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7. Hand and Wrist MCQs

Practice Set 160 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 3181

Topic: Hand Trauma & Infection

A 28-year-old carpenter presents with a swollen, painful index finger 3 days after sustaining a puncture wound from a wood splinter. Examination reveals a finger held in slight flexion, fusiform swelling, and tenderness along the entire flexor tendon sheath. Which of the following signs is considered the most reliable and specific for diagnosing suppurative flexor tenosynovitis in its early stages?

. Erythema extending to the palmar crease
. Resting posture of the digit in rigid extension
. Fusiform swelling of the digit alone
. Severe pain with passive extension of the digit
. Localized fluctuance over the distal phalanx

Correct Answer & Explanation

. Severe pain with passive extension of the digit

Explanation

Kanavel's four cardinal signs of flexor tenosynovitis are 1) fusiform swelling of the digit, 2) resting posture of the digit in slight flexion, 3) tenderness along the flexor tendon sheath, and 4) excruciating pain with passive extension of the digit. Pain on passive extension is widely considered the most specific and earliest reliable clinical sign of suppurative flexor tenosynovitis.

Question 3182

Topic: Nerve & Tendon

During an anterior submuscular transposition of the ulnar nerve for refractory cubital tunnel syndrome, the surgeon must mobilize the nerve proximally to prevent tethering. Which of the following structures is located approximately 8 cm proximal to the medial epicondyle and must be carefully released to prevent a new site of nerve compression?

. Ligament of Struthers
. Osborne's ligament
. Arcade of Struthers
. Arcade of Frohse
. Lacertus fibrosus

Correct Answer & Explanation

. Arcade of Struthers

Explanation

The arcade of Struthers is a fascial band extending from the medial head of the triceps to the medial intermuscular septum, located approximately 8 cm proximal to the medial epicondyle. During anterior transposition of the ulnar nerve, failure to release the arcade of Struthers can lead to proximal tethering and iatrogenic compression of the nerve. The ligament of Struthers is an anomalous structure in the distal humerus associated with median nerve and brachial artery compression. Osborne's ligament forms the roof of the cubital tunnel. The arcade of Frohse is associated with PIN compression.

Question 3183

Topic: 7. Hand and Wrist
A 52-year-old man presents with chronic wrist pain and decreased grip strength. Radiographs reveal a chronic scaphoid nonunion with advanced osteoarthritic changes at the radioscaphoid and capitolunate joints. The radiolunate joint shows no evidence of arthritis. Which of the following is the most appropriate surgical treatment?
. Proximal row carpectomy
. Scaphoid excision and four-corner arthrodesis
. Radial styloidectomy and structural bone grafting
. Total wrist arthroplasty
. Open reduction and internal fixation of the scaphoid

Correct Answer & Explanation

. Scaphoid excision and four-corner arthrodesis

Explanation

The patient's clinical and radiographic presentation is consistent with Scaphoid Nonunion Advanced Collapse (SNAC) stage III, which is characterized by arthrosis of the radioscaphoid and capitolunate joints with preservation of the radiolunate joint. Because the capitate head is arthritic, a proximal row carpectomy (PRC) is generally contraindicated, as the arthritic capitate would articulate directly with the lunate fossa, leading to persistent pain and failure. Therefore, a scaphoid excision and four-corner arthrodesis (capitate, hamate, lunate, triquetrum) is the motion-preserving procedure of choice. Total wrist arthrodesis is reserved for SNAC stage IV (pancarpal arthritis).

Question 3184

Topic: Nerve & Tendon

A 45-year-old man presents with numbness and tingling in his small and ring fingers, along with subjective weakness in his grip. Electromyography confirms isolated ulnar neuropathy at the elbow. During surgical decompression, which of the following structures is identified as the most common primary site of ulnar nerve compression?

. Arcade of Struthers
. Medial intermuscular septum
. Osborne's ligament (cubital tunnel retinaculum)
. Flexor carpi ulnaris (FCU) aponeurosis
. Deep flexor pronator aponeurosis

Correct Answer & Explanation

. Osborne's ligament (cubital tunnel retinaculum)

Explanation

Cubital tunnel syndrome is the second most common compression neuropathy in the upper extremity. While compression can occur at multiple sites (Arcade of Struthers, medial intermuscular septum, Osborne's ligament, FCU aponeurosis, and deep flexor pronator aponeurosis), the most frequent primary site of compression is at the cubital tunnel retinaculum, also known as Osborne's ligament, which spans between the olecranon and the medial epicondyle.

