation

The Lanz classification describes anatomical variations of the recurrent motor branch of the median nerve. The normal and most common anatomy is extraligamentous (the nerve branches distally and turns radially to the transverse carpal ligament). A transligamentous branch (Lanz group 1 variation) arises within the tunnel and pierces directly through the transverse carpal ligament to reach the thenar musculature. Recognizing this variation is critical to avoid iatrogenic nerve transection during standard ligament release.

Question 3173

Topic: Nerve & Tendon
A 55-year-old carpenter presents with a 6-month history of paresthesias in the right small and ulnar half of the ring finger, along with subjective weakness in hand grip. Electromyography confirms a compressive ulnar neuropathy at the elbow. During surgical decompression, the surgeon must systematically release several potential sites of compression. Which of the following anatomic structures is NOT a recognized site of ulnar nerve compression in this region?
. Ligament of Struthers
. Arcade of Struthers
. Medial intermuscular septum
. Osborne's ligament
. Aponeurosis of the flexor carpi ulnaris

Correct Answer & Explanation

. Ligament of Struthers

Explanation

The Ligament of Struthers is a potential site of MEDIAN nerve compression in the distal arm (associated with an anomalous supracondylar process of the humerus), not the ulnar nerve. Recognized sites of ulnar nerve compression around the elbow include the Arcade of Struthers (a fascial band extending from the medial head of the triceps to the medial intermuscular septum), the medial intermuscular septum (especially susceptible after anterior transposition of the nerve), the medial epicondyle, Osborne's ligament (the retinaculum bridging the two heads of the FCU), and the deep flexor-pronator aponeurosis.

Question 3174

Topic: 7. Hand and Wrist
A 32-year-old manual laborer presents with progressive dorsal wrist pain and decreased grip strength. Radiographs demonstrate increased sclerosis of the lunate without carpal collapse or fragmentation, and a negative ulnar variance of 3 mm. MRI confirms avascular necrosis of the lunate. According to the Lichtman classification, this represents Stage II disease. Which of the following surgical interventions is most appropriate for this patient?
. Proximal row carpectomy (PRC)
. Scaphoid-trapezium-trapezoid (STT) fusion
. Radial shortening osteotomy
. Total wrist arthrodesis
. Lunate excision and silastic replacement

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

The patient has Kienböck's disease (avascular necrosis of the lunate) Lichtman stage II (sclerosis without collapse) associated with ulnar negative variance. In patients with early-stage Kienböck's (Lichtman I, II, or IIIa) and ulnar negative variance, joint-leveling procedures such as a radial shortening osteotomy are the treatment of choice. This biomechanically unloads the lunate by shifting compressive forces to the ulnocarpal joint, thereby promoting revascularization and preventing further collapse. Salvage procedures like proximal row carpectomy (PRC) or intercarpal fusions are reserved for advanced stages with carpal collapse and secondary osteoarthritis (Lichtman IIIb and IV).

Question 3175

Topic: Nerve & Tendon

During an in situ ulnar nerve decompression for cubital tunnel syndrome, a surgeon sequentially releases the structures of the cubital tunnel. Which of the following structures constitutes the primary roof of the cubital tunnel?

. Medial intermuscular septum
. Arcade of Struthers
. Osborne's ligament
. Ligament of Struthers
. Lacertus fibrosus

Correct Answer & Explanation

. Osborne's ligament

Explanation

The roof of the cubital tunnel is primarily formed by Osborne's ligament (the cubital tunnel retinaculum spanning from the medial epicondyle to the olecranon) and the aponeurosis of the two heads of the flexor carpi ulnaris (FCU). The Arcade of Struthers is a fascial band located proximal to the medial epicondyle.

Question 3176

Topic: Wrist & Carpus

A 65-year-old woman sustained a non-displaced distal radius fracture treated in a short arm cast for 4 weeks. Six weeks post-injury, she reports a sudden, painless loss of the ability to extend her thumb at the interphalangeal joint. Tenodesis effect of the thumb is absent. What is the most likely diagnosis?

. Flexor pollicis longus rupture
. Extensor pollicis longus rupture
. Anterior interosseous nerve palsy
. Posterior interosseous nerve palsy
. Trigger thumb (stenosing tenosynovitis)

Correct Answer & Explanation

. Extensor pollicis longus rupture

Explanation

Extensor pollicis longus (EPL) tendon rupture is a known complication following non-displaced or minimally displaced distal radius fractures. It occurs secondary to mechanical attrition or relative ischemia within the intact third dorsal compartment as a fracture hematoma expands. A painless drop of the thumb IP joint and loss of thumb retropulsion are classic findings.

