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7. Hand and Wrist MCQs

Practice Set 17 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 321

Topic: Hand Trauma & Infection
Septic flexor tenosynovitis may involve all of the following areas except the:
. Radial bursa
. Thenar space
. Parona's space
. Snuffbox
. Ulnar bursa

Correct Answer & Explanation

. Snuffbox

Explanation

The radial and ulnar bursae are extensions of the tendon sheaths of the flexor pollicis longus and the flexor digitorum profundus of the small fingers. They can easily be involved in a case of pyogenic flexor tenosynovitis. Although not direct extensions of the flexor sheaths, the thenar space and Parona's space are adjacent to the flexor sheaths and can be involved in suppurative conditions. The snuffbox, however, does not have any contributions from the flexor system and is not usually involved in cases of pyogenic flexor tenosynovitis.

Question 322

Topic: 7. Hand and Wrist
Meleney's infection is a:
. Spreading ulcer rimmed with gangrenous skin
. Patchy gangrenous involvement of the hand
. Dry gangrene with superimposed infection
. Multiple infective ulcer of the forearm
. Creates a sinus fistula to the midcarpal space

Correct Answer & Explanation

. Spreading ulcer rimmed with gangrenous skin

Explanation

Found in necrotizing fasciitis, Meleney's infection is a spreading ulcer rimmed with gangrenous skin. The affected area must be debrided immediately. Cultures are taken at the time of surgery to tailor antibiotic coverage. Amputation is not unusual to control the spread of the gangrenous infection.

Question 323

Topic: Hand Trauma & Infection
"Collar button" abscess refers to:
. Web space infection
. Finger pulp infection
. Extension of infection from mid-palmar space to Parona's space in the forearm
. Eponychial infection
. Septic joint with dorsal and palmar extension

Correct Answer & Explanation

. Web space infection

Explanation

Collar button abscess is an infection of the web space and is usually a result of penetrating trauma. Treatment of such abscesses requires incision and drainage through dorsal and palmar incisions. Care must be taken to avoid the neurovascular bundles. Finger pulp infections are known as a felon. Infections involving Parona's space are typically involved in a horseshoe abscess. Eponychial infections are limited to the nail fold. Collar button abscesses do not include joint involvement.

Question 324

Topic: 7. Hand and Wrist

All of the following nerves are involved in infection with Mycobacterium leprae except the:

. Ulnar nerve at the elbow
. Median nerve in the carpal tunnel
. Supraorbital nerve
. Vagus nerve
. Spinal accessory nerve

Correct Answer & Explanation

. Ulnar nerve at the elbow

Explanation

Mycobacterium leprae causes skin, nerve, and tendon sheath infections. M leprae commonly affects the hands because it has a predilection for cool parts of the body. M leprae causes neuropathy, which frequently involves the ulnar nerve at the elbow and the median nerve at the wrist. The resulting limb deformities require various surgical procedures. C ranial nerves and autonomic nerves are not affected.

Question 325

Topic: 7. Hand and Wrist

Which of the following is the atypical mycobacterium that infects a penetrating wound sustained in an aquatic environment:

. Mycobacterium avium
. Mycobacterium marinum
. Mycobacterium aquaticum
. Mycobacterium tuberculosis hominis
. Mycobacterium chelorei

Correct Answer & Explanation

. Mycobacterium marinum

Explanation

Tuberculosis is the most common chronic infection found in the hand. Mycobacterium marinum is the atypical mycobacterium that can infect a wound sustained in a marine environment, freshwater lake, or tropical fish tanks. It is also called swimming pool granuloma or fish tank granuloma.

Question 326

Topic: 7. Hand and Wrist

Which of the following is not true for infections caused by Mycobacterium marinum:

. Noncaseating granuloma is present.
. Minocycline is the preferred treatment.
. Lowenstein-Jensen media can be used for cultures.
. Painful swelling of digit, palm, or wrist is present with redness, warmth, and tenderness.
. It is also referred to as fish tank granuloma.

