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7. Hand and Wrist MCQs

Practice Set 18 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 341

Topic: 7. Hand and Wrist

Dupuytren contracture is a progressive disease involving:

. Proliferative fibrodysplasia of the flexor tendons in the palm.
. Pretendinous bands of the palmar aponeurosis which form nodules and cords causing metacarpophalangeal joint contracture.
. A chronic inflammatory response with an increase in type 2 collagen in the flexor tendon sheath.
. C ontracture beginning distally at the level of the distal interphalangeal joint and extending proximally as the disease progresses.
. A predilection for young women between the ages of 20 and 40 with exacerbation of symptoms during pregnancy.

Correct Answer & Explanation

. Pretendinous bands of the palmar aponeurosis which form nodules and cords causing metacarpophalangeal joint contracture.

Explanation

Dupuytren contracture involves proliferative fibrodysplasia of the subcutaneous palmar connective tissue. The flexor tendons are not involved. Pretendinous bands of the palmer aponeurosis form nodules and cords causing metacarpophalangeal joint contracture. The interphalangeal joint can be affected but only rarely is the distal interphalangeal joint involved. There is no inflammatory response but a proliferation of myofibroblasts with an increase in Type 3 collagen. The disease is most often seen in men between the ages of 40 and 60 years old and is associated with epilespy, alcoholism and diabetes. C arpal tunnel syndrome is often seen in young women and can be exacerbated by pregnancy.

Question 342

Topic: Nerve & Tendon
Which of the following statements is true?
. Spinner's sign is an early sign of anterior interosseous nerve compression.
. Electromyography/nerve conduction velocity is usually normal in pronator syndrome.
. The ligament of Struthers and the arcade of Struthers refer to the same structure.
. Forearm pronation is usually weak with anterior interosseous nerve syndrome.
. The pain of pronator syndrome is dull aching in the proximal forearm that is worse with activity and awakens patients at night.

Correct Answer & Explanation

. Electromyography/nerve conduction velocity is usually normal in pronator syndrome.

Explanation

Electromyography/nerve conduction velocity is usually normal in pronator syndrome, but abnormal in anterior interosseous nerve syndrome. The arcade of Struthers describes a possible point of compression of the ulnar nerve. The ligament of Struthers describes a possible point of compression of the median nerve. In AIN syndrome, forearm pronation may be weak due to weakness of the pronator quadratus, but the pronator teres is unaffected. There is no strict correlation between the pain of pronator syndrome and sleeplessness.

Question 343

Topic: 7. Hand and Wrist
Initial treatment for De Quervain disease involves:
. Occupational therapy with active range of motion and strengthening of the wrist extensors.
. Surgical release of the extensor pollicis longus tendon as it wraps around Lister's tubercle.
. Steroid injection of the second dorsal compartment followed by range of motion exercises.
. Activity modification, steroid injection of the first dorsal compartment, followed by splinting full time for 3 to 4 weeks.
. Surgical release of the first dorsal compartment.

Correct Answer & Explanation

. Activity modification, steroid injection of the first dorsal compartment, followed by splinting full time for 3 to 4 weeks.

Explanation

Initial treatment for De Quervain tenosynovitis involves rest and splinting with steroid injection into the first dorsal compartment. The splint should be worn as much as possible for 3 to 4 weeks. The extensor carpi radialis brevis has been implicated in lateral epicondylitis. The extensor pollicis longus can be a source of pain as it wraps over the wrist extensor giving the classic symptoms of intersection syndrome between the second and third dorsal compartments. Surgical release is only indicated in persistent cases that have failed conservative management. In 20% to 30% of cases, the first compartment is divided by longitudinal septations into two distinct tunnels. Care must be taken to identify and release both of these tunnels, as well as any multiple tendinous slips, when performing a surgical release.