Question 3177

Topic: 7. Hand and Wrist
A 38-year-old man presents with chronic, progressive wrist pain and stiffness. Radiographs demonstrate a scaphoid nonunion advanced collapse (SNAC) pattern. There is established arthritis of the radioscaphoid joint and the capitolunate joint, but the radiolunate joint is completely spared. Which of the following is the most appropriate surgical intervention?
. Radial styloidectomy and scaphoid open reduction internal fixation (ORIF)
. Scaphoid excision and capitolunate arthrodesis
. Proximal row carpectomy
. Total wrist arthroplasty
. Radiocarpal arthrodesis

Correct Answer & Explanation

. Proximal row carpectomy

Explanation

The patient has Stage III SNAC wrist, characterized by arthritis of the radioscaphoid and capitolunate joints with a preserved radiolunate joint. The standard motion-preserving salvage procedures for this stage are proximal row carpectomy (PRC) or scaphoid excision with four-corner fusion. Radial styloidectomy is reserved for Stage I SNAC. Total wrist fusion is typically indicated for pan-carpal arthritis (Stage IV).

Question 3178

Topic: 7. Hand and Wrist

A 28-year-old skier sustains an acute abduction injury to his right thumb. Examination reveals significant laxity to valgus stress at the metacarpophalangeal (MCP) joint with no firm endpoint. An MRI demonstrates the adductor aponeurosis interposed between the ruptured ulnar collateral ligament (UCL) and its insertion site on the proximal phalanx. What is the name of this pathoanatomic lesion and the recommended treatment?

. Gamekeeper's lesion; immobilization in a thumb spica cast
. Stener lesion; surgical repair of the UCL
. Stener lesion; dynamic splinting for 6 weeks
. Bennett's lesion; closed reduction and percutaneous pinning
. Rolando's lesion; open reduction and internal fixation

Correct Answer & Explanation

. Stener lesion; surgical repair of the UCL

Explanation

A Stener lesion occurs when the torn ulnar collateral ligament of the thumb MCP joint displaces superficial to the adductor aponeurosis. Because the aponeurosis blocks the ligament from returning to its anatomic insertion on the proximal phalanx, anatomic healing cannot occur conservatively, making surgical repair the standard of care.

Question 3179

Topic: 7. Hand and Wrist

During an open carpal tunnel release, the surgeon must completely divide the transverse carpal ligament to decompress the median nerve. Which specific carpal bones serve as the radial and ulnar osseous attachment sites for this ligament?

. Scaphoid and trapezium radially; pisiform and hook of hamate ulnarly
. Trapezoid and scaphoid radially; triquetrum and pisiform ulnarly
. Lunate and capitate radially; hook of hamate and pisiform ulnarly
. Scaphoid and capitate radially; triquetrum and hook of hamate ulnarly
. Trapezium and capitate radially; pisiform and triquetrum ulnarly

Correct Answer & Explanation

. Scaphoid and trapezium radially; pisiform and hook of hamate ulnarly

Explanation

The transverse carpal ligament (flexor retinaculum) forms the roof of the carpal tunnel. It attaches radially to the tuberosity of the scaphoid and the crest of the trapezium, and ulnarly to the pisiform and the hook of the hamate.

Question 3180

Topic: Nerve & Tendon

A 50-year-old mechanic complains of numbness in his small and ring fingers, accompanied by intrinsic muscle weakness. Electromyography (EMG) confirms compressive neuropathy of the ulnar nerve at the elbow. Which of the following anatomic structures represents the most common site of ulnar nerve compression in this syndrome?

. Arcade of Struthers
. Medial intermuscular septum
. Osborne's ligament
. Deep flexor pronator aponeurosis
. Guyon's canal

Correct Answer & Explanation

. Osborne's ligament

Explanation

Cubital tunnel syndrome is the second most common compressive neuropathy of the upper extremity. The most frequent site of ulnar nerve compression at the elbow is between the humeral and ulnar heads of the flexor carpi ulnaris (FCU), deep to Osborne's ligament (the fascial band connecting the two heads). The Arcade of Struthers and the medial intermuscular septum are less common sites.

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