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7. Hand and Wrist MCQs

Practice Set 165 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 3281

Topic: 7. Hand and Wrist

A 24-year-old male presents with persistent wrist pain 12 weeks after falling on an outstretched hand. MRI confirms a proximal pole scaphoid nonunion with avascular necrosis. Which of the following surgical options offers the most reliable rate of union in this specific scenario?

. Percutaneous screw fixation alone
. Non-vascularized distal radius bone graft
. 1,2 Intercompartmental supraretinacular artery (1,2 ICSRA) vascularized bone graft
. Four-corner arthrodesis
. Proximal row carpectomy

Correct Answer & Explanation

. 1,2 Intercompartmental supraretinacular artery (1,2 ICSRA) vascularized bone graft

Explanation

For a proximal pole scaphoid nonunion complicated by avascular necrosis, a vascularized bone graft (such as the 1,2 ICSRA graft) is indicated to restore blood supply and promote healing. Non-vascularized grafts have a high failure rate in the presence of AVN.

Question 3282

Topic: 7. Hand and Wrist

A 58-year-old woman presents with progressive wrist pain 10 years after an untreated wrist injury. A radiograph is shown in Figure 60.

Assuming the typical progressive arthritic pattern seen in Scapholunate Advanced Collapse (SLAC), which articulation is characteristically spared from degenerative changes even in late stages?

. Radioscaphoid joint
. Radiolunate joint
. Capitolunate joint
. Scaphotrapezial joint
. Scaphocapitate joint

Correct Answer & Explanation

. Radiolunate joint

Explanation

In SLAC wrist, the spherical shape of the lunate maintains a congruent and load-sharing articulation with the lunate fossa of the distal radius. Therefore, the radiolunate joint is characteristically spared from arthritis, which allows for salvage procedures like a four-corner fusion.

Question 3283

Topic: Wrist & Carpus

A 62-year-old woman returns to the clinic 8 months after undergoing volar plate fixation for a distal radius fracture. She reports a sudden inability to actively flex the interphalangeal joint of her thumb. Radiographs reveal the hardware is intact but positioned distal to the watershed line. Which of the following is the most appropriate surgical management?

. Flexor carpi radialis (FCR) to flexor pollicis longus (FPL) tendon transfer
. Extensor indicis proprius (EIP) to FPL tendon transfer
. Primary end-to-end repair of the FPL tendon
. Free tendon graft using the palmaris longus
. Hardware removal and tenolysis only

Correct Answer & Explanation

. Extensor indicis proprius (EIP) to FPL tendon transfer

Explanation

Rupture of the FPL tendon post-volar plating is due to chronic attrition over the prominent plate and cannot be reliably repaired primarily. An EIP to FPL tendon transfer is the standard and most reliable method to restore thumb interphalangeal flexion.

Question 3284

Topic: Nerve & Tendon

A 22-year-old rugby player sustained a hyperextension injury to his ring finger while grasping an opponent's jersey. He cannot actively flex the distal interphalangeal (DIP) joint. Examination reveals tenderness localized to the palm. According to the Leddy and Packer classification, what is the appropriate management for this injury?

. Splinting in extension for 6 weeks
. Primary tendon repair within 7-10 days
. Primary tendon repair within 6 weeks
. Two-stage tendon reconstruction
. DIP joint arthrodesis

Correct Answer & Explanation

. Primary tendon repair within 7-10 days

Explanation

This is a Type I Jersey finger (FDP avulsion) where the tendon retracts into the palm, disrupting both the vincular blood supply and the tendon's nutritional pathways. It requires early surgical repair within 7 to 10 days to prevent permanent tendon retraction and necrosis.

Question 3285

Topic: Nerve & Tendon

A 40-year-old carpenter presents with numbness and tingling in his small and ring fingers. He also notes clumsiness when handling small nails. Nerve conduction studies confirm 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
. Aponeurosis of the flexor carpi ulnaris
. Deep flexor pronator aponeurosis

Correct Answer & Explanation

. Osborne's ligament

Explanation

Cubital tunnel syndrome is most commonly caused by compression of the ulnar nerve at Osborne's ligament (the cubital tunnel retinaculum) which connects the humeral and ulnar heads of the flexor carpi ulnaris.