Correct Answer & Explanation

. Painful swelling of digit, palm, or wrist is present with redness, warmth, and tenderness.

Explanation

Tuberculous infections are chronic infections and do not produce acute signs of inflammation. Therefore, pain and tenderness are present in these infections but warmth and redness are absent. Abscesses produced in tuberculous infections are termed "cold abcesses."

Question 327

Topic: 7. Hand and Wrist
Which of the following structures contribute to the formation of the spiral cord:
. Pretendinous band, Grayson's ligament, and Cleland's ligament
. Pretendinous band, lateral digital sheet, and Grayson's ligament
. Pretendinous band, Landsmeer ligament, and Grayson's ligament
. Pretendinous band, Landsmeer ligament, and natatory ligament
. Cleland's ligament and Grayson's ligament

Correct Answer & Explanation

. Pretendinous band, lateral digital sheet, and Grayson's ligament

Explanation

The spiral cord is formed from the pretendinous band, spiral band, Grayson's ligament, and lateral digital sheet. Cleland's ligament is not affected in Dupuytren's contracture. Remember that bands and ligaments give rise to cords, which are the diseased state.

Question 328

Topic: 7. Hand and Wrist
Surgical release in Dupuytren's disease is indicated in which of the following:
. A 15° metacarpophalangeal (MP) joint contracture and a 15° proximal interphalangeal (PIP) joint contracture
. A 15° MP joint contracture and a 0° PIP joint contracture
. Palpable spiral cord involving ring and small fingers
. Palpable spiral cord involving ring and small fingers with multiple skin pits
. Palpable spiral cord involving ring and small fingers in both of the hands

Correct Answer & Explanation

. A 15° metacarpophalangeal (MP) joint contracture and a 15° proximal interphalangeal (PIP) joint contracture

Explanation

The indication for surgery in Dupuytren's disease is MP joint contracture larger than 30° and any degree of PIP joint deformity. The other answers are incorrect because they are subjective descriptions and do not necessarily indicate joint involvement.

Question 329

Topic: 7. Hand and Wrist
A 35-year-old male presents with chronic wrist pain. Radiographs reveal a scaphoid nonunion advanced collapse (SNAC) pattern with arthritis involving the radioscaphoid and capitolunate joints. The radiolunate joint is spared. What is the most appropriate surgical intervention?
. Scaphoid excision and four-corner fusion
. Proximal row carpectomy (PRC)
. Total wrist arthroplasty
. Radial styloidectomy
. Vascularized bone grafting

Correct Answer & Explanation

. Scaphoid excision and four-corner fusion

Explanation

In a Stage II or III SNAC wrist where the capitolunate joint is arthritic but the radiolunate joint is spared, a scaphoid excision and four-corner fusion is indicated. Proximal row carpectomy is contraindicated if the capitate head is arthritic.

Question 330

Topic: 7. Hand and Wrist
A 28-year-old carpenter sustains a laceration to the volar aspect of his index finger at the level of the proximal phalanx, resulting in loss of both superficialis and profundus tendon function. This injury corresponds to which flexor tendon zone?
. Zone I
. Zone II
. Zone III
. Zone IV
. Zone V

Correct Answer & Explanation

. Zone II

Explanation

Zone II, historically known as "no man's land," extends from the A1 pulley to the insertion of the flexor digitorum superficialis (FDS). Injuries here involve both the FDS and FDP tendons within the narrow fibro-osseous sheath.

Question 331

Topic: Nerve & Tendon

A 6-year-old boy sustains a significantly displaced extension-type supracondylar humerus fracture. On examination, he has weakness of thumb interphalangeal joint flexion and index finger distal interphalangeal joint flexion. Which nerve is injured?

. Ulnar nerve
. Posterior interosseous nerve
. Anterior interosseous nerve
. Superficial radial nerve
. Musculocutaneous nerve

Correct Answer & Explanation

. Anterior interosseous nerve

Explanation

The anterior interosseous nerve (AIN), a branch of the median nerve, is the most commonly injured nerve in extension-type supracondylar humerus fractures. Injury manifests as an inability to make an "OK" sign due to weakness of the FPL and index FDP.