Question 344

Topic: Nerve & Tendon

The ulnar nerve arises from:

. The lateral cord of the brachial plexus containing fibers from the C 6 and C 7 nerve roots.
. The medial cord of the brachial plexus containing fibers from the C 8 and T1 nerve roots.
. The posterior cord of the brachial plexus containing fibers of the C 5 and C 6 nerve roots.
. The lateral trunk of the brachial plexus containing fibers from C 7 through T1.
. The C 5 through C 7 nerve roots immediately before the upper trunk.

Correct Answer & Explanation

. The medial cord of the brachial plexus containing fibers from the C 8 and T1 nerve roots.

Explanation

The ulnar nerve is the continuation of the medial cord of the brachial plexus containing fibers of the C 8 and T1 nerve roots. Radiculopathy at the C 8-T1 level may mimic a more distal compression of the nerve in the cubital tunnel. The axillary and radial nerves come off the posterior cord. There is no lateral trunk of the brachial plexus. The nerve to the rhomboids comes directly off of the C 5 nerve root and its presence is often helpful in differentiating pre-ganglionic from post-ganglionic lesions of the brachial plexus. The lateral cord forms the musculocutaneous nerve. The medial cord forms the ulnar nerve. The medial and lateral cords form the median nerve. The radial nerve arises from the posterior cord.

Question 345

Topic: Nerve & Tendon

Which of the following statements is true:

. Posterior interosseous nerve syndrome and radial tunnel syndrome describe the same clinical syndrome with separate causes.
. The radial nerve spirals around the humeral shaft with the radial artery.
. The posterior interosseous nerve contains both motor and sensory fibers.
. Wartenberg's sign and Wartenberg's syndrome are both related to radial nerve compression.
. The most common site of proximal radial nerve compression is the leash of Henry.

Correct Answer & Explanation

. Wartenberg's sign and Wartenberg's syndrome are both related to radial nerve compression.

Explanation

The PIN contains motor fibers to the EDC , EDQP, EC U, APL, EPB, EPL, and EIP. Occasionally it gives motor fibers to the EC RB. It terminates with a sensory branch to the carpus and wrist capsule. There is, however, no cutaneous sensation. In radial tunnel syndrome, the entire radial nerve is compressed, including a sensory component. The radial nerve passes posteriorly and laterally next to the humerus, but not with the radial artery. Wartenberg's sign is an isolated ulnar nerve palsy. This syndrome relates to the compression of the superficial branch of the radial nerve. The most common site of radial nerve compression is the arcade of Frohse.

Question 346

Topic: Nerve & Tendon

The treatment of stenosing tenosynovitis should include all of the following except:

. Release of the A1 pulley.
. Release of the A1 pulley and flexor tendon tenosynovectomy.
. Splinting and nonsteroidal anti-inflammatory drugs (NSAIDs).
. Steroid injections between the flexor tendon and the A1 pulley.
. Release of the A1 and A2 pulleys.

Correct Answer & Explanation

. Release of the A1 pulley.

Explanation

The A2 pulley should not be released as part of the treatment for trigger finger. Its presence, along with the A4 pulley, is important in maintaining efficient flexor tendon function. The pathology usually involves the A1 pulley and its release is usually all that is necessary. Other modalities include NSAIDs, splinting, tenosynovectomy, and steroid injections.

Question 347

Topic: 7. Hand and Wrist

Swan-neck deformity can be caused by which of the following:

. C entral slip rupture
. Flexor digitorum profundus avulsion fracture (Jersey finger)
. Acute extensor tendon avulsion fracture
. Dorsal proximal interphalangeal joint dislocation (middle phalanx dorsal to proximal phalanx)
. Metaphalangeal (MP) arthroplasty

Correct Answer & Explanation

. Dorsal proximal interphalangeal joint dislocation (middle phalanx dorsal to proximal phalanx)

Explanation

A chronic mallet finger results in proximal retraction of the extensor mechanism and overpull of the central slip. Isolated central slip rupture does not cause this deformity. Rupture of the flexor digitorum sublimis can cause Swan-neck deformity. MP arthroplasty is not associated with this deformity. The sequalae of dorsal proximal interphalangeal joint dislocation (e.g., volar plate laxity or deficiency) leads to Swan-neck deformity.