Question 3286

Topic: 7. Hand and Wrist
A 35-year-old manual laborer presents with dorsal wrist pain and decreased grip strength. Radiographs reveal sclerosis and fragmentation of the lunate with a negative ulnar variance of 3 mm. The radioscaphoid joint appears entirely normal. What is the most appropriate surgical intervention?
. Proximal row carpectomy
. Four-corner arthrodesis
. Radial shortening osteotomy
. Ulnar shortening osteotomy
. Total wrist arthrodesis

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

This patient has Kienbock's disease (Stage IIIa) with negative ulnar variance. A joint-leveling procedure, such as a radial shortening osteotomy, offloads the radiolunate joint and halts disease progression before widespread carpal collapse occurs.

Question 3287

Topic: 7. Hand and Wrist

A 48-year-old avid cyclist presents with profound intrinsic muscle weakness in his hand, manifesting as a positive Wartenberg sign and an inability to cross his fingers. Sensation on both the volar and dorsal aspects of the hand is completely normal. Compression of the ulnar nerve is most likely occurring in which anatomical zone of Guyon's canal?

. Zone 1
. Zone 2
. Zone 3
. Zone 4
. Proximal to the wrist crease

Correct Answer & Explanation

. Zone 3

Explanation

Guyon's canal Zone 2 contains only the deep motor branch of the ulnar nerve. Compression here (often due to a hook of hamate fracture or ganglion) causes isolated motor deficits without sensory abnormalities.

Question 3288

Topic: Wrist & Carpus

A 28-year-old man undergoes an open reduction and internal fixation of a distal radius fracture under regional anesthesia. During the administration of a supraclavicular brachial plexus block, the patient suddenly develops perioral numbness, tinnitus, and subsequent generalized seizures followed by ventricular arrhythmias. Which of the following local anesthetics was most likely used, given its high potential for irreversible cardiac toxicity?

. Lidocaine
. Ropivacaine
. Mepivacaine
. Bupivacaine
. Chloroprocaine

Correct Answer & Explanation

. Bupivacaine

Explanation

The clinical scenario describes Local Anesthetic Systemic Toxicity (LAST). Bupivacaine is a long-acting amide local anesthetic that is notoriously lipophilic and has a high affinity for cardiac voltage-gated sodium channels. If inadvertently injected intravascularly, it can cause severe, refractory cardiac arrhythmias (such as ventricular fibrillation) and cardiovascular collapse. Its cardiac toxicity is much more difficult to resuscitate (often requiring lipid emulsion therapy) compared to lidocaine. Ropivacaine was developed specifically as an alternative to bupivacaine because it is less lipophilic and has a significantly improved cardiac safety profile.

Question 3289

Topic: 7. Hand and Wrist

Following a primary surgical repair of a complete flexor digitorum profundus (FDP) laceration in Zone II of the hand, a specific post-operative rehabilitation protocol is initiated to prevent adhesions while promoting tendon healing. Within this digital synovial sheath, the majority of the nutritional supply for the healing tendon is provided by:

. Direct vascular supply from the vincula brevia and longa
. Synovial fluid diffusion
. Perfusion from the distal phalangeal insertion
. Longitudinal intraneural vessels from the palm
. Direct capillary ingrowth from the epitenon layer alone

Correct Answer & Explanation

. Synovial fluid diffusion

Explanation

Flexor tendons within the digital synovial sheath (Zone II) receive nutrition via a dual mechanism: vascular perfusion (through the vincula system) and synovial diffusion. Experimental studies have firmly established that synovial fluid diffusion is the predominant source of nutrition for these tendons, providing the majority of the essential nutrients. This diffusion is significantly enhanced by the physical pumping action of tendon gliding, reinforcing the physiologic rationale for early motion rehabilitation.