Question 3185

Topic: 7. Hand and Wrist

A 22-year-old man falls on an outstretched hand and sustains a minimally displaced fracture of the proximal pole of the scaphoid. He is counseled regarding the high risk for nonunion and avascular necrosis (AVN). Which of the following accurately describes the primary arterial blood supply to the proximal pole of the scaphoid?

. Volar scaphoid branches entering distally and flowing proximally
. Dorsal carpal branch of the radial artery entering via the dorsal ridge and flowing proximally via intraosseous retrograde flow
. Superficial palmar arch branches entering the proximal pole directly
. Anterior interosseous artery branches entering the volar waist
. Ulnar artery branches entering through the scapholunate interosseous ligament

Correct Answer & Explanation

. Dorsal carpal branch of the radial artery entering via the dorsal ridge and flowing proximally via intraosseous retrograde flow

Explanation

The scaphoid relies on a tenuous blood supply, predominantly from the radial artery. The major blood supply (70-80%) arises from the dorsal carpal branch of the radial artery, which enters the bone distally at the dorsal ridge (near the waist) and provides retrograde intraosseous flow to the proximal pole. Because of this retrograde flow, fractures of the proximal pole frequently disrupt the blood supply to the proximal fragment, leading to a high rate of avascular necrosis.

Question 3186

Topic: 7. Hand and Wrist

A 58-year-old woman is evaluated 6 months after open reduction and internal fixation of a distal radius fracture utilizing a volar locking plate. She reports a sudden inability to actively flex the interphalangeal joint of her thumb, which occurred painlessly while wringing out a towel. What is the most likely cause of this complication?

. Attritional rupture of the flexor pollicis longus (FPL) tendon due to a prominent plate placed distal to the watershed line
. Extensor pollicis longus (EPL) rupture secondary to prominent dorsal screws penetrating the third extensor compartment
. Iatrogenic laceration of the FPL tendon during the initial surgical exposure
. Late median nerve entrapment beneath the distal aspect of the plate
. Trigger thumb secondary to localized flexor tenosynovitis at the A1 pulley

Correct Answer & Explanation

. Attritional rupture of the flexor pollicis longus (FPL) tendon due to a prominent plate placed distal to the watershed line

Explanation

Flexor tendon rupture, most notably of the flexor pollicis longus (FPL), is a well-documented complication of volar plating for distal radius fractures. It most commonly occurs when the plate is positioned too distally, beyond the 'watershed line' (the volar margin of the distal radius articular surface). This causes the FPL tendon to rub against the prominent distal edge of the plate or screw heads during active wrist and thumb motion, leading to attritional wear and sudden, often painless, rupture.

Question 3187

Topic: Nerve & Tendon

A 20-year-old collegiate baseball pitcher is undergoing ulnar collateral ligament (UCL) reconstruction utilizing an autograft. To minimize the risk of postoperative ulnar neuropathy, a common and devastating complication, which of the following intraoperative principles is most critical regarding the handling of the ulnar nerve?

. Routine anterior submuscular transposition of the ulnar nerve in all cases regardless of preoperative symptoms
. Placing the ulnar bone tunnel as far posteriorly as possible to avoid proximity to the nerve
. Avoiding excessive traction and retractors on the ulnar nerve if it is left in situ, and resecting the medial intermuscular septum to prevent tethering
. Creating an enlarged ulnar bone tunnel to intentionally allow for concomitant decompression of the nerve within the cubital tunnel
. Performing a routine medial epicondylectomy to offload tension on the ulnar nerve pathway

Correct Answer & Explanation

. Avoiding excessive traction and retractors on the ulnar nerve if it is left in situ, and resecting the medial intermuscular septum to prevent tethering

Explanation

Ulnar neuropathy is the most common complication following UCL reconstruction. Historically, routine anterior transposition was performed (as in the classic Jobe technique), which carried a high rate of nerve-related complications. Modern techniques (such as the docking technique or muscle-splitting approach) often leave the nerve in situ to preserve its vascularity. When leaving the nerve in situ, it is critical to avoid placing retractors directly on the nerve, to minimize traction, and to release the medial intermuscular septum if there is any tension, thereby preventing tethering or iatrogenic compression.

Question 3188

Topic: 7. Hand and Wrist
A 45-year-old man presents with chronic, progressive wrist pain 10 years after sustaining an untreated fall on an outstretched hand. Radiographs demonstrate a scaphoid waist nonunion with cystic changes and sclerosis, alongside marked narrowing of the radioscaphoid and capitolunate joint spaces. The radiolunate joint is well-preserved. Which of the following is the most appropriate surgical management?
. Radial styloidectomy and scaphoid nonunion takedown with bone grafting
. Proximal row carpectomy (PRC)
. Scaphoid excision and four-corner (capitate-lunate-hamate-triquetrum) fusion
. Total wrist arthrodesis
. Scapholunate ligament reconstruction

Correct Answer & Explanation

. Scaphoid excision and four-corner (capitate-lunate-hamate-triquetrum) fusion

Explanation

This patient has Scaphoid Nonunion Advanced Collapse (SNAC) stage III, characterized by radioscaphoid and capitolunate arthritis with a spared radiolunate joint. Proximal row carpectomy (PRC) is contraindicated in SNAC/SLAC stage III because it relies on articulating the proximal capitate with the lunate fossa; an arthritic capitate will result in continued pain and failure. Scaphoid excision and four-corner fusion eliminates the arthritic capitolunate and radioscaphoid joints while preserving functional motion through the intact radiolunate joint.

Question 3189

Topic: Wrist & Carpus

A 62-year-old woman presents with the sudden inability to bend the tip of her thumb. Twelve months prior, she underwent open reduction and internal fixation of a distal radius fracture with a volar locking plate. Lateral radiographs show the plate is positioned prominent and distal to the watershed line. Given the likely diagnosis, what is the most appropriate surgical treatment?

. Hardware removal and direct end-to-end repair of the ruptured tendon
. Hardware removal and transfer of the ring finger flexor digitorum superficialis (FDS) to the ruptured tendon
. Thumb interphalangeal (IP) joint arthrodesis
. Hardware removal and transfer of the extensor indicis proprius (EIP) to the ruptured tendon
. Hardware removal and tenolysis of the flexor pollicis longus (FPL)

Correct Answer & Explanation

. Hardware removal and transfer of the ring finger flexor digitorum superficialis (FDS) to the ruptured tendon

Explanation

The patient has a flexor pollicis longus (FPL) tendon rupture, a known complication of prominent volar hardware placed distal to the watershed line of the distal radius. Chronic attrition leads to rupture with retracted and degenerated tendon ends, precluding direct repair. The standard treatment is hardware removal and tendon transfer, most commonly utilizing the flexor digitorum superficialis (FDS) of the ring finger.

Question 3190

Topic: Nerve & Tendon

A 42-year-old mechanic complains of clumsiness, weakness in his grip, and numbness in his small and ring fingers. During physical examination, the examiner asks the patient to hold a piece of paper laterally between his thumb and index finger. As the examiner pulls the paper away, the patient strongly flexes the interphalangeal (IP) joint of his thumb. Which muscle is compensating to produce this clinical sign?

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

Correct Answer & Explanation

. Adductor pollicis

Explanation

This describes a positive Froment's sign, which tests for ulnar nerve palsy. The primary muscle for key pinch is the adductor pollicis (innervated by the ulnar nerve). When the adductor pollicis is weak, the patient compensates by hyperflexing the thumb interphalangeal (IP) joint using the flexor pollicis longus (FPL), which is innervated by the anterior interosseous nerve (AIN), a branch of the median nerve.

Question 3191

Topic: Nerve & Tendon

A 45-year-old male bodybuilder undergoes a single-incision anterior approach for the repair of a complete distal biceps tendon rupture. Postoperatively, he complains of numbness over the radial aspect of his forearm. Which nerve was most likely injured or stretched during the surgical exposure?

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

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve (LABCN)

Explanation

The lateral antebrachial cutaneous nerve (LABCN) is the most commonly injured nerve during a single-incision anterior approach for distal biceps repair. It runs superficially in the subcutaneous tissues on the lateral aspect of the anterior elbow and provides sensation to the radial forearm. The posterior interosseous nerve (PIN) is at higher risk during a two-incision approach or with deep retractor placement on the radial neck.

Question 3192

Topic: 7. Hand and Wrist
A 32-year-old male presents with chronic dorsal wrist pain and weakened grip strength. Radiographs reveal sclerosis, cystic changes, and early fragmentation of the lunate, consistent with Kienböck's disease (Lichtman Stage IIIA). Ulnar variance is measured at -3 mm. MRI confirms the articular cartilage of the radiocarpal and midcarpal joints remains intact. What is the most appropriate surgical intervention?
. Proximal row carpectomy
. Scaphoid-trapezium-trapezoid (STT) fusion
. Radial shortening osteotomy
. Capitate shortening osteotomy
. Lunate excision and silastic replacement

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

In Kienböck's disease with negative ulnar variance and intact carpal articular cartilage (Stage I to IIIA), joint-leveling procedures are indicated to mechanically unload the lunate. Radial shortening osteotomy is the gold standard and most reliable method to achieve this in the setting of ulnar minus variance. Capitate shortening is reserved for patients with neutral or positive ulnar variance.

