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7. Hand and Wrist MCQs

Practice Set 163 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 3241

Topic: Wrist & Carpus

A 35-year-old construction worker falls from a ladder and sustains a comminuted radial head fracture. During evaluation, he complains of wrist pain, and radiographs reveal positive ulnar variance and disruption of the distal radioulnar joint (DRUJ). He is diagnosed with an Essex-Lopresti injury. Which of the following surgical management strategies is most appropriate?

. Radial head excision and pinning of the DRUJ in supination
. Open reduction internal fixation of the radial head and immediate DRUJ motion
. Radial head arthroplasty and stabilization of the DRUJ
. Radial head excision with an ulnar shortening osteotomy
. Closed reduction of the DRUJ and casting in pronation

Correct Answer & Explanation

. Radial head arthroplasty and stabilization of the DRUJ

Explanation

An Essex-Lopresti injury consists of a radial head fracture, rupture of the interosseous membrane, and disruption of the DRUJ, leading to longitudinal radioulnar dissociation. Excision of the radial head without replacement is strictly contraindicated, as it will lead to rapid proximal migration of the radius and severe wrist and elbow dysfunction. Management requires restoring the lateral column of the elbow, typically with a radial head arthroplasty (since comminuted fractures are usually unfixable), followed by assessment and stabilization of the DRUJ (which may include TFCC repair and/or pinning the DRUJ in supination).

Question 3242

Topic: 7. Hand and Wrist

Following an extensive flexor tendon repair in zone II, a surgeon must release part of the pulley system to allow tendon glide. To prevent significant bowstringing and loss of active flexion mechanics, which pulleys are considered the most critical to preserve?

. A1 and A3
. A2 and A4
. A3 and A5
. A1 and A5
. A2 and A3

Correct Answer & Explanation

. A2 and A4

Explanation

The A2 and A4 pulleys are the major biomechanical pulleys of the digital flexor sheath. They arise from the periosteum of the proximal and middle phalanges, respectively. Loss of both the A2 and A4 pulleys leads to profound bowstringing, mechanical disadvantage, and loss of full active flexion. Preserving or reconstructing the A2 and A4 pulleys remains a fundamental principle in hand surgery to maintain the moment arm of the flexor tendons.

Question 3243

Topic: 7. Hand and Wrist
A 38-year-old man presents with chronic wrist pain. Radiographs reveal a scaphoid nonunion with radioscaphoid arthritis and capitolunate arthritis, but the radiolunate joint is anatomically spared. This is consistent with a Stage III SNAC wrist. Which of the following is the most appropriate surgical treatment?
. Proximal row carpectomy (PRC)
. Radial styloidectomy
. Total wrist arthrodesis
. Scaphoid excision and four-corner (capitate-hamate-lunate-triquetrum) fusion
. Scaphoid open reduction and internal fixation with vascularized bone graft

Correct Answer & Explanation

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

Explanation

The patient has a Stage III Scaphoid Nonunion Advanced Collapse (SNAC) wrist, characterized by radioscaphoid and capitolunate arthritis, but sparing of the radiolunate joint. Proximal row carpectomy (PRC) relies on a preserved proximal capitate articular surface articulating with the lunate fossa; since capitolunate arthritis is present, PRC is contraindicated. A scaphoid excision and four-corner fusion (capitate, hamate, lunate, triquetrum) preserves the normal radiolunate articulation, providing pain relief while maintaining approximately 50% of normal wrist motion.

Question 3244

Topic: Nerve & Tendon

A 34-year-old male presents with persistent cubital tunnel syndrome despite 6 months of conservative management. He has a history of a childhood supracondylar humerus fracture and presents with a significant cubitus valgus deformity. EMG confirms severe ulnar neuropathy at the elbow. Which of the following surgical interventions is most appropriate?

. In situ ulnar nerve decompression
. Medial epicondylectomy
. Anterior ulnar nerve transposition
. Endoscopic in situ decompression
. Cubital tunnel release with division of the medial intermuscular septum only

Correct Answer & Explanation

. Anterior ulnar nerve transposition

Explanation

Anterior transposition of the ulnar nerve is indicated for cubital tunnel syndrome in the setting of structural deformities such as cubitus valgus (tardy ulnar palsy from a prior supracondylar fracture), hardware from prior surgeries, nerve instability/subluxation, or a recurrent condition. In situ decompression is a reliable option for idiopathic cases without anatomic distortion, but it is insufficient when bony deformity places chronic tension on the nerve.