Question 332

Topic: 7. Hand and Wrist

In Scapholunate Advanced Collapse (SLAC) of the wrist, which articular surface is typically spared due to its concentric articulation?

. Radioscaphoid joint
. Capitolunate joint
. Radiolunate joint
. Scaphotrapezial joint
. Capitoscaphoid joint

Correct Answer & Explanation

. Radiolunate joint

Explanation

The radiolunate joint is typically spared in SLAC wrists because the lunate maintains a concentric, congruent articulation with the lunate fossa of the distal radius. This distinct biomechanical feature allows for motion-preserving salvage procedures like the four-corner fusion.

Question 333

Topic: 7. Hand and Wrist

In the flexor tendon zone classification of the hand, Zone II extends from the insertion of the flexor digitorum superficialis (FDS) proximally to which of the following landmarks?

. The carpal tunnel
. The distal palmar crease (proximal edge of the A1 pulley)
. The metacarpophalangeal joint line
. The proximal interphalangeal joint line
. The wrist flexion crease

Correct Answer & Explanation

. The distal palmar crease (proximal edge of the A1 pulley)

Explanation

Zone II, historically known as "no man's land" due to poor primary repair outcomes, begins at the proximal edge of the A1 pulley near the distal palmar crease. It ends distally at the insertion of the FDS tendon on the middle phalanx.

Question 334

Topic: Nerve & Tendon

A cyclist presents with numbness in the ring and small fingers along with weakness in finger abduction. Sensation over the dorsal ulnar aspect of the hand is preserved. Where is the most likely site of ulnar nerve compression?

. Cubital tunnel
. Arcade of Struthers
. Zone 1 of Guyon's canal
. Zone 2 of Guyon's canal
. Zone 3 of Guyon's canal

Correct Answer & Explanation

. Zone 1 of Guyon's canal

Explanation

Compression in Zone 1 of Guyon's canal affects both the motor and sensory branches of the ulnar nerve. Preserved dorsal ulnar sensation rules out cubital tunnel syndrome, as the dorsal ulnar cutaneous nerve branches off proximal to the wrist.

Question 335

Topic: Nerve & Tendon
A 25-year-old rugby player presents with an inability to actively flex the distal interphalangeal (DIP) joint of his ring finger after grabbing an opponent's jersey. Radiographs show a bony avulsion fragment retracted to the level of the proximal interphalangeal (PIP) joint. According to the Leddy and Packer classification, what type of injury is this?
. Type I
. Type II
. Type III
. Type IV
. Type V

Correct Answer & Explanation

. Type II

Explanation

In a Leddy and Packer Type II Jersey finger, the flexor digitorum profundus (FDP) tendon retracts to the level of the PIP joint. It is held in this position by the intact vinculum longum, which preserves some of its blood supply.

Question 336

Topic: Nerve & Tendon

A 50-year-old diabetic female complains of locking and pain at the base of her right thumb. Examination reveals a palpable nodule over the palmar aspect of the metacarpophalangeal joint. The pathology of this condition primarily involves thickening of which specific pulley?

. A1 pulley
. A2 pulley
. A3 pulley
. Oblique pulley
. A4 pulley

Correct Answer & Explanation

. A1 pulley

Explanation

Trigger digit (stenosing tenosynovitis) is caused by a size mismatch between the flexor tendon and the A1 pulley, leading to catching or locking. Surgical release specifically targets the A1 pulley.

Question 337

Topic: Nerve & Tendon

A typical presentation of thoracic outlet syndrome is likely to include:

. An upper plexus constellation involving median nerve innervated muscles being the most common.
. Sensory loss and diminished strength at initial evaluation
. Venous obstruction presenting as edema and cyanosis progress to subclavian or axillary vein thrombosis.
. Symptoms that are present at rest and alleviated by upper extremity acitivity
. Normal somatosensory evoked potentials in the affected extremity

Correct Answer & Explanation

. Venous obstruction presenting as edema and cyanosis progress to subclavian or axillary vein thrombosis.

Explanation

A lower plexus symptom constellation involving muscles supplied by the ulnar nerve is most typical of thoracic outlet syndrome. Objective signs of sensory loss and diminished strength are often not found. Somatosensory evoked potential abnormalities are common (74%), but are non-specific and may be seen in asymptomatic individuals. Although venous obstruction is rare, it may lead to subclavian or axillary vein thrombosis necessitating fibrinolytic treatment. Symptoms are usually exacerbated by upper extremity activities.

Question 338

Topic: 7. Hand and Wrist

The term acrosyndactyly describes digits that are:

. Joined by bone only
. Joined by soft tissue only
. Joined proximally but separated distally
. Joined along the entire length of the web space
. Joined at the tips but separated proximally

Correct Answer & Explanation

. Joined at the tips but separated proximally

Explanation

Acrosyndactyly describes digits that are joined distally but remain separated by a proximal cleft. Acrosyndactylized digits initially develop normal web spaces, but are subsequently joined by secondary events, such as the formation of constriction bands. In contrast to syndactylized fingers, which remain joined due to failure of formation of the web space between contiguous digits, acrosyndactyly may form between non-contiguous digits. C omplex syndactyly involves a confluence of distal osseous and nail elements in addition to soft-tissue bridging. Simple syndactyly describes digits that are joined by soft tissue only. Finally, complete syndactyly refers to digits that are joined along their entire lengths, while incomplete syndactyly describes a web that extends more distally than usual, but not all the way to the finger tips.

Question 339

Topic: 7. Hand and Wrist
Syndactyly may be isolated, it may be bilateral, or it may occur as part of a broader genetic syndrome. Which of the following syndromes are commonly associated with syndactyly?
. Down syndrome (trisomy-21)
. Poland's anomaly
. Marfan syndrome
. VATER association
. Hunter syndrome

Correct Answer & Explanation

. Poland's anomaly

Explanation

Individuals afflicted by Poland's anomaly exhibit unilateral symbrachydactyly (simple syndactyly with short or absent middle phalanges), absent sternocostal head of the pectoralis major, and hypoplasia of the ipsilateral breast and nipple. Apert's syndrome, the other syndrome most commonly associated with syndactyly, is characterized by complex acrosyndactyly of the hands and feet associated with premature closure of the cranial sutures. The features of the VATER association include vertebral anomalies and/or ventricular septal defect, anal atresia, T-E fistula, and renal anomalies and/or radial dysplasia (pre-axial syndactyly is a possible but inconsistent feature). Individuals with Marfan syndrome exhibit arachnodactyly in addition to retinal detachments, lens subluxations, aortic dilatations/aneurysms, and tall stature with long, thin limbs. Hand manifestations of Down syndrome include short metacarpals and phalanges, clinodactyly, and abnormal crease patterns, but not syndactyly. Hunter syndrome (mucopolysaccharidosis II) is marked by stiffened joints and the development of a clawhand, but not by syndactyly.

Question 340

Topic: 7. Hand and Wrist

Surgical separation of syndactylized fingers produces two separate digits with an increase in total surface area. How are the gaps in coverage left by eliminating the common side between the two fingers best addressed:

. Full-thickness skin graft
. Split-thickness skin graft
. Fascio-cutaneous graft
. Rotation flap
. No graft is necessary; the defects will heal by secondary intention

Correct Answer & Explanation

. Full-thickness skin graft

Explanation

If syndactyly release is to be successful, contractures must be avoided at all costs. Tension-free closures are imperative to this effort. The surface area of two complete fingers is substantially greater than that of two fingers that share a common side, so primary closure of the skin on both sides of the new web is not possible without tension except in very proximal, incomplete syndactylies. For this reason, a strategy other than primary closure is necessary. Healing by secondary intention and splitthickness grafting are both prone to produce contracture. Fascio-cutaneous grafting and rotation flaps are unnecessary, since the defect is confined to the dermal layer. Full- thickness skin graft is least likely to contract, and thus is the material of choice for closing the separated digits.

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