Question 3193

Topic: Wrist & Carpus

A 22-year-old male presents with a proximal pole scaphoid fracture after a fall. Operative fixation is planned. Which of the following is true regarding the surgical approach and relevant anatomy for this specific fracture pattern?

. A volar approach is preferred to preserve the dorsal vascular supply.
. The blood supply to the proximal pole is direct from the superficial palmar arch.
. A dorsal approach allows for a screw trajectory perpendicular to the fracture and along the central axis of the scaphoid.
. A volar approach provides the most direct visualization of the proximal pole.
. The dorsal approach requires complete division of the radioscapholunate ligament.

Correct Answer & Explanation

. A dorsal approach allows for a screw trajectory perpendicular to the fracture and along the central axis of the scaphoid.

Explanation

Proximal pole scaphoid fractures are best approached dorsally. The blood supply to the scaphoid enters the dorsal ridge at the waist and flows in a retrograde fashion to the proximal pole. A dorsal approach, when done carefully, does not compromise this blood supply. More importantly, it provides direct access to the proximal pole, allowing for a screw trajectory that is parallel to the central axis of the scaphoid and perpendicular to the fracture plane, which maximizes biomechanical compression.

Question 3194

Topic: 7. Hand and Wrist

A 60-year-old woman sustained a nondisplaced distal radius fracture treated in a short arm cast. Six weeks later, she develops a sudden inability to actively extend her thumb interphalangeal joint. What is the most likely pathomechanism of this complication?

. Entrapment of the posterior interosseous nerve within the cast.
. Iatrogenic injury from a prominent screw.
. Subluxation of the extensor pollicis longus tendon from the Lister tubercle.
. Ischemic necrosis or mechanical attrition of the extensor pollicis longus tendon within the third extensor compartment.
. Avulsion of the extensor pollicis longus insertion at the distal phalanx.

Correct Answer & Explanation

. Ischemic necrosis or mechanical attrition of the extensor pollicis longus tendon within the third extensor compartment.

Explanation

Extensor pollicis longus (EPL) rupture is a known complication of nondisplaced distal radius fractures. The EPL tendon takes a sharp turn around Lister's tubercle and passes through a tight third extensor compartment. In nondisplaced fractures, the extensor retinaculum remains intact; combined with fracture hematoma, this increases the pressure within the compartment, leading to ischemic necrosis and mechanical attrition of the tendon. Treatment typically involves an extensor indicis proprius (EIP) to EPL tendon transfer.

Question 3195

Topic: 7. Hand and Wrist

A 45-year-old man undergoes repair of a distal biceps tendon rupture via a dorsal and volar two-incision technique. Postoperatively, he is unable to actively extend his fingers and thumb, but wrist extension is preserved with radial deviation. Which nerve is most likely injured, and what is its anatomic relationship in the forearm?

. Radial nerve; it runs deep to the brachioradialis.
. Posterior interosseous nerve; it passes between the superficial and deep heads of the supinator.
. Anterior interosseous nerve; it passes between the two heads of the pronator teres.
. Median nerve; it passes deep to the bicipital aponeurosis.
. Ulnar nerve; it passes between the two heads of the flexor carpi ulnaris.

Correct Answer & Explanation

. Posterior interosseous nerve; it passes between the superficial and deep heads of the supinator.

Explanation

The posterior interosseous nerve (PIN) is highly susceptible to injury during a two-incision distal biceps repair, particularly during the dorsal dissection or through injudicious retractor placement. The PIN enters the arcade of Frohse and travels between the superficial and deep heads of the supinator muscle. A PIN injury results in the inability to extend the fingers and thumb. Wrist extension is preserved but deviates radially because the extensor carpi radialis longus (ECRL) is innervated by the radial nerve proper proximal to the PIN branch.