Question 3245

Topic: 7. Hand and Wrist
A 32-year-old manual laborer presents with chronic dorsal wrist pain. Radiographs demonstrate sclerosis and fragmentation of the lunate, with negative ulnar variance. The radioscaphoid angle is normal. What is the most appropriate initial surgical intervention for this patient?
. Proximal row carpectomy
. Radial shortening osteotomy
. Scaphoid-trapezium-trapezoid (STT) fusion
. Capitate shortening osteotomy
. Total wrist arthrodesis

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

Kienbock disease is avascular necrosis of the lunate. In early stages (Lichtman Stage II or IIIA, indicating sclerosis or early fragmentation without carpal collapse) in a patient with negative ulnar variance, a joint-leveling procedure is indicated. A radial shortening osteotomy offloads the radiolunate joint, reducing mechanical stress on the lunate and allowing potential revascularization or cessation of collapse. Proximal row carpectomy or fusions are reserved for advanced stages with carpal collapse and secondary arthritis.

Question 3246

Topic: 7. Hand and Wrist

A 55-year-old woman undergoes volar locked plating for a displaced distal radius fracture. Six months postoperatively, she suddenly loses the ability to actively flex her thumb interphalangeal joint. What is the most likely cause of this complication?

. Median nerve compression at the carpal tunnel
. Rupture of the extensor pollicis longus (EPL) tendon
. Rupture of the flexor pollicis longus (FPL) tendon
. Nonunion of the distal radius
. Prominent dorsal screws

Correct Answer & Explanation

. Rupture of the flexor pollicis longus (FPL) tendon

Explanation

Volar locking plates have become the gold standard for many displaced distal radius fractures. However, if the plate is placed too distally (beyond the watershed line), the flexor tendons, most notably the flexor pollicis longus (FPL), can rub against the prominent distal edge of the plate. Over time, this attrition can lead to a sudden, painless rupture of the FPL tendon, presenting as a loss of active thumb interphalangeal joint flexion. Extensor tendon ruptures are more commonly associated with prominent dorsal screws protruding through the dorsal cortex.

Question 3247

Topic: 7. Hand and Wrist
A 45-year-old construction worker presents with chronic radial-sided wrist pain. Radiographs demonstrate a scaphoid nonunion with advanced degenerative changes involving the radioscaphoid and capitolunate joints. The radiolunate joint is well preserved. Which of the following is the most appropriate surgical treatment?
. Proximal row carpectomy (PRC)
. Scaphoid excision and four-corner fusion
. Total wrist arthrodesis
. Radial styloidectomy
. Vascularized bone grafting of the scaphoid

Correct Answer & Explanation

. Scaphoid excision and four-corner fusion

Explanation

The patient has Scaphoid Nonunion Advanced Collapse (SNAC) stage III, which is characterized by arthritis at the radioscaphoid and capitolunate joints with sparing of the radiolunate joint. Proximal row carpectomy (PRC) is contraindicated in this setting because it requires a pristine capitate head to articulate with the lunate fossa of the radius. Because the capitolunate joint (and thus the capitate head) is arthritic, a PRC would result in continued pain. Scaphoid excision and four-corner fusion (capitate, lunate, hamate, triquetrum) is the standard of care as it preserves the unaffected radiolunate joint and removes the arthritic articulations.

Question 3248

Topic: 7. Hand and Wrist

A 55-year-old woman undergoes volar locked plating for a comminuted, intra-articular fracture of the distal radius. Six months later, she returns to the clinic reporting a sudden inability to actively flex the interphalangeal joint of her thumb. Radiographs demonstrate an anatomically healed fracture. What is the most likely cause of this complication?

. Intracompartmental pressure leading to Volkmann's contracture
. Prominent screws penetrating the dorsal cortex
. Prominence of the plate at or distal to the watershed line
. Unrecognized injury to the anterior interosseous nerve
. Attritional rupture of the flexor digitorum profundus tendon

Correct Answer & Explanation

. Prominence of the plate at or distal to the watershed line

Explanation

The patient has experienced an attritional rupture of the flexor pollicis longus (FPL) tendon. The FPL tendon runs in close proximity to the volar cortex of the distal radius. If a volar plate is placed too distally (at or beyond the watershed line), the hardware prominence causes friction and attritional wear on the tendon during wrist motion, eventually leading to FPL rupture.

Question 3249

Topic: 7. Hand and Wrist
A 30-year-old manual laborer presents with chronic dorsal wrist pain. Radiographs demonstrate sclerosis and early fragmentation of the lunate, with normal carpal alignment and a negative ulnar variance of -3 mm. There is no evidence of radiocarpal or midcarpal arthritis. MRI confirms avascular necrosis of the lunate. Which of the following is the most appropriate initial surgical management?
. Proximal row carpectomy
. Scaphoid excision and four-corner fusion
. Radial shortening osteotomy
. Ulnar lengthening osteotomy
. Total wrist arthrodesis

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

The patient has Lichtman Stage II or early Stage IIIA Kienbock's disease (avascular necrosis of the lunate) with ulnar negative variance. In the absence of carpal collapse and arthritis, joint-leveling procedures are indicated to mechanically unload the lunate. A radial shortening osteotomy is the preferred procedure, as it reliably unloads the radiolunate joint and is associated with fewer complications (e.g., nonunion) than ulnar lengthening.

Question 3250

Topic: Nerve & Tendon

A 45-year-old carpenter complains of progressive numbness in the small and ring fingers of his right hand, along with weakness in grip strength. Examination shows intrinsic muscle wasting and a positive Tinel's sign at the cubital tunnel. EMG reveals severe ulnar neuropathy at the elbow. During surgical exploration for ulnar nerve decompression, the ulnar nerve is observed to subluxate anteriorly over the medial epicondyle during elbow flexion. Which of the following is the most appropriate surgical procedure?

. In situ decompression of the ulnar nerve
. Anterior transposition of the ulnar nerve
. Medial epicondylectomy
. Ulnar nerve repair with autograft
. Guyon's canal release

Correct Answer & Explanation

. Anterior transposition of the ulnar nerve

Explanation

While in situ decompression is an effective treatment for many cases of primary cubital tunnel syndrome, a nerve that subluxates anteriorly over the medial epicondyle during elbow flexion after decompression is at high risk for friction neuritis and recurrent symptoms. Therefore, the presence of dynamic nerve subluxation is a direct indication to perform an anterior transposition (subcutaneous, intramuscular, or submuscular) of the ulnar nerve to stabilize it in an anterior position.

Question 3251

Topic: Wrist & Carpus

A 45-year-old man presents with a sudden inability to flex the interphalangeal joint of his right thumb. He sustained a distal radius fracture 8 weeks ago that was treated with volar locked plating. Radiographs demonstrate the fracture is healing in good alignment, but the plate is positioned prominent and distal to the watershed line. Which of the following is the most likely etiology of his current deficit?

. Extensor pollicis longus rupture from dorsal screw protrusion
. Anterior interosseous nerve neuropraxia from localized edema
. Flexor pollicis longus rupture due to implant impingement
. Ischemic contracture of the thenar eminence
. Unrecognized associated scaphoid fracture with nonunion

Correct Answer & Explanation

. Flexor pollicis longus rupture due to implant impingement

Explanation

Volar plates placed distal to the watershed line of the distal radius can impinge on the flexor tendons. The flexor pollicis longus (FPL) tendon lies directly over the volar-ulnar aspect of the radius and is the most susceptible to attrition and rupture from prominent hardware. The patient's inability to actively flex the thumb interphalangeal joint is classic for an iatrogenic FPL rupture, which typically requires plate removal and tendon reconstruction (e.g., tendon transfer or graft).

Question 3252

Topic: 7. Hand and Wrist

A 55-year-old manual laborer presents with progressive wrist pain, stiffness, and diminished grip strength over the past 2 years. He had a scaphoid fracture 10 years ago that was treated nonoperatively. Radiographs show a scaphoid nonunion with narrowing of the radioscaphoid joint and midcarpal joint, but sparing of the radiolunate joint. What is the most appropriate surgical treatment for this patient?

. Proximal row carpectomy (PRC)
. Scaphoid excision and four-corner fusion
. Radial styloidectomy and scaphoid nonunion takedown with bone grafting
. Total wrist arthrodesis
. Total wrist arthroplasty

Correct Answer & Explanation

. Scaphoid excision and four-corner fusion

Explanation

The patient has a Scaphoid Nonunion Advanced Collapse (SNAC) wrist. Radiographs reveal involvement of the midcarpal joint (capitolunate joint), consistent with a Stage 3 SNAC wrist. In a high-demand manual laborer with capitate involvement, scaphoid excision and four-corner fusion is the treatment of choice. Proximal row carpectomy (PRC) relies on a pristine capitate head; since the midcarpal joint is arthritic, PRC is contraindicated. Total wrist arthrodesis is a salvage procedure, and total wrist arthroplasty is contraindicated in heavy laborers.

Question 3253

Topic: Wrist & Carpus

A 32-year-old male sustains a volar shear fracture of the distal radius (volar Barton fracture). During open reduction and internal fixation via a classic Henry approach, which of the following structures must be carefully protected to preserve the primary volar stabilizer of the radiocarpal joint?

