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7. Hand and Wrist MCQs

Practice Set 162 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 3221

Topic: 7. Hand and Wrist

A 32-year-old basketball player presents with a 'dropped' distal phalanx of his long finger after the ball struck the tip of his extended finger. Radiographs show a small dorsal avulsion fracture of the distal phalanx involving 15% of the articular surface with no volar subluxation. Nonoperative management is chosen. What is the most appropriate splinting protocol for this Zone I extensor tendon injury?

. Continuous splinting of the DIP and PIP joints in extension for 6 weeks
. Continuous splinting of the DIP joint in extension for 6 to 8 weeks, leaving the PIP joint free
. Splinting of the DIP joint in extension for 3 weeks, followed by nighttime splinting only
. Splinting of the DIP joint in slight flexion to approximate the fracture fragments
. Dynamic extension splinting of the entire digit for 6 weeks

Correct Answer & Explanation

. Continuous splinting of the DIP joint in extension for 6 to 8 weeks, leaving the PIP joint free

Explanation

Mallet finger injuries (Zone I extensor tendon injuries) with or without a small avulsion fracture (less than 30% to 50% of the articular surface and without volar subluxation) are best treated nonoperatively. The standard protocol involves continuous, uninterrupted splinting of the distal interphalangeal (DIP) joint in extension (or slight hyperextension) for 6 to 8 weeks. The proximal interphalangeal (PIP) joint must be left free to allow active motion and prevent stiffness. If the splint is removed and the distal phalanx is allowed to flex at any point during this period, the healing tissue is disrupted, and the 6-to-8-week clock must be restarted.

Question 3222

Topic: Wrist & Carpus

A 58-year-old woman undergoes volar locked plating for a displaced distal radius fracture. Six months postoperatively, she presents with a sudden inability to actively flex the interphalangeal joint of her thumb. Radiographs demonstrate that the volar plate is positioned distal to the watershed line. Which of the following is the most likely mechanism for her current deficit?

. Attritional rupture of the flexor pollicis longus tendon
. Compression of the anterior interosseous nerve
. Avulsion of the flexor pollicis brevis
. Rupture of the extensor pollicis longus tendon
. Nonunion of the distal radius fracture

Correct Answer & Explanation

. Attritional rupture of the flexor pollicis longus tendon

Explanation

Placement of a volar plate distal to the watershed line of the distal radius increases the risk of flexor tendon irritation and subsequent attritional rupture. The flexor pollicis longus (FPL) tendon is the most commonly affected due to its close anatomical proximity to the prominent distal edge of the plate. Treatment typically involves plate removal and tendon transfer (e.g., brachioradialis or FDS to FPL) or grafting.

Question 3223

Topic: Nerve & Tendon

A 48-year-old typist presents with numbness in his small and ring fingers. Examination reveals a positive Tinel's sign at the cubital tunnel and weakness in finger abduction. EMG confirms severe ulnar neuropathy at the elbow. During a submuscular ulnar nerve transposition, which of the following fascial structures represents a potential site of nerve compression that MUST be released to prevent postoperative failure?

. Ligament of Struthers
. Lacertus fibrosus
. Arcade of Frohse
. Arcade of Struthers
. Oblique cord

Correct Answer & Explanation

. Arcade of Struthers

Explanation

During an ulnar nerve transposition, it is critical to release all potential sites of compression. These sites include the Arcade of Struthers (a fascial band extending from the medial intermuscular septum to the medial head of the triceps), the medial intermuscular septum, Osborne's ligament, and the deep flexor-pronator aponeurosis. The Ligament of Struthers and Lacertus fibrosus compress the median nerve. The Arcade of Frohse compresses the posterior interosseous nerve.

Question 3224

Topic: 7. Hand and Wrist

A 25-year-old man presents with chronic wrist pain. Radiographs reveal a scaphoid waist nonunion with a 'humpback' deformity (volar angulation) and a dorsal intercalated segment instability (DISI) pattern. There is no midcarpal arthritis. Which of the following is the most appropriate surgical management to restore carpal alignment and heal the nonunion?

. Scaphoid excision and four-corner fusion
. Proximal row carpectomy
. Volar wedge grafting and screw fixation
. Vascularized bone graft from the 1,2 ICSRA via a dorsal approach
. Percutaneous headless compression screw fixation without grafting

Correct Answer & Explanation

. Volar wedge grafting and screw fixation

Explanation

A scaphoid nonunion with a 'humpback' deformity requires correction of the scaphoid alignment to restore normal carpal kinematics and treat the DISI posture. This is best achieved using a volar approach, inserting an anterior (volar) wedge graft combined with rigid internal fixation. A dorsal approach with 1,2 ICSRA graft cannot easily correct significant volar angulation. Proximal row carpectomy or four-corner fusions are salvage operations for SNAC arthritis.

Question 3225

Topic: 7. Hand and Wrist
A 62-year-old woman presents with debilitating pain at the base of her thumb, unresponsive to conservative care. Radiographs demonstrate Eaton-Littler Stage III advanced trapeziometacarpal joint arthritis with complete loss of joint space and subluxation. Which of the following surgical procedures provides the most reliable long-term pain relief and functional restoration for this specific presentation?
. First metacarpal extension osteotomy
. Arthroscopic joint debridement
. Trapeziectomy with or without ligament reconstruction and tendon interposition (LRTI)
. Metacarpophalangeal (MCP) joint arthrodesis
. Silicone implant arthroplasty

Correct Answer & Explanation

. Trapeziectomy with or without ligament reconstruction and tendon interposition (LRTI)

Explanation

Trapeziectomy, with or without ligament reconstruction and tendon interposition (LRTI), is the most commonly performed and reliable procedure for advanced (Eaton-Littler Stage III or IV) thumb carpometacarpal (CMC) arthritis. Metacarpal osteotomy is indicated for early-stage disease (Stage I or II). MCP arthrodesis does not address CMC joint pathology, though it may be an adjunct if hyperextension instability is present.

Question 3226

Topic: 7. Hand and Wrist
A 32-year-old carpenter presents with dorsal wrist pain and decreased grip strength. Radiographs reveal sclerosis and fragmentation of the lunate (Lichtman stage IIIA). Ulnar variance is measured at -3 mm. Which of the following is the most appropriate initial surgical treatment?
. Proximal row carpectomy
. Radial shortening osteotomy
. Ulnar lengthening osteotomy
. Scaphoid-trapezium-trapezoid (STT) arthrodesis
. Total wrist arthrodesis

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

This patient has Lichtman stage IIIA Kienböck's disease and ulnar minus variance. Joint-leveling procedures are indicated to decrease the compressive forces across the radiolunate joint. Radial shortening osteotomy is the preferred and most reliable joint-leveling procedure due to a high union rate. Ulnar lengthening is associated with a higher risk of nonunion. PRC or wrist fusion are reserved for stage IV disease with extensive carpal arthritis.

Question 3227

Topic: Nerve & Tendon

A 45-year-old carpenter presents with numbness and tingling in his small and ring fingers, which is exacerbated by prolonged elbow flexion. Electrodiagnostic studies confirm isolated ulnar neuropathy at the elbow. Which of the following is the most common site of ulnar nerve compression in this condition?

. Arcade of Struthers
. Medial intermuscular septum
. Osborne's ligament (cubital tunnel retinaculum)
. Deep flexor pronator aponeurosis
. Guyon's canal

Correct Answer & Explanation

. Osborne's ligament (cubital tunnel retinaculum)

Explanation

The most common site of ulnar nerve compression at the elbow is between the two heads of the flexor carpi ulnaris (FCU), specifically under Osborne's ligament (the cubital tunnel retinaculum). Compression can also occur at the arcade of Struthers, medial intermuscular septum, or deep flexor pronator aponeurosis, but Osborne's ligament is statistically the most frequent location.

Question 3228

Topic: Wrist & Carpus

A 62-year-old woman sustained a minimally displaced distal radius fracture treated nonoperatively in a short arm cast for 6 weeks. Three weeks after cast removal, she suddenly loses the ability to actively extend her thumb interphalangeal joint. She denies any new trauma. What is the most appropriate management?

. Primary repair of the ruptured tendon
. Extensor indicis proprius (EIP) to extensor pollicis longus (EPL) tendon transfer
. Flexor digitorum superficialis (FDS) to EPL tendon transfer
. Splinting for 6 weeks followed by occupational therapy
. Corticosteroid injection into the third dorsal compartment

Correct Answer & Explanation

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

Explanation

Extensor pollicis longus (EPL) tendon ruptures typically occur 3 to 8 weeks after minimally displaced distal radius fractures. This is due to ischemia or mechanical attrition at the Lister tubercle. Because the tendon ends retract and undergo necrosis, primary repair is usually not possible. An EIP to EPL tendon transfer is the gold standard surgical treatment, providing an expendable donor with a matching vector and excursion.

Question 3229

Topic: 7. Hand and Wrist
A 32-year-old carpenter presents with dorsal wrist pain and decreased grip strength. Radiographs reveal sclerosis and early fragmentation of the lunate, but the carpal height is maintained. An MRI confirms avascular necrosis of the lunate. Radiographs confirm an ulnar variance of negative 2 mm. What is the most appropriate surgical intervention?
. Proximal row carpectomy
. Total wrist arthrodesis
. Radial shortening osteotomy
. Ulnar lengthening osteotomy
. Lunate excision and silastic replacement

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

The patient has Lichtman Stage IIIa Kienböck disease (fragmentation of the lunate but maintained carpal height) and ulnar negative variance. A joint-leveling procedure, specifically a radial shortening osteotomy, is indicated to offload the lunate and shift loads to the radioulnar joint. Ulnar lengthening is rarely performed due to higher nonunion rates.

Question 3230

Topic: 7. Hand and Wrist

During an open carpal tunnel release, the surgeon must carefully identify and protect the recurrent motor branch of the median nerve. In the most common anatomical variation (Lanz Group 1), how does the recurrent motor branch exit the median nerve in relation to the transverse carpal ligament (TCL)?

. Pre-ligamentous (proximal to the TCL)
. Sub-ligamentous (within the carpal tunnel and courses under the TCL)
. Trans-ligamentous (piercing directly through the TCL)
. Post-ligamentous (extraligamentous, branching distal to the TCL and coursing recurrently)
. Ulnarward exiting (from the ulnar side of the median nerve)

Correct Answer & Explanation

. Post-ligamentous (extraligamentous, branching distal to the TCL and coursing recurrently)

Explanation

According to the Lanz classification of the median nerve motor branch, the extraligamentous (post-ligamentous) pattern is the most common (approximately 46-90%). In this variation, the nerve branches from the radial aspect of the median nerve distal to the transverse carpal ligament and courses recurrently to innervate the thenar musculature.

Question 3231

Topic: Wrist & Carpus

A 55-year-old woman presents with the inability to actively flex the interphalangeal joint of her right thumb 8 months after undergoing volar locked plating for a distal radius fracture.

Lateral radiographs demonstrate a prominent plate edge over the volar cortex. What is the most likely cause of her current symptom?

. Dorsal penetration of screws causing extensor pollicis longus rupture
. Placement of the plate distal to the watershed line
. Suboptimal reduction of the sigmoid notch
. Injury to the anterior interosseous nerve during the surgical approach
. Unrecognized partial laceration of the tendon during the initial trauma

Correct Answer & Explanation

. Placement of the plate distal to the watershed line

Explanation

The patient has suffered a rupture of the flexor pollicis longus (FPL) tendon, which is a known complication of volar plating of distal radius fractures. The FPL tendon is at particular risk for attrition and rupture when the volar plate is placed distal to the watershed line of the distal radius. This leads to prominence of the hardware that rubs against the tendon during excursion. Dorsal penetration of screws causes extensor tendon irritation or rupture (e.g., EPL), not flexor tendon injury.

Question 3232

Topic: Wrist & Carpus
A 35-year-old man fell from a ladder 6 months ago, sustaining a radial head fracture that was treated nonoperatively. He now presents with chronic, progressive wrist pain and ulnar-sided swelling. Examination reveals tenderness at the distal radioulnar joint (DRUJ) and a positive ulnar variance on radiographs. What is the most appropriate management for this chronic condition?
. Radial head arthroplasty alone
. Ulnar shortening osteotomy and radial head arthroplasty
. Distal ulna resection (Darrach procedure)
. Radial head resection and interosseous membrane reconstruction
. Sauvé-Kapandji procedure

Correct Answer & Explanation

. Ulnar shortening osteotomy and radial head arthroplasty

Explanation

The patient has a missed Essex-Lopresti injury (radial head fracture, interosseous membrane tear, and DRUJ disruption). In the chronic setting, longitudinal radioulnar dissociation leads to proximal migration of the radius, causing ulnar impaction and DRUJ arthritis. Treatment requires restoring the radiocapitellar joint and leveling the radioulnar joint. Radial head arthroplasty alone cannot pull the radius back out to length once soft tissues have contracted. Therefore, an ulnar shortening osteotomy combined with radial head arthroplasty is indicated to restore DRUJ congruity and unload the ulnar carpus.