Question 3290

Topic: Nerve & Tendon

A cyclist presents with isolated weakness of the dorsal interossei and adductor pollicis, with completely normal sensation in the small and ring fingers. A lesion in which anatomical zone of Guyon's canal is most likely responsible?

. Zone 1
. Zone 2
. Zone 3
. Zone 4
. Zone 5

Correct Answer & Explanation

. Zone 2

Explanation

Zone 1 contains the mixed ulnar nerve before its bifurcation. Zone 2 contains only the deep motor branch, which innervates the interossei and adductor pollicis; compression here causes isolated motor deficits.

Question 3291

Topic: Nerve & Tendon

A patient presents with median nerve compression symptoms proximal to the elbow. Imaging reveals a supracondylar process of the humerus. Which anatomical structure typically connects this process to the medial epicondyle and compresses the median nerve?

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

Correct Answer & Explanation

. Ligament of Struthers

Explanation

The ligament of Struthers connects an anomalous supracondylar process to the medial epicondyle. It can compress the median nerve and the brachial artery, which pass deep to this ligament.

Question 3292

Topic: 7. Hand and Wrist

The lumbrical muscles of the hand are crucial for coordinating finger flexion and extension. Which of the following accurately describes their origin and insertion?

. Origin from the flexor digitorum superficialis tendons, inserting into the lateral bands of the extensor hood
. Origin from the metacarpal shafts, inserting into the proximal phalanges
. Origin from the flexor digitorum profundus tendons, inserting into the radial lateral bands of the extensor hood
. Origin from the flexor digitorum profundus tendons, inserting into the ulnar lateral bands of the extensor hood
. Origin from the carpal bones, inserting into the central slip of the extensor mechanism

Correct Answer & Explanation

. Origin from the flexor digitorum profundus tendons, inserting into the radial lateral bands of the extensor hood

Explanation

The lumbricals originate from the tendons of the flexor digitorum profundus and insert onto the radial side of the lateral bands of the extensor expansion. This unique anatomy allows them to flex the MCP joints and extend the IP joints.

Question 3293

Topic: 7. Hand and Wrist

A patient sustains a scaphoid waist fracture. The proximal pole is highly susceptible to avascular necrosis due to its retrograde blood supply. Which vessel is the primary source of arterial inflow to the proximal pole?

. Palmar carpal branch of the radial artery
. Dorsal carpal branch of the radial artery
. Deep palmar arch
. Anterior interosseous artery
. Ulnar artery via the superficial palmar arch

Correct Answer & Explanation

. Dorsal carpal branch of the radial artery

Explanation

The scaphoid is predominantly supplied by the dorsal carpal branch of the radial artery, which enters the bone distally at the dorsal ridge. The blood then flows retrogradely to supply the proximal pole.

Question 3294

Topic: Wrist & Carpus

A 22-year-old gymnast requires arthroscopic repair of a triangular fibrocartilage complex (TFCC) tear. Healing potential is closely related to the local vascularity. Which portion of the TFCC possesses the most robust blood supply?

. Central articular disc
. Radial attachment
. Peripheral 10-20% at the ulnar attachment
. Volar capsular margin only
. The entire structure is avascular

Correct Answer & Explanation

. Peripheral 10-20% at the ulnar attachment

Explanation

The TFCC receives its blood supply exclusively at its periphery, predominantly at the ulnar attachment (the peripheral 10-20%). The central portion is avascular and generally requires debridement rather than repair if torn.

Question 3295

Topic: Nerve & Tendon

When performing a volar release for de Quervain's tenosynovitis, care must be taken to avoid injury to sensory nerve branches. Which nerve is most at risk during the surgical release of the first dorsal compartment?