Question 348

Topic: Nerve & Tendon
Which of the following identifies the clinical finding of inadvertent hyperextension of the thumb metacarpophalangeal joint during attempted thumb-index finger pinch?
. Froment's sign
. Jeanne's sign
. Duchenne's sign
. Pollock's sign
. Wartenberg's sign

Correct Answer & Explanation

. Jeanne's sign

Explanation

Jeanne's sign identifies thumb metacarpophalangeal joint hyperextension of 10° to 15° with key pinch or gross grip. Froment's sign refers to the exaggeration of thumb interphalangeal joint flexion during key pinch by the flexor pollicis longus in ulnar nerve palsies. Wartenberg's sign is the inability to adduct the extended small finger due to an ulnar nerve palsy. Duchenne's sign refers to clawing of the ring and small fingers. Pollock's sign is the inability to flex the distal interphalangeal joints of the ring and small fingers in high palsies.

Question 349

Topic: 7. Hand and Wrist

The Bunnell procedure to provide index finger abduction in ulnar nerve palsies refers to:

. Transfer extensor indicis proprius (EIP) to the first dorsal interosseous
. Split and transfer EIP to the first dorsal interosseous and the adductor pollicis
. Transfer extensor pollicis brevis (EPB) to the first dorsal interosseous
. Transfer EPB with EIP to the adductor pollicis
. Transfer flexor digitorum sublimis to the proximal phalanx of the thumb

Correct Answer & Explanation

. Transfer extensor indicis proprius (EIP) to the first dorsal interosseous

Explanation

The Bunnell procedure transfers the EIP to the first dorsal interosseous. Answers B through E refer to the Omer technique, Bruner technique, Abreu technique, and Graham procedure or Riordan procedure, respectively.

Question 350

Topic: 7. Hand and Wrist

Ganglions most commonly arise from the:

. Scapholunate interosseous ligament
. Scaphotrapezial joint
. Pisotriquetral joint
. Dorsal distal interphalangeal joint
. Flexor tendon sheath

Correct Answer & Explanation

. Scapholunate interosseous ligament

Explanation

Sixty percent to 70% of all ganglion cysts occur on the dorsum of the wrist. A majority of ganglions emanate from the scapholunate interosseous ligament. Volar wrist ganglions are prevalent in 16% to 20% of cases, followed by volar retinacular ganglions occurring at the metacarpophalangeal joints and proximal interphalangeal joints (7% to 12%), and mucous cysts presenting dorsally at the level of the joint.

Question 351

Topic: 7. Hand and Wrist

Pain from a dorsal carpal ganglion is caused by:

. Tendinitis
. Posterior interosseous nerve impingement
. Median nerve impingement
. Premalignant synovial degeneration
. Mass effect

Correct Answer & Explanation

. Posterior interosseous nerve impingement

Explanation

Dorsal carpal ganglions arising from the scapholunate interosseous ligament may expand to a large size without causing significant pain. Alternatively, small ganglions that compress the sensory terminus of the posterior interosseous nerve may be painful. The median nerve, on the volar side of the wrist, is not affected by dorsal ganglions. Dorsal carpal ganglions are benign. They have no potential for malignant degeneration and are not a significant cause of tendinitis.

Question 352

Topic: Nerve & Tendon

The following pair of tendons is affected in De Quervain disease:

. Extensor pollicis longus and extensor pollicis brevis
. Abductor pollicis longus and extensor pollicis longus
. Abductor pollicis brevis and extensor pollicis longus
. Opponens pollicis and abductor pollicis brevis
. Abductor pollicis longus and extensor pollicis brevis

Correct Answer & Explanation

. Abductor pollicis longus and extensor pollicis brevis

Explanation

De Quervain disease affects the tendons in the first dorsal compartment, the extensor pollicis brevis and the abductor pollicis longus (consisting of 2 to 7 individual tendon slips). The extensor pollicis longus traverses the third dorsal compartment. The abductor pollicis brevis and the opponens pollicis are thenar muscles and do not lie within any of the dorsal compartments.

Question 353

Topic: Nerve & Tendon

Poor or incomplete resolution of symptoms following first dorsal compartment release for De Quervain disease would most likely occur as a result of:

. Early return to activity
. Superficial radial sensory nerve injury
. Abductor pollicis longus laceration
. Incomplete release
. Pseudoaneurysm in the radial artery

Correct Answer & Explanation

. Incomplete release

Explanation

The most common reason for recurrent or persistent symptoms of first dorsal compartment stenosis is failure to recognize and release a separate extensor pollicis brevis subsheath. The superficial radial sensory nerve may be injured in surgery for De Quervain disease, but the resulting neuroma is often more painful than the original symptoms and is of a different character. Abductor pollicis longus laceration would result in loss of radial abduction of the thumb. Early motion of the thumb is recommended following release of the first dorsal compartment.

Question 354

Topic: 7. Hand and Wrist

When performing a tendon transfer to restore thumb index finger lateral pinch in an ulnar nerve palsy, which tendon, when transferred to the 1st dorsal interosseous provides the greatest power?

. Flexor digitorum profundus (FDP)
. Extensor indicis proprius (EIP)
. Extensor digitorum communis (EDC )
. Extensor carpi radialis brevis (EC RB)
. Extensor carpi radialis lingus (EC RL)

Correct Answer & Explanation

. Extensor carpi radialis brevis (EC RB)

Explanation

The EC RB transfer gives the greatest return of power pinch due to the strength of this wrist motor. This transfer should be coupled with a thumb MP arthrodesis to provide the best results. The ideal pinch transfer is an extensor pollicis brevis to first dorsal interosseous with a metaphalangeal (MP) arthrodesis at the thumb. The FDP and EDC tendons are not good choices because they are not independent tendons. The EIP provides power, but the vector of the transfer is not ideal. Transfer of the EC RL would unbalance the wrist.

Question 355

Topic: 7. Hand and Wrist

In the diagnosis of a boutonniere deformity, a patient will not present with:

. Laxity in the intrinsic system leading to passive hyperflexion of the distal interphalangeal joint, with the proximal interphalangeal joint held in extension.
. Ecchymosis at the base of the middle phalanx, with a dorsal avulsion fragment from the middle phalanx base on the x-ray.
. Full extension at the proximal interphalangeal joint, with the wrist and metacarpophalangeal joint fully flexed but inability to extend the distal interphalangeal joint with the hand in this position.
. Active hyperextension at the proximal interphalangeal joint, with full flexion at the distal interphalangeal joint, but no active flexion at the proximal interphalangeal joint.
. Pain and swelling over the metacarpophalangeal joint, with full flexion and extension over the proximal interphalangeal joint and distal interphalangeal joint.

Correct Answer & Explanation

. Active hyperextension at the proximal interphalangeal joint, with full flexion at the distal interphalangeal joint, but no active flexion at the proximal interphalangeal joint.

Explanation

A boutonniere deformity refers to a finger in which the PIP joint is in a flexed position and the DIP joint is in a hyperextended position. These deformities may be acute or chronic. With the exception of answer choice D, all of the other answers describe possible presentations of a patient with boutonniere deformity. A patient with active hyperextension at the PIP joint with full flexion at the DIP joint, but no active flexion at the PIP joint has a swan-neck deformity.

Question 356

Topic: 7. Hand and Wrist

In the diagnosis of a boutonniere deformity, a patient may present with:

. Laxity in the intrinsic system leading to passive hyperflexion of the distal interphalangeal joint, with the proximal interphalangeal joint held in extension.
. Flexion deformity of the PIP joint with ecchymosis at the base of the middle phalanx, with a dorsal avulsion fragment at the middle phalanx base on radiograph, as well as inability to actively extend the PIP joint.
. Full extension at the proximal interphalangeal joint, with the wrist and metacarpophalangeal joint fully flexed but inability to extend the distal interphalangeal joint with the hand in this position.
. Active hyperextension at the proximal interphalangeal joint, with full flexion at the distal interphalangeal joint, but no active flexion at the proximal interphalangeal joint.
. Pain and swelling over the metacarpophalangeal joint, with full flexion and extension over the proximal interphalangeal joint and distal interphalangeal joint.

Correct Answer & Explanation

. Flexion deformity of the PIP joint with ecchymosis at the base of the middle phalanx, with a dorsal avulsion fragment at the middle phalanx base on radiograph, as well as inability to actively extend the PIP joint.

Explanation

A bony boutonniere injury is a fracture of the base of middle phalanx with the central slip of the extensor mechanism attached. With this injury, the patient is unable to actively extend the PIP joint from its flexed position.

Question 357

Topic: Nerve & Tendon

All of the following may be seen with preganglionic lesion EXC EPT:

. Horner syndrome
. Hemi-diaphragmatic palsy
. Positive Histamine test
. Tinel sign

Correct Answer & Explanation

. Tinel sign

Explanation

Tinel sign is seen with postganglionic lesions.

Question 358

Topic: 7. Hand and Wrist

A patient sustains a laceration to the volar aspect of the index finger over the proximal phalanx (Zone II). During surgical repair, both the flexor digitorum superficialis (FDS) and profundus (FDP) tendons are found to be completely transected. What is the current standard of care regarding the repair of these tendons?

. Repair only the FDP and excise the FDS slips
. Repair both FDP and FDS tendons
. Repair only the FDS and excise the FDP
. Perform a primary tendon graft
. Perform a two-stage tendon reconstruction

Correct Answer & Explanation

. Repair both FDP and FDS tendons

Explanation

The current standard of care for Zone II flexor tendon injuries is primary repair of both the FDS and FDP tendons. Repairing both helps maintain the blood supply via the vincula, reduces the risk of joint contracture, and provides a smoother gliding surface.

Question 359

Topic: 7. Hand and Wrist

A 28-year-old male sustains a proximal pole scaphoid fracture. The fracture is displaced by 2 mm. Which of the following represents the most reliable blood supply to the scaphoid, explaining the high risk of avascular necrosis in this fracture pattern?

. Volar carpal branch of the radial artery
. Dorsal carpal branch of the radial artery entering distally
. Dorsal carpal branch of the ulnar artery entering proximally
. Superficial palmar arch entering at the waist
. Anterior interosseous artery entering the proximal pole

Correct Answer & Explanation

. Dorsal carpal branch of the radial artery entering distally

Explanation

The scaphoid receives 70-80% of its blood supply from the dorsal carpal branch of the radial artery, which enters at the dorsal ridge and flows retrograde to the proximal pole. Proximal pole fractures disrupt this retrograde supply, leading to a high rate of avascular necrosis.

Question 360

Topic: 7. Hand and Wrist
A 35-year-old male presents with scaphoid nonunion advanced collapse (SNAC). Radiographs show arthritis involving the radioscaphoid and capitolunate joints, but the radiolunate joint is spared. Which surgical procedure is most appropriate?
. Scaphoid excision and four-corner arthrodesis
. Proximal row carpectomy
. Total wrist arthroplasty
. Radioscapholunate arthrodesis
. Scaphoid open reduction and internal fixation

Correct Answer & Explanation

. Scaphoid excision and four-corner arthrodesis

Explanation

In Stage III SNAC wrists, arthritis involves the capitolunate joint, making a proximal row carpectomy contraindicated due to an arthritic capitate head. Scaphoid excision with four-corner arthrodesis relies on the spared radiolunate joint for residual motion.

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