Question 3233

Topic: 7. Hand and Wrist
A 50-year-old man presents with chronic, worsening radial-sided wrist pain. He recalls a severe wrist sprain 15 years ago. Radiographs reveal scaphoid nonunion advanced collapse (SNAC) with arthritis involving the radioscaphoid and capitolunate joints, while the radiolunate joint is perfectly spared. What is the most appropriate surgical treatment?
. Radial styloidectomy
. Proximal row carpectomy (PRC)
. Scaphoid excision and four-corner fusion
. Total wrist arthrodesis
. Distal scaphoid excision

Correct Answer & Explanation

. Scaphoid excision and four-corner fusion

Explanation

The patient has Stage III SNAC wrist (radioscaphoid and midcarpal/capitolunate arthritis). The radiolunate joint is typically spared because the lunate facet of the radius and the proximal lunate have congruent spherical shapes that preserve cartilage. Proximal row carpectomy (PRC) is contraindicated in Stage III SNAC because it relies on a healthy articulation between the capitate head and the lunate fossa; in Stage III, the capitate head is already arthritic. Therefore, scaphoid excision and four-corner fusion (capitate, hamate, lunate, triquetrum) is the procedure of choice.

Question 3234

Topic: 7. Hand and Wrist

A 62-year-old woman presents with base of thumb pain that is exacerbated by gripping and pinching. On examination, she has tenderness directly over the flexor carpi radialis (FCR) tendon and pain with resisted wrist flexion and radial deviation.

Radiographs reveal isolated scaphotrapezialtrapezoid (STT) arthritis. The first carpometacarpal (CMC) joint is radiographically normal. If conservative management fails, which of the following surgical procedures allows for preservation of carpal kinematics and avoids the risk of nonunion?

. Trapeziectomy with ligament reconstruction and tendon interposition
. Scaphotrapezialtrapezoid (STT) arthrodesis
. Distal pole scaphoid excision
. Proximal row carpectomy
. Total wrist arthrodesis

Correct Answer & Explanation

. Distal pole scaphoid excision

Explanation

The patient has isolated STT arthritis. While STT arthrodesis is a traditional option, it carries risks of nonunion and significantly alters carpal kinematics, specifically decreasing wrist radial deviation and flexion. Distal pole scaphoid excision is an effective alternative for isolated STT arthritis that preserves carpal kinematics, has a shorter recovery time, and completely avoids the complication of nonunion associated with STT fusion. Trapeziectomy is reserved for CMC arthritis, which is not present here.

Question 3235

Topic: Nerve & Tendon

A 40-year-old mechanic complains of recurrent numbness and tingling in his small and ring fingers, 6 months after an in situ open ulnar nerve decompression at the elbow. On examination, the ulnar nerve is palpated subluxating over the medial epicondyle during elbow flexion.

What is the best surgical option for this patient?

. Revision in situ decompression
. Medial epicondylectomy
. Anterior transposition of the ulnar nerve
. Ulnar nerve wrapping with vein graft
. Endoscopic ulnar nerve release

Correct Answer & Explanation

. Anterior transposition of the ulnar nerve

Explanation

The patient has recurrent cubital tunnel syndrome with a subluxating ulnar nerve following a previous in situ release. Instability and subluxation of the ulnar nerve over the medial epicondyle is a primary indication for anterior transposition (subcutaneous, intramuscular, or submuscular). A revision in situ decompression would not address the dynamic instability causing neuritis. Anterior transposition relocates the nerve anterior to the axis of elbow motion, preventing subluxation and decreasing tension on the nerve during active flexion.

Question 3236

Topic: 7. Hand and Wrist

A 52-year-old man presents with a highly comminuted intra-articular distal radius fracture. On the true lateral radiograph of the wrist, a displaced 'teardrop' fragment is identified. This radiographic sign represents a fracture of which of the following structures?

. Volar margin of the scaphoid facet
. Dorsal margin of the lunate facet
. Volar margin of the lunate facet
. Radial styloid
. Lister's tubercle

Correct Answer & Explanation

. Volar margin of the lunate facet

Explanation

The 'teardrop' sign on a lateral radiograph of the distal radius represents the volar margin of the lunate facet. This is a critical fragment to recognize and stabilize, as it provides the origin for the short radiolunate ligament. Failure to adequately fix this 'critical corner' can lead to volar subluxation of the carpus.