. Palmar cutaneous branch of the median nerve
. Superficial sensory branch of the radial nerve
. Dorsal sensory branch of the ulnar nerve
. Lateral antebrachial cutaneous nerve
. Posterior interosseous nerve

Correct Answer & Explanation

. Superficial sensory branch of the radial nerve

Explanation

The superficial sensory branch of the radial nerve courses over the first dorsal compartment (containing APL and EPB). It is highly susceptible to injury during surgical release for de Quervain's tenosynovitis.

Question 3296

Topic: 7. Hand and Wrist

The major blood supply to the proximal pole of the scaphoid enters the bone at which specific anatomical location?

. Dorsal ridge
. Volar tubercle
. Distal articular surface
. Proximal articular surface
. Scapholunate ligament insertion

Correct Answer & Explanation

. Dorsal ridge

Explanation

The major blood supply to the scaphoid comes from the dorsal carpal branch of the radial artery, which enters the bone distally at the dorsal ridge. It supplies the proximal 80% of the bone via retrograde flow.

Question 3297

Topic: Nerve & Tendon

A patient suffers a laceration to the recurrent motor branch of the median nerve at the wrist. Which of the following muscles will subsequently lose its innervation?

. Adductor pollicis
. Opponens pollicis
. First dorsal interosseous
. Flexor pollicis brevis (deep head)
. Abductor digiti minimi

Correct Answer & Explanation

. Adductor pollicis

Explanation

The recurrent motor branch of the median nerve innervates the thenar muscles: Opponens pollicis, Abductor pollicis brevis, and the superficial head of the Flexor pollicis brevis (OAF). The adductor pollicis and deep head of the FPB are ulnar nerve supplied.

Question 3298

Topic: 7. Hand and Wrist

Which of the following anatomical landmarks best approximates the origin of the recurrent motor branch of the median nerve in the palm, serving as a safe zone reference during limited open carpal tunnel release?

. The intersection of Kaplan's cardinal line and a line drawn along the radial border of the middle finger
. The intersection of Kaplan's cardinal line and the distal wrist crease
. The intersection of the superficial palmar arch and the flexor retinaculum
. The hook of the hamate and the pisiform
. The intersection of the distal palmar crease and the longitudinal axis of the index finger

Correct Answer & Explanation

. The intersection of Kaplan's cardinal line and a line drawn along the radial border of the middle finger

Explanation

The recurrent motor branch of the median nerve generally arises near the intersection of Kaplan's cardinal line and a longitudinal line extending from the radial border of the middle finger. It curves radially to innervate the thenar musculature.

Question 3299

Topic: 7. Hand and Wrist

A 22-year-old male sustains a displaced fracture of the scaphoid waist. Avascular necrosis of the proximal pole is a known major complication. What is the primary arterial supply to the proximal pole of the scaphoid that dictates this risk pattern?

. Volar carpal branch of the radial artery entering distally
. Dorsal carpal branch of the radial artery entering distally
. Superficial palmar arch branches entering proximally
. Deep palmar arch branches entering volarly
. Anterior interosseous artery branches entering proximally

Correct Answer & Explanation

. Dorsal carpal branch of the radial artery entering distally

Explanation

The primary blood supply to the scaphoid is retrograde, originating predominantly from the dorsal carpal branch of the radial artery. This vessel enters the scaphoid distally at the dorsal ridge, making proximal pole fractures highly susceptible to avascular necrosis.

Question 3300

Topic: 7. Hand and Wrist

A rock climber sustains an acute closed rupture of the A2 pulley in his middle finger. Based on flexor tendon pulley anatomy, the normal A2 pulley originates from the periosteum of which structure?

. The volar plate of the metacarpophalangeal joint
. The proximal half of the proximal phalanx
. The distal half of the proximal phalanx
. The volar plate of the proximal interphalangeal joint
. The shaft of the middle phalanx

Correct Answer & Explanation

. The proximal half of the proximal phalanx

Explanation

The A2 and A4 pulleys are the major biomechanical stabilizers of the flexor tendons and arise directly from bone. The A2 pulley originates from the periosteum of the proximal half of the proximal phalanx.

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