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7. Hand and Wrist MCQs

Practice Set 161 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 3201

Topic: Wrist & Carpus

A 55-year-old woman presents with sudden inability to actively flex the interphalangeal joint of her right thumb. She underwent open reduction and internal fixation of a right distal radius fracture with a volar locking plate 4 years ago. Radiographs show the plate is positioned distally, overriding the watershed line. Which of the following is the most appropriate definitive management for her current condition?

. Flexor pollicis longus primary repair
. Flexor digitorum superficialis to flexor pollicis longus tendon transfer
. Flexor digitorum profundus to flexor pollicis longus tendon transfer
. Extensor indicis proprius to flexor pollicis longus tendon transfer
. Thumb interphalangeal joint arthrodesis

Correct Answer & Explanation

. Flexor digitorum superficialis to flexor pollicis longus tendon transfer

Explanation

The patient has a rupture of the Flexor Pollicis Longus (FPL) tendon, a known complication of volar plating of the distal radius when the plate is placed distal to the watershed line, leading to attrition over the hardware. Because the rupture often presents late with tendon retraction and poor tissue quality, primary repair is usually impossible. The standard treatment is hardware removal and a tendon transfer, most commonly using the Flexor Digitorum Superficialis (FDS) of the ring or middle finger to restore FPL function.

Question 3202

Topic: 7. Hand and Wrist

A 28-year-old mechanic complains of an inability to pinch objects using his right thumb and index finger. On examination, when asked to make an 'OK' sign, he compensates by using the pulps of his thumb and index finger rather than the tips, resulting in a flat pinch. Sensation in the hand is completely normal. Which of the following muscles is most likely paralyzed?

. Flexor digitorum superficialis
. Adductor pollicis
. Flexor pollicis longus
. Abductor pollicis brevis
. Extensor pollicis longus

Correct Answer & Explanation

. Flexor pollicis longus

Explanation

The patient's clinical presentation is classic for Anterior Interosseous Nerve (AIN) syndrome, characterized by a pure motor palsy. The AIN innervates the flexor pollicis longus (FPL), the radial half of the flexor digitorum profundus (FDP), and the pronator quadratus. Paralysis of the FPL and FDP to the index finger leads to an inability to flex the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger, resulting in the characteristic abnormal 'OK' sign (positive Kiloh-Nevin sign). Sensation is spared because the AIN carries no cutaneous sensory fibers.

Question 3203

Topic: 7. Hand and Wrist
A 28-year-old laborer presents with progressive dorsal radial wrist pain 3 years after a fall. He did not seek medical attention initially. Radiographs and an MRI confirm a scaphoid waist nonunion with radioscaphoid arthritis and capitolunate arthritis, but the radiolunate joint is preserved. What is the most appropriate surgical treatment?
. Scaphoid open reduction internal fixation with vascularized bone graft
. Proximal row carpectomy (PRC)
. Scaphoid excision and four-corner arthrodesis
. Total wrist arthrodesis
. Radial styloidectomy

Correct Answer & Explanation

. Scaphoid excision and four-corner arthrodesis

Explanation

The clinical scenario describes Scaphoid Nonunion Advanced Collapse (SNAC) stage III, which involves arthritis of the radioscaphoid and capitolunate joints with a preserved radiolunate joint. Proximal row carpectomy (PRC) is contraindicated when there is significant arthritis of the capitate head (capitolunate joint). Therefore, the most appropriate salvage procedure is scaphoid excision and four-corner (capitate, lunate, hamate, triquetrum) arthrodesis, which relies on the preserved radiolunate articulation to maintain functional wrist motion.

Question 3204

Topic: Nerve & Tendon

A 55-year-old male complains of numbness and tingling in his small and ring fingers that awakens him at night. Examination shows a positive Tinel's sign at the elbow and a positive Froment's sign. He has clinically palpable snapping over the medial epicondyle during elbow flexion. Electrodiagnostic studies confirm severe ulnar neuropathy at the elbow. He fails a 6-month trial of conservative management.

What is the primary indication for choosing an anterior transposition of the ulnar nerve over an in situ decompression in this patient?

. Decreased risk of postoperative neuroma formation
. Improved long-term electrodiagnostic outcomes in severe neuropathy
. Prevention of nerve subluxation
. Faster return to heavy manual labor
. Reduced risk of injury to the medial antebrachial cutaneous nerve

Correct Answer & Explanation

. Prevention of nerve subluxation

Explanation

Randomized controlled trials have generally shown no significant difference in clinical outcomes between simple in situ decompression and anterior transposition for the treatment of primary cubital tunnel syndrome. However, anterior transposition is specifically indicated in patients with a subluxating ulnar nerve, a valgus deformity of the elbow, or post-traumatic stiffness requiring a tension-free route. In this patient, the palpable snapping over the medial epicondyle indicates nerve subluxation, dictating an anterior transposition to prevent ongoing mechanical irritation.

Question 3205

Topic: 7. Hand and Wrist
A 35-year-old mechanic presents with chronic, progressive dorsal wrist pain and decreased grip strength. Imaging demonstrates sclerosis and fragmentation of the lunate with negative ulnar variance, but no fixed carpal collapse (Lichtman Stage IIIA). What is the most appropriate initial surgical intervention?
. Proximal row carpectomy
. Radial shortening osteotomy
. Scaphoid-trapezium-trapezoid (STT) arthrodesis
. Total wrist arthrodesis
. Lunate excision and silastic replacement

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

The presentation is classic for Kienböck's disease (avascular necrosis of the lunate). For Lichtman Stage II or IIIA (fragmentation without fixed scaphoid rotation or carpal collapse) associated with negative ulnar variance, joint-leveling procedures are the treatment of choice. A radial shortening osteotomy unloads the lunate by shifting compressive forces to the ulnocarpal articulation, potentially halting disease progression in the early stages.

Question 3206

Topic: 7. Hand and Wrist

A 65-year-old woman sustains a distal radius fracture. The lateral radiograph (Figure 3) demonstrates a volarly displaced fracture fragment of the lunate facet ("volar teardrop"). Failure to adequately stabilize this specific fragment is most likely to result in which of the following complications?

. Extensor pollicis longus tendon rupture
. Flexor pollicis longus tendon rupture
. Volar carpal subluxation
. Dorsal carpal subluxation
. Distal radioulnar joint arthritis

Correct Answer & Explanation

. Volar carpal subluxation

Explanation

The volar lunate facet fragment ("volar teardrop") is a critical stabilizing structure of the radiocarpal joint because the short radiolunate ligament originates from this fragment. Failure to capture and stabilize this fragment (often requiring fragment-specific fixation if standard volar plates do not securely capture it) can lead to volar subluxation of the carpus.

Question 3207

Topic: Nerve & Tendon

A 22-year-old collegiate baseball pitcher undergoes ulnar collateral ligament (UCL) reconstruction using a palmaris longus autograft. To minimize the risk of postoperative ulnar neuropathy, which of the following techniques or principles is recommended during the surgical approach?

. Routine subcutaneous transposition of the ulnar nerve
. Routine submuscular transposition of the ulnar nerve
. Splitting the flexor carpi ulnaris (FCU) muscle longitudinally
. Avoiding the use of a tourniquet
. Detaching the common flexor origin from the medial epicondyle

Correct Answer & Explanation

. Splitting the flexor carpi ulnaris (FCU) muscle longitudinally

Explanation

A muscle-splitting approach through the flexor carpi ulnaris (FCU) provides excellent exposure to the sublime tubercle and the native UCL while minimizing trauma to the ulnar nerve. Routine transposition of the ulnar nerve is not recommended unless there are preoperative ulnar nerve symptoms or the nerve subluxates during surgery, as transposition can paradoxically increase the risk of postoperative ulnar neuropathy.

Question 3208

Topic: 7. Hand and Wrist
A 35-year-old manual laborer presents with chronic radial-sided wrist pain that is exacerbated by heavy lifting. He reports a history of falling onto an outstretched hand 2 years ago, for which he did not seek medical attention. Radiographs reveal a scaphoid nonunion with advanced degenerative changes at both the radioscaphoid and capitolunate joints. The radiolunate joint space is well preserved. What is the most appropriate surgical management for this patient?
. Total wrist arthrodesis
. Proximal row carpectomy
. Radial styloidectomy
. Scaphoid excision and four-corner arthrodesis
. Open reduction internal fixation with vascularized bone grafting of the scaphoid

Correct Answer & Explanation

. Scaphoid excision and four-corner arthrodesis

Explanation

This patient has Scaphoid Nonunion Advanced Collapse (SNAC) Stage III, which is characterized by arthritic changes extending to the capitolunate joint, while sparing the radiolunate joint. Proximal row carpectomy (PRC) is contraindicated in SNAC Stage III because successful PRC requires a pristine capitate head to articulate with the lunate fossa of the radius. Therefore, scaphoid excision and four-corner (capitate, lunate, hamate, triquetrum) arthrodesis is the most appropriate management. Radial styloidectomy is reserved for SNAC Stage I, and total wrist arthrodesis is indicated for SNAC Stage IV (pancarpal arthritis).