Question 3237

Topic: 7. Hand and Wrist
A 47-year-old male construction worker presents with chronic radial-sided wrist pain. Radiographs demonstrate a scaphoid nonunion with advanced arthritic changes at the radioscaphoid and capitolunate joints. The radiolunate joint space is well preserved. Which of the following is the most appropriate surgical treatment?
. Total wrist arthrodesis
. Proximal row carpectomy (PRC)
. Scaphoid excision and four-corner arthrodesis
. Radial styloidectomy and scaphoid nonunion takedown with bone grafting
. Distal scaphoid pole excision

Correct Answer & Explanation

. Scaphoid excision and four-corner arthrodesis

Explanation

The patient has Stage III Scaphoid Nonunion Advanced Collapse (SNAC), which is characterized by radioscaphoid and capitolunate arthritis, with sparing of the radiolunate joint. Scaphoid excision and four-corner fusion is the treatment of choice. Proximal row carpectomy (PRC) is contraindicated in this scenario because the capitate head is arthritic and would articulate with the lunate fossa of the radius, leading to persistent pain.

Question 3238

Topic: 7. Hand and Wrist

A 65-year-old woman returns to the clinic 8 weeks after suffering a nondisplaced distal radius fracture that was treated conservatively in a short-arm cast. The fracture has healed uneventfully. However, she now presents with an inability to actively extend the interphalangeal joint of her thumb. She reports feeling a sudden 'pop' at the dorsal wrist yesterday while attempting to open a jar. What is the standard surgical treatment for this condition?

. Primary end-to-end repair of the extensor pollicis longus (EPL) tendon
. Transfer of the extensor indicis proprius (EIP) to the EPL tendon
. Transfer of the brachioradialis to the EPL tendon
. Palmaris longus tendon autograft interposition
. Release of the first dorsal compartment

Correct Answer & Explanation

. Transfer of the extensor indicis proprius (EIP) to the EPL tendon

Explanation

Delayed rupture of the extensor pollicis longus (EPL) tendon is a well-known complication of nondisplaced distal radius fractures. It occurs due to a combination of mechanical attrition against the fracture callus and watershed ischemia within the third dorsal compartment. Because the tendon ends are typically degenerative and retracted, primary repair is usually not feasible. EIP to EPL tendon transfer is the gold standard for restoring functional thumb extension.

Question 3239

Topic: Nerve & Tendon

An elite collegiate baseball pitcher undergoes ulnar collateral ligament (UCL) reconstruction using a docking technique. Preoperatively, he had no signs or symptoms of ulnar neuropathy, and his EMG/NCS were normal. During the procedure, what is the most universally recommended management of the ulnar nerve?

. Routine subcutaneous transposition
. Routine submuscular transposition
. Ulnar nerve left in situ without transposition
. Intramuscular transposition
. Routine medial epicondylectomy

Correct Answer & Explanation

. Ulnar nerve left in situ without transposition

Explanation

In UCL reconstruction for overhead athletes without preoperative ulnar nerve symptoms, the ulnar nerve is generally left in situ. Routine transposition (subcutaneous or submuscular) in asymptomatic patients has been associated with a higher incidence of iatrogenic postoperative ulnar neuropathy and is typically reserved for patients with preoperative ulnar nerve symptoms or significant intraoperative subluxation of the nerve.

Question 3240

Topic: 7. Hand and Wrist
A 52-year-old manual laborer presents with progressive right wrist pain and stiffness. Radiographs demonstrate complete loss of the radioscaphoid joint space and narrowing of the capitolunate joint space, but the radiolunate articulation remains well preserved. Based on these findings, what is the most appropriate surgical intervention?
. Proximal row carpectomy (PRC)
. Total wrist arthrodesis
. Scaphotrapeziotrapezoid (STT) arthrodesis
. Four-corner arthrodesis with scaphoid excision
. Scaphoid excision and radio-lunate arthrodesis

Correct Answer & Explanation

. Four-corner arthrodesis with scaphoid excision

Explanation

This patient has Stage III Scapholunate Advanced Collapse (SLAC), characterized by arthritis involving the radioscaphoid and capitolunate joints while sparing the radiolunate joint. Proximal row carpectomy (PRC) is contraindicated in Stage III SLAC because the capitate articular surface is degenerate, which would lead to painful capitate-lunate fossa articulation. The gold standard surgical treatment for Stage III SLAC wrist in an active patient is a four-corner arthrodesis (fusion of the capitate, hamate, lunate, and triquetrum) combined with scaphoid excision. Total wrist arthrodesis is typically reserved for pancarpal arthritis (Stage IV) or salvage after failed limited arthrodesis.

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