. Radioscaphocapitate ligament
. Volar radioulnar ligament
. Lunotriquetral ligament
. Triangular fibrocartilage complex
. Dorsal radiocarpal ligament

Correct Answer & Explanation

. Radioscaphocapitate ligament

Explanation

The radioscaphocapitate (RSC) ligament is a critical volar stabilizer of the wrist, preventing ulnar translation of the carpus. During a volar approach to the distal radius (e.g., Henry approach), dissection distal to the watershed line must be minimized to avoid damaging the stout volar radiocarpal ligaments (RSC, long radiolunate, short radiolunate).

Question 3254

Topic: 7. Hand and Wrist

A 42-year-old manual laborer presents with chronic right wrist pain. Radiographs reveal a scaphoid nonunion with arthritic changes at the radioscaphoid joint and the scaphocapitate joint, but the radiolunate joint is spared. This is consistent with Stage II Scaphoid Nonunion Advanced Collapse (SNAC). Which of the following is the most appropriate surgical treatment?

. Radial styloidectomy
. Scaphoid excision and four-corner arthrodesis
. Total wrist arthrodesis
. Proximal row carpectomy
. Distal radius osteotomy

Correct Answer & Explanation

. Scaphoid excision and four-corner arthrodesis

Explanation

Stage II SNAC wrist involves arthritis of the radioscaphoid and scaphocapitate joints with preservation of the radiolunate joint. Proximal row carpectomy (PRC) is contraindicated if there is capitate arthritis (which is present in Stage II SNAC) because the capitate must articulate directly with the lunate fossa in a PRC. Therefore, scaphoid excision and four-corner arthrodesis (capitate, hamate, lunate, triquetrum) is the preferred motion-preserving salvage procedure.

Question 3255

Topic: 7. Hand and Wrist

A 45-year-old female presents with aching pain in her proximal forearm and paresthesias in the thumb, index, and middle fingers. Phalen's test and Tinel's sign at the wrist are negative. Which of the following physical examination findings best distinguishes Pronator Syndrome from Carpal Tunnel Syndrome?

. Weakness of the abductor pollicis brevis
. Decreased sensation over the volar tip of the index finger
. Decreased sensation over the thenar eminence
. A positive Froment sign
. Wartenberg's sign

Correct Answer & Explanation

. Decreased sensation over the thenar eminence

Explanation

Pronator syndrome is a compressive neuropathy of the median nerve in the proximal forearm. It shares sensory symptoms in the median nerve distribution with Carpal Tunnel Syndrome (CTS). However, the palmar cutaneous branch of the median nerve, which provides sensation to the thenar eminence, branches off proximal to the carpal tunnel and travels superficial to the transverse carpal ligament. Therefore, sensation over the thenar eminence is preserved in CTS but frequently decreased in Pronator Syndrome.

Question 3256

Topic: Hand Trauma & Infection

A 38-year-old diabetic male presents with a severely swollen, erythematous left thumb that he holds in a flexed posture. He reports severe pain with passive extension. Over the next 24 hours, he develops similar swelling, pain, and flexed posture in his little finger, while the index, middle, and ring fingers remain relatively asymptomatic. This classic spread of infection occurs through which of the following anatomical spaces?

. Midpalmar space
. Thenar space
. Space of Parona
. Deep subaponeurotic space
. Hypothenar space

Correct Answer & Explanation

. Space of Parona

Explanation

This clinical presentation describes a 'horseshoe abscess,' resulting from pyogenic flexor tenosynovitis. The radial bursa (which surrounds the flexor pollicis longus tendon sheath) and the ulnar bursa (which contains the flexor tendons of the little finger) communicate in the distal forearm via the Space of Parona in approximately 50-80% of individuals. This anatomical connection allows an infection to spread rapidly from the thumb to the little finger (or vice versa), sparing the central digits.

Question 3257

Topic: 7. Hand and Wrist
A 52-year-old man presents with chronic, progressive wrist pain and weakness 15 years after a fall on an outstretched hand. Radiographs demonstrate a chronic scaphoid waist nonunion with severe degenerative changes between the distal scaphoid fragment and the radial styloid, as well as narrowing of the capitolunate joint space. The radiolunate joint is widely preserved. What is the most appropriate surgical procedure for this patient?
. Scaphoid open reduction and internal fixation with a vascularized bone graft
. Proximal row carpectomy (PRC)
. Scaphoid excision and four-corner (capitate-lunate-hamate-triquetrum) fusion
. Total wrist arthrodesis
. Radial styloidectomy

Correct Answer & Explanation

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

Explanation

This patient has Scaphoid Nonunion Advanced Collapse (SNAC) Stage III arthritis. In SNAC III, arthritis involves the radioscaphoid and capitolunate joints, while the radiolunate articulation is classically preserved. Proximal row carpectomy (PRC) is contraindicated because the procedure relies on a healthy capitate head to articulate with the lunate fossa of the radius; in SNAC III, the capitolunate joint (and thus the capitate head) is arthritic. Therefore, a scaphoid excision and four-corner fusion is the best motion-preserving salvage option. Total wrist arthrodesis is typically reserved for pan-carpal arthritis (SNAC IV).