Question 3209

Topic: Nerve & Tendon

A 45-year-old mechanic presents with a 6-month history of numbness and tingling in his ring and small fingers, which worsens when he keeps his elbow flexed during telephone calls. Examination shows a strongly positive Tinel's sign over the posteromedial elbow and a positive Froment's sign. Electromyography confirms severe ulnar neuropathy isolated to the elbow. During a surgical ulnar nerve release, the primary site of compression is identified between the humeral and ulnar heads of the flexor carpi ulnaris (FCU). What anatomical structure forms the roof of this specific compression site?

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

Correct Answer & Explanation

. Osborne's ligament

Explanation

The ulnar nerve can be compressed at several distinct sites around the elbow, most commonly at the cubital tunnel. The cubital tunnel itself is bordered by the medial epicondyle anteriorly, the olecranon laterally, and the two heads of the flexor carpi ulnaris (FCU) distally. The roof of the tunnel, which connects the humeral and ulnar heads of the FCU, is formed by Osborne's ligament (or Osborne's fascia). The Arcade of Struthers is a fascial band proximal to the medial epicondyle. The Ligament of Struthers and the Lacertus fibrosus are associated with median nerve compression.

Question 3210

Topic: Nerve & Tendon

A 28-year-old competitive weightlifter complains of painful snapping on the medial aspect of his dominant right elbow when performing triceps extensions. Physical examination reveals a palpable snap over the medial epicondyle during active elbow flexion and extension. Dynamic ultrasound confirms the diagnosis of snapping triceps syndrome. What is the most common anatomical variant associated with this condition?

. Accessory anconeus epitrochlearis muscle
. Hypertrophy of the medial head of the triceps
. Osborne's ligament hypertrophy
. Arcade of Struthers thickening
. Medial collateral ligament insufficiency

Correct Answer & Explanation

. Hypertrophy of the medial head of the triceps

Explanation

Snapping triceps syndrome is characterized by the concurrent subluxation of the ulnar nerve and the medial head of the triceps over the medial epicondyle during elbow flexion. It is most commonly associated with hypertrophy of the medial head of the triceps, often seen in weightlifters or manual laborers. It must be differentiated from isolated ulnar nerve subluxation to ensure both pathologies are addressed surgically if conservative measures fail.

Question 3211

Topic: 7. Hand and Wrist

A 24-year-old male presents with chronic radial-sided wrist pain. He sustained a hyperextension injury to his wrist 2 years ago but did not seek medical treatment. Radiographs reveal a scaphoid waist nonunion with a "humpback" deformity and a dorsal intercalated segment instability (DISI) pattern. There is no radiographic evidence of radiocarpal arthritis. Which of the following is the most appropriate surgical treatment?

. Percutaneous headless compression screw fixation
. Proximal row carpectomy
. Volar wedge bone grafting and internal fixation
. Scaphoid excision and four-corner fusion
. Dorsal vascularized bone graft (1,2 ICSRA)

Correct Answer & Explanation

. Volar wedge bone grafting and internal fixation

Explanation

A scaphoid nonunion with a "humpback" deformity (volar angulation of the scaphoid) and a resulting DISI posture indicates a collapse of the normal carpal architecture. To correct the deformity and restore carpal kinematics, a volar approach with a structural wedge bone graft (usually from the iliac crest) and internal fixation is required. Salvage procedures (PRC or 4-corner fusion) are reserved for cases with established radiocarpal arthritis (SNAC wrist).

Question 3212

Topic: Wrist & Carpus

A 62-year-old female who was treated nonoperatively for a nondisplaced distal radius fracture presents 6 weeks post-injury with a sudden inability to actively extend her right thumb. Examination reveals a lack of active retropulsion of the thumb, but she is able to extend the interphalangeal joint when the thumb is held in adduction. Which of the following is the most appropriate surgical intervention?

. Primary end-to-end repair of the extensor pollicis longus (EPL)
. Extensor indicis proprius (EIP) to EPL tendon transfer
. Extensor carpi radialis longus (ECRL) to EPL tendon transfer
. Flexor digitorum superficialis (FDS) to EPL tendon transfer
. Tenolysis and corticosteroid injection

Correct Answer & Explanation

. Extensor indicis proprius (EIP) to EPL tendon transfer

Explanation

Extensor pollicis longus (EPL) rupture is a classic complication following distal radius fractures, particularly those treated nonoperatively. The rupture is typically due to attrition over the bony callus or ischemia within the third dorsal compartment. Because the tendon ends are usually retracted and degenerated, primary end-to-end repair is rarely feasible. The standard of care is a tendon transfer, with the extensor indicis proprius (EIP) to EPL transfer being the most common and reliable procedure.

Question 3213

Topic: Nerve & Tendon

A 58-year-old woman with a history of poorly controlled type 2 diabetes mellitus presents with a locked trigger finger of the right ring finger. She has had no prior treatments. Which of the following statements regarding the management of trigger finger in diabetic patients is most accurate?

. Corticosteroid injections are equally effective in diabetic and non-diabetic patients.
. Surgical release of the A1 pulley is strictly contraindicated due to infection risk.
. Diabetic patients have a higher rate of treatment failure following single or multiple corticosteroid injections compared to non-diabetic patients.
. Percutaneous A1 pulley release is universally the preferred initial treatment over injections.
. Trigger finger in diabetics is most commonly isolated to a single digit over their lifetime.

Correct Answer & Explanation

. Diabetic patients have a higher rate of treatment failure following single or multiple corticosteroid injections compared to non-diabetic patients.

Explanation

Diabetic patients with trigger finger (stenosing tenosynovitis) tend to have a more recalcitrant disease course than non-diabetics. Extensive literature demonstrates that diabetic patients have a significantly higher rate of treatment failure with corticosteroid injections and are more likely to eventually require surgical release of the A1 pulley. They also have a higher incidence of multiple digit involvement. Despite the higher failure rate, an initial injection is still often utilized, but patients should be counseled on the increased likelihood of needing surgery.

Question 3214

Topic: Wrist & Carpus

A 65-year-old woman presents with the sudden inability to extend her thumb. She reports that 5 weeks ago she sustained a nondisplaced distal radius fracture, which was treated nonoperatively in a short arm cast. Physical examination reveals an inability to retro-extend the thumb at the interphalangeal joint, but tenodesis effect is intact. What is the most appropriate surgical management?

. Observation and physical therapy
. 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
. Interposition tendon grafting using the palmaris longus

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 nondisplaced distal radius fractures. The rupture typically occurs at Lister's tubercle due to a combination of mechanical attrition and vascular ischemia within the intact third extensor compartment. Because of the delay in presentation and degeneration of the tendon ends, primary end-to-end repair is usually impossible. The gold standard treatment is a tendon transfer utilizing the extensor indicis proprius (EIP).

Question 3215

Topic: 7. Hand and Wrist
A 32-year-old carpenter presents with a 6-month history of dorsal wrist pain and decreased grip strength. Radiographs reveal sclerosis, cystic changes, and early fragmentation of the lunate, without carpal collapse. Ulnar variance is noted to be negative 2 mm. Which of the following is the most appropriate surgical intervention?
. Proximal row carpectomy
. Radial shortening osteotomy
. Capitate shortening osteotomy
. Scaphoid-trapezium-trapezoid (STT) fusion
. Lunate excision and silastic replacement

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

The patient has Kienböck's disease (avascular necrosis of the lunate) stage IIIa (sclerosis and fragmentation without carpal collapse or scaphoid rotation). In a patient with negative ulnar variance and an intact carpal architecture (stages I, II, and IIIa), a joint-leveling procedure such as a radial shortening osteotomy or ulnar lengthening is indicated to biomechanically unload the lunate. Proximal row carpectomy or intercarpal fusions are reserved for more advanced stages (IIIb or IV) with carpal collapse or arthritis.

Question 3216

Topic: 7. Hand and Wrist

A 24-year-old man presents with chronic radial-sided wrist pain following a fall onto an outstretched hand one year ago. Imaging confirms a nonunion of the proximal pole of the scaphoid with avascular necrosis, but no radiocarpal arthritis is present. The surgeon elects to perform a pedicled vascularized bone graft based on the 1,2 intercompartmental supraretinacular artery (1,2 ICSRA). From which anatomic location is this graft harvested?

. Volar distal radius
. Dorsal distal radius
. Base of the second metacarpal
. Medial femoral condyle
. Iliac crest

Correct Answer & Explanation

. Dorsal distal radius

Explanation

The 1,2 intercompartmental supraretinacular artery (1,2 ICSRA) vascularized bone graft is harvested from the dorsal aspect of the distal radius. It utilizes a pedicle located between the first and second extensor compartments. It is a well-described option for the treatment of scaphoid proximal pole nonunions complicated by avascular necrosis. The medial femoral condyle is used for free vascularized bone grafting, not a local pedicled flap.

Question 3217

Topic: Nerve & Tendon

During a routine in situ ulnar nerve decompression for cubital tunnel syndrome, the surgeon must systematically evaluate and release potential sites of nerve compression. Which of the following structures represents the most proximal potential site of ulnar nerve entrapment?

. Arcade of Struthers
. Osborne's ligament
. Medial intermuscular septum
. Aponeurosis of the flexor carpi ulnaris (FCU)
. Anconeus epitrochlearis

Correct Answer & Explanation

. Arcade of Struthers

Explanation

The ulnar nerve can be compressed at several sites around the elbow. From proximal to distal, these sites are: the arcade of Struthers (a fascial band extending from the medial intermuscular septum to the medial head of the triceps, located about 8 cm proximal to the medial epicondyle), the medial intermuscular septum, the medial epicondyle, Osborne's ligament (the retinaculum forming the roof of the cubital tunnel), and the aponeurosis of the two heads of the flexor carpi ulnaris (FCU). Therefore, the arcade of Struthers is the most proximal site.

Question 3218

Topic: Wrist & Carpus

A 65-year-old woman undergoes volar locked plating for a displaced intra-articular distal radius fracture. Postoperative lateral radiographs demonstrate that the plate is positioned distally, bridging the watershed line. Three months postoperatively, she presents with an inability to actively flex the interphalangeal joint of her thumb. Which of the following is the most likely cause of her current presentation?

. Rupture of the flexor pollicis longus (FPL) tendon due to plate prominence
. Iatrogenic anterior interosseous nerve injury during the surgical approach
. Adhesion of the FPL tendon to the pronator quadratus
. Extensor pollicis longus (EPL) rupture secondary to dorsal screw penetration
. Unrecognized concomitant FPL laceration at the time of the initial injury

Correct Answer & Explanation

. Rupture of the flexor pollicis longus (FPL) tendon due to plate prominence

Explanation

The watershed line is a critical anatomic landmark for volar plating of distal radius fractures. Plates placed distal to this line become prominent and impinge on the flexor tendons, particularly the flexor pollicis longus (FPL), leading to attrition and secondary rupture. Soong et al. classified volar plate position relative to the watershed line, with grade 2 (plate completely distal to the watershed line) having the highest risk of FPL rupture. Dorsal screw penetration is a well-known risk for EPL rupture, not FPL.

Question 3219

Topic: 7. Hand and Wrist

In the surgical management of recalcitrant trigger finger (stenosing tenosynovitis) in the middle digit, the primary structure targeted for release is the A1 pulley. During this procedure, great care must be taken to avoid violating the adjacent A2 pulley. What is the primary biomechanical consequence of a complete iatrogenic transection of the A2 pulley?

. Rotational deformity of the digit during active flexion
. Subluxation of the central slip of the extensor mechanism
. Bowstringing of the flexor tendons and subsequent loss of grip strength
. Development of a rigid swan neck deformity
. Quadriga effect during composite fist formation

Correct Answer & Explanation

. Bowstringing of the flexor tendons and subsequent loss of grip strength

Explanation

The flexor tendon pulley system of the hand consists of annular and cruciate pulleys that keep the flexor tendons closely applied to the phalanges. The A2 (located over the proximal phalanx) and A4 (over the middle phalanx) pulleys are the most critical mechanically. Complete release or rupture of the A2 pulley results in 'bowstringing' of the flexor tendons away from the axis of rotation during active flexion. While this increases the tendon's moment arm, it significantly limits the active range of motion and decreases overall grip strength, as a large amount of tendon excursion is wasted in pulling the tendon away from the bone rather than flexing the joint.

Question 3220

Topic: 7. Hand and Wrist

A 55-year-old carpenter presents with progressive numbness and tingling in his small and ring fingers of his right hand, along with clumsiness when handling small tools. Examination reveals intrinsic muscle wasting and a positive Froment's sign. Which of the following findings would differentiate a compressive neuropathy at the cubital tunnel from one at Guyon's canal?

. Weakness of the adductor pollicis
. Sensory loss over the volar aspect of the little finger
. Sensory loss over the dorsal ulnar aspect of the hand
. The presence of Wartenberg's sign
. Atrophy of the first dorsal interosseous muscle

Correct Answer & Explanation

. Sensory loss over the dorsal ulnar aspect of the hand

Explanation

The dorsal ulnar cutaneous nerve branches off the main ulnar nerve approximately 5 to 8 cm proximal to the wrist joint and provides sensation to the dorsoulnar aspect of the hand. A compressive ulnar neuropathy at the elbow (cubital tunnel syndrome) will affect this branch, resulting in sensory loss over the dorsal ulnar hand. In contrast, compression at Guyon's canal (at the wrist) occurs distal to the takeoff of the dorsal ulnar cutaneous nerve, thereby sparing dorsal ulnar sensation. Both compression sites can cause intrinsic muscle wasting, a positive Froment's sign, Wartenberg's sign, and volar sensory loss in the ulnar digits.

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