Question 3196

Topic: 7. Hand and Wrist
A 55-year-old manual laborer presents with chronic, progressively worsening radial-sided wrist pain. Radiographs demonstrate advanced narrowing of the radioscaphoid joint and capitulolunate joint, with a preserved radiolunate joint. Which of the following is the most appropriate surgical treatment?
. Proximal row carpectomy (PRC)
. Scaphoid excision and four-corner arthrodesis
. Radioscapholunate arthrodesis
. Total wrist arthrodesis
. Scaphotrapezialtrapezoid (STT) arthrodesis

Correct Answer & Explanation

. Scaphoid excision and four-corner arthrodesis

Explanation

The patient has Stage III Scapholunate Advanced Collapse (SLAC) wrist, characterized by radioscaphoid and midcarpal (capitolunate) arthritis, while characteristically sparing the radiolunate joint. A proximal row carpectomy (PRC) is contraindicated in Stage III SLAC because the capitate head is arthritic and cannot smoothly articulate with the lunate fossa. Therefore, scaphoid excision with four-corner (capitate, hamate, lunate, triquetrum) arthrodesis is the most appropriate motion-preserving surgical treatment.

Question 3197

Topic: 7. Hand and Wrist
A 28-year-old carpenter presents with dorsal wrist pain. MRI confirms osteonecrosis of the lunate. Radiographs demonstrate lunate sclerosis and fragmentation, but the carpal height ratio is preserved and there is no radioscaphoid arthritis. Ulnar variance is -3 mm. Which of the following is the most appropriate operative intervention?
. Proximal row carpectomy
. Lunate excision and four-corner arthrodesis
. Radial shortening osteotomy
. Total wrist arthrodesis
. Ulnar lengthening osteotomy

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

This patient has Lichtman Stage IIIa Kienböck's disease (lunate fragmentation without fixed scaphoid rotation or carpal collapse). In the presence of ulnar minus variance, a joint-leveling procedure such as a radial shortening osteotomy is indicated. This procedure unloads the lunate by shifting compressive forces to the ulnocarpal joint, preventing further collapse. Ulnar lengthening is associated with higher nonunion rates. Salvage procedures like PRC or intercarpal fusions are reserved for Stage IIIb or IV disease.

Question 3198

Topic: Nerve & Tendon

A 45-year-old diabetic man presents with persistent ulnar neuropathy 6 months after an in situ ulnar nerve decompression at the cubital tunnel. EMG shows active denervation in the abductor digiti minimi. During revision surgery, the nerve is embedded in dense scar tissue and subluxates anteriorly with elbow flexion. Which of the following is the most appropriate next step?

. Repeat in situ decompression and medial epicondylectomy
. Subcutaneous ulnar nerve transposition
. Guyon's canal release
. Submuscular ulnar nerve transposition
. Intermuscular ulnar nerve transposition

Correct Answer & Explanation

. Submuscular ulnar nerve transposition

Explanation

In the setting of revision cubital tunnel surgery, especially when the ulnar nerve is embedded in scar tissue and demonstrating subluxation, a submuscular transposition is widely considered the procedure of choice. It moves the nerve out of the scarred, poorly vascularized primary surgical bed and places it in a healthy, well-vascularized environment deep to the flexor-pronator mass, simultaneously correcting the dynamic subluxation.

Question 3199

Topic: 7. Hand and Wrist

A 24-year-old man falls on an outstretched hand. Initial radiographs are negative, but an MRI obtained 2 weeks later confirms a non-displaced proximal pole scaphoid fracture. Due to the high risk of nonunion, surgical fixation is recommended. The blood supply to the proximal pole of the scaphoid is primarily derived from branches of which of the following arteries?

. Ulnar artery
. Anterior interosseous artery
. Posterior interosseous artery
. Radial artery
. Superficial palmar arch

Correct Answer & Explanation

. Radial artery

Explanation

The scaphoid receives its primary blood supply from the dorsal carpal branch of the radial artery, which enters at the waist and courses in a retrograde fashion to the proximal pole. Fractures of the proximal pole disrupt this delicate supply, placing it at a high risk for avascular necrosis and nonunion.

Question 3200

Topic: 7. Hand and Wrist

A 24-year-old man falls on an outstretched hand and sustains a fracture of the scaphoid. The fracture line passes through the proximal pole. He is at high risk for avascular necrosis due to the unique blood supply of the scaphoid. The predominant blood supply to the proximal pole is derived from a retrograde flow pattern originating from which of the following vessels?

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

Correct Answer & Explanation

. Dorsal carpal branch of the radial artery

Explanation

The scaphoid receives its primary blood supply from the dorsal carpal branch of the radial artery, which enters the bone distally at the dorsal ridge and supplies the proximal 70-80% of the bone via retrograde flow. A fracture through the proximal pole disrupts this retrograde supply, placing the proximal fragment at a very high risk of avascular necrosis and nonunion.

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