Question 3258

Topic: 7. Hand and Wrist

A 66-year-old female with long-standing rheumatoid arthritis reports a sudden inability to flex the interphalangeal (IP) joint of her right thumb. She denies any preceding trauma or acute pain. On physical examination, she is unable to actively flex the thumb IP joint. Passive extension of the wrist does not produce passive flexion of the thumb IP joint. Flexion of the index and long fingers is normal. What is the most likely etiology of her deficit?

. Anterior interosseous nerve (AIN) syndrome
. Attritional rupture of the flexor pollicis longus (FPL) tendon
. Locked trigger thumb
. Rupture of the extensor pollicis longus (EPL) tendon
. Metacarpophalangeal joint volar plate disruption

Correct Answer & Explanation

. Attritional rupture of the flexor pollicis longus (FPL) tendon

Explanation

The patient has a Mannerfelt lesion, which is an attritional rupture of the flexor pollicis longus (FPL) tendon as it tracks over a bony spur (osteophyte) on the volar scaphoid in patients with rheumatoid arthritis. The critical distinguishing factor on physical exam between an FPL tendon rupture and an Anterior Interosseous Nerve (AIN) palsy is the tenodesis test. In AIN palsy, the tendon is intact, so passive wrist extension will cause the thumb IP joint to flex (positive tenodesis effect). In an FPL rupture, the tenodesis effect is absent.

Question 3259

Topic: Wrist & Carpus
A 39-year-old female presents with persistent ulnar-sided wrist pain that is exacerbated by gripping, pronation, and ulnar deviation. Conservative measures including splinting and NSAIDs have failed. Radiographs reveal 3.5 mm of positive ulnar variance. An MRI arthrogram demonstrates a degenerative, central perforation of the triangular fibrocartilage complex (TFCC) and corresponding chondromalacia on the proximal ulnar aspect of the lunate. What is the most appropriate surgical intervention?
. Arthroscopic primary TFCC repair to the fovea
. Ulnar shortening osteotomy
. Darrach procedure (distal ulnar resection)
. Sauvé-Kapandji procedure
. Proximal row carpectomy

Correct Answer & Explanation

. Ulnar shortening osteotomy

Explanation

This patient's presentation is classic for ulnar impaction syndrome with a Palmer Class 2C degenerative TFCC tear. The underlying biomechanical issue is excessive ulnar length (positive ulnar variance), leading to increased load transmission across the ulnocarpal joint. The most appropriate treatment for symptomatic ulnar impaction syndrome with ulnar variance >2 mm that has failed conservative care is an ulnar shortening osteotomy. This extra-articular procedure unloads the ulnocarpal joint and typically tightens the ulnocarpal ligaments. An arthroscopic wafer procedure may be considered if variance is <2 mm.

Question 3260

Topic: 7. Hand and Wrist

A 42-year-old man undergoes surgical repair of a complete distal biceps tendon rupture using a single-incision anterior approach. Postoperatively, he cannot actively extend his thumb or the metacarpophalangeal joints of his fingers, but wrist extension is maintained with noticeable radial deviation. Sensation in the hand and forearm is entirely intact. Which of the following is the most likely cause of this complication?

. Vigorous medial retraction injuring the median nerve
. Vigorous lateral retraction injuring the posterior interosseous nerve
. Injury to the lateral antebrachial cutaneous nerve during superficial dissection
. Ischemic injury to the extensor muscle mass due to tourniquet time
. Radial nerve transection during exposure of the radial tuberosity

Correct Answer & Explanation

. Vigorous lateral retraction injuring the posterior interosseous nerve

Explanation

The clinical scenario describes a posterior interosseous nerve (PIN) palsy, characterized by the inability to extend the fingers and thumb at the MCP joints. 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 bifurcation, while the extensor carpi ulnaris (ECU) is denervated. In a single-incision anterior approach to the distal biceps, the PIN is highly vulnerable, most commonly due to vigorous lateral retraction of the brachioradialis and supinator, or by placing retractors directly on the radial neck.

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