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7. Hand and Wrist MCQs

Practice Set 194 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 3861

Topic: 7. Hand and Wrist
A 35-year-old patient presents with chronic pain and stiffness in the left wrist, diagnosed with Kienböck's disease, Lichtman Stage IIIA. Radiographs show evidence of lunate collapse and increased sclerosis, but no radioscaphoid arthritis. The patient has a positive ulnar variance. Which of the following surgical interventions is most appropriate to relieve pain and preserve wrist motion in this stage?
. Total wrist arthrodesis
. Proximal row carpectomy (PRC)
. Radial shortening osteotomy
. Capitolunate fusion
. Lunate excision with tendon interposition

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

For Lichtman Stage IIIA Kienböck's disease with positive ulnar variance (meaning the ulna is longer than the radius), a radial shortening osteotomy is the most appropriate surgical intervention. This procedure aims to reduce the load on the lunate, potentially halting or slowing disease progression, relieving pain, and preserving wrist motion by restoring neutral or negative ulnar variance. PRC is typically reserved for later stages with significant arthritis or collapse but intact capitolunate articulation. Capitolunate fusion is a salvage procedure for later stages to prevent further collapse. Total wrist arthrodesis is a last resort for end-stage arthritis. Lunate excision is rarely performed now due to poor outcomes.

Question 3862

Topic: 7. Hand and Wrist

A patient presents with chronic Dorsal Intercalated Segment Instability (DISI) due to scapholunate (SL) dissociation, with evidence of early radioscaphoid arthritis. The patient experiences significant pain and wrist dysfunction. What is the most appropriate surgical option aimed at pain relief and preserving some wrist motion?

. Scapholunate ligament repair with K-wire fixation
. Four-corner arthrodesis (lunocapitate, triquetrohamate, triquetrolunate, scaphocapitate)
. Proximal Row Carpectomy (PRC)
. Total wrist arthrodesis
. STT (scaphotrapeziotrapezoid) fusion

Correct Answer & Explanation

. Proximal Row Carpectomy (PRC)

Explanation

For chronic DISI secondary to scapholunate dissociation with early radioscaphoid arthritis, Proximal Row Carpectomy (PRC) is a commonly performed salvage procedure. It involves excising the scaphoid, lunate, and triquetrum, allowing the capitate to articulate directly with the radius. This provides good pain relief and preserves a functional range of motion, making it a valuable option before total wrist fusion. Scapholunate ligament repair is typically for acute or subacute dissociations without significant arthritis. Four-corner arthrodesis is an option but might compromise more motion than PRC. Total wrist arthrodesis is a last resort, sacrificing all motion for complete pain relief and stability. STT fusion is for specific carpal instabilities and not directly for radioscaphoid arthritis with DISI.

Question 3863

Topic: Nerve & Tendon

A 35-year-old carpenter sustains a deep laceration to his proximal volar forearm. After wound closure, he is unable to make an 'OK' sign, demonstrating an extended distal interphalangeal joint of the index finger and an extended interphalangeal joint of the thumb. Which of the following muscles is most likely spared in this specific isolated nerve injury?

. Flexor pollicis longus
. Flexor digitorum profundus to the index finger
. Flexor digitorum profundus to the middle finger
. Pronator quadratus
. Flexor carpi radialis

Correct Answer & Explanation

. Flexor carpi radialis

Explanation

The patient has an Anterior Interosseous Nerve (AIN) palsy, characterized by the inability to form the 'OK' sign due to paralysis of the Flexor Pollicis Longus (FPL) and the Flexor Digitorum Profundus (FDP) to the index (and often middle) finger. The AIN also innervates the Pronator Quadratus. The Flexor Carpi Radialis (FCR) is innervated by the main branch of the median nerve before it gives off the AIN, and is therefore spared in an isolated AIN injury.

Question 3864

Topic: Wrist & Carpus

A patient sustains a distal radius fracture and undergoes volar locked plating. Three months postoperatively, she develops an inability to actively extend the interphalangeal joint of her thumb. During exploration, a ruptured tendon is found within the third dorsal extensor compartment. Which of the following bony landmarks does this tendon natively use as a fulcrum?

. Radial styloid
. Lister's tubercle
. Ulnar styloid
. Scaphoid tubercle
. Pisiform

Correct Answer & Explanation

. Lister's tubercle

Explanation

The tendon of the Extensor Pollicis Longus (EPL) resides solely within the 3rd dorsal extensor compartment. It uses Lister's tubercle (the dorsal tubercle of the radius) as a fulcrum to angle towards the thumb. EPL rupture is a known complication following both conservative and surgical management of distal radius fractures.

Question 3865

Topic: 7. Hand and Wrist

A 28-year-old rock climber presents with a painful 'bowstringing' deformity of his dominant long finger after hearing a loud 'pop' while dynamically loading a one-finger pocket hold. He likely ruptured the two most biomechanically critical annular pulleys. Which pulleys are these, and what are their anatomical origins?

. A1 and A3, originating primarily from the volar plates
. A2 and A4, originating primarily from the proximal and middle phalanges
. A1 and A5, originating primarily from the metacarpal and distal phalanx
. A2 and A4, originating primarily from the volar plates
. A1 and A3, originating primarily from the proximal and middle phalanges

Correct Answer & Explanation

. A2 and A4, originating primarily from the proximal and middle phalanges

Explanation

The A2 and A4 pulleys are the most critical for preventing bowstringing of the flexor tendons. They have osseous origins: the A2 pulley arises from the periosteum of the proximal phalanx, and the A4 pulley arises from the periosteum of the middle phalanx. The A1, A3, and A5 pulleys originate primarily from the volar plates of the MP, PIP, and DIP joints, respectively.

Question 3866

Topic: Nerve & Tendon

A 2-year-old girl is brought in for a locked interphalangeal joint of her right thumb. Her mother reports a small nodule at the base of the thumb on the volar surface. Active extension is absent, but passive extension is painful and yields a palpable click. What is the most appropriate initial management?

. Immediate surgical release of the A1 pulley
. Corticosteroid injection into the flexor tendon sheath
. Night splinting in extension for 6 weeks
. Observation and reassurance
. Extracorporeal shockwave therapy

Correct Answer & Explanation

. Observation and reassurance

Explanation

Pediatric trigger thumb presents with a locked IP joint in flexion and a palpable Notta's node at the A1 pulley. Unlike adult trigger digit, initial management in a young child (< 3 years) is observation, as up to 30-60% of cases will resolve spontaneously. Corticosteroid injections are generally not recommended in this age group. Surgical release of the A1 pulley is indicated if the condition persists beyond age 3 to 4 years.

Question 3867

Topic: Nerve & Tendon

A 60-year-old male with severe cubital tunnel syndrome presents with noticeable intrinsic muscle wasting in his hand. When asked to firmly pinch a piece of paper between his thumb and index finger, his thumb interphalangeal joint strongly flexes. This compensatory finding (Froment's sign) is driven by which of the following muscles?

. Flexor digitorum profundus of the index finger
. Flexor pollicis longus
. Abductor pollicis brevis
. Extensor pollicis longus
. Opponens pollicis

Correct Answer & Explanation

. Flexor pollicis longus

Explanation

Froment's sign is positive when the patient compensates for a weak adductor pollicis (ulnar nerve innervation) by heavily recruiting the flexor pollicis longus (anterior interosseous nerve/median nerve innervation) to maintain pinch grip, resulting in hyperflexion of the thumb interphalangeal joint.

Question 3868

Topic: Nerve & Tendon

During a submuscular anterior transposition of the ulnar nerve, the surgeon must diligently release all potential sites of compression. One such structure is the Arcade of Struthers. Which of the following accurately describes the anatomical location of this structure?

. A fascial band located approximately 8 cm proximal to the medial epicondyle
. A fibrous tunnel situated within the two heads of the flexor carpi ulnaris
. A dense aponeurosis at the level of the supinator muscle in the proximal forearm
. A retinacular band located strictly at Guyon's canal in the wrist
. A fibrous structure passing directly underneath the lacertus fibrosus

Correct Answer & Explanation

. A fascial band located approximately 8 cm proximal to the medial epicondyle

Explanation

The Arcade of Struthers is a fascial band extending from the medial head of the triceps to the medial intermuscular septum. It is located approximately 8 cm proximal to the medial epicondyle and is a critical potential site of ulnar nerve compression, especially if not released during anterior transposition.

Question 3869

Topic: 7. Hand and Wrist

A 40-year-old female presents with a 6-month history of aching pain in her proximal lateral forearm. Physical examination reveals no wrist or finger drop, but she has focal tenderness 4 cm distal to the lateral epicondyle. Pain is exacerbated by resisted extension of the middle finger with the elbow extended. In Radial Tunnel Syndrome, what is the most common anatomic site of nerve compression?

. Fibrous bands anterior to the radiocapitellar joint
. The recurrent radial vessels (Leash of Henry)
. The tendinous margin of the extensor carpi radialis brevis (ECRB)
. The proximal tendinous edge of the supinator muscle (Arcade of Frohse)
. The distal edge of the supinator muscle

Correct Answer & Explanation

. The proximal tendinous edge of the supinator muscle (Arcade of Frohse)

Explanation

The patient's presentation is classic for Radial Tunnel Syndrome (compression of the posterior interosseous nerve without significant motor loss). While compression can occur at the fibrous bands over the radiocapitellar joint, the Leash of Henry, or the ECRB margin, the most frequent site of PIN compression is the proximal tendinous arch of the supinator, known as the Arcade of Frohse.

Question 3870

Topic: Nerve & Tendon

During elbow arthroscopy, establishing standard portals requires precise knowledge of regional neurovascular anatomy. When creating the standard anteromedial portal, which neural structure is at the greatest risk of injury due to its close proximity (often 1-2 mm) to the arthroscopic trocar?

. Ulnar nerve
. Median nerve
. Posterior interosseous nerve
. Medial antebrachial cutaneous nerve
. Lateral antebrachial cutaneous nerve

Correct Answer & Explanation

. Medial antebrachial cutaneous nerve

Explanation

The medial antebrachial cutaneous nerve (MABCN) is the structure at greatest risk during the establishment of the anteromedial portal in elbow arthroscopy, often passing within 1-2 mm of the portal site. The ulnar nerve is protected posterior to the medial epicondyle (unless subluxated), and the median nerve is generally located further laterally, safely away from the portal if established properly.

Question 3871

Topic: 7. Hand and Wrist
A 45-year-old man falls from a ladder and sustains a highly comminuted, unsalvageable radial head fracture (Mason III). During evaluation, he is also noted to have intense pain at the wrist and extreme instability of the distal radioulnar joint (DRUJ), indicative of an Essex-Lopresti injury. If the surgeon simply excises the radial head without replacing it, what is the most profound long-term biomechanical consequence?
. Proximal migration of the radius leading to positive ulnar variance and ulnocarpal impaction
. Distal migration of the radius leading to negative ulnar variance and Kienböck's disease
. Severe varus elbow instability resulting in tardy radial nerve palsy
. Isolated proximal radioulnar joint (PRUJ) ankylosis
. Cubitus valgus leading to tardy median nerve palsy

Correct Answer & Explanation

. Proximal migration of the radius leading to positive ulnar variance and ulnocarpal impaction

Explanation

An Essex-Lopresti injury involves a radial head fracture, rupture of the interosseous membrane (IOM), and disruption of the DRUJ. The radial head and IOM are the primary stabilizers against proximal migration of the radius. If the radial head is excised and not replaced in the setting of IOM disruption, the radius will migrate proximally. This results in significant positive ulnar variance, leading to severe ulnocarpal impaction syndrome and chronic wrist pain. Radial head arthroplasty is strictly required to maintain length.

Question 3872

Topic: 7. Hand and Wrist

A 40-year-old female complains of a vague, aching pain in her proximal volar forearm. She reports numbness in the radial three and a half digits. Phalen's test and Tinel's sign at the carpal tunnel are negative. She experiences significant pain reproduction upon resisted pronation of the forearm while her elbow is held in full extension. Which structure is most likely causing the nerve compression?

. Ligament of Struthers
. Bicipital aponeurosis (lacertus fibrosus)
. Pronator teres muscle
. Flexor digitorum superficialis (FDS) fibrous arch
. Transverse carpal ligament

Correct Answer & Explanation

. Flexor digitorum superficialis (FDS) fibrous arch

Explanation

This patient has Pronator Syndrome, a proximal median neuropathy. The provocative maneuvers can help isolate the site of compression. Resisted forearm pronation with the elbow extended tests the two heads of the pronator teres. Resisted elbow flexion in supination isolates the bicipital aponeurosis (lacertus fibrosus). Resisted flexion of the PIP joint of the middle finger implicates the FDS fibrous arch.

Question 3873

Topic: 7. Hand and Wrist

A 45-year-old male presents with sudden inability to make an 'OK' sign with his thumb and index finger following an episode of viral neuritis. He has normal sensation throughout the hand and forearm. Which of the following muscle groups is innervated by the specific nerve involved in this condition?

. Flexor carpi radialis and palmaris longus
. Flexor digitorum profundus to the middle and ring fingers
. Flexor pollicis longus, flexor digitorum profundus to the index and middle fingers, and pronator quadratus
. Adductor pollicis and the deep head of the flexor pollicis brevis
. Flexor digitorum superficialis to the index, middle, ring, and small fingers

Correct Answer & Explanation

. Flexor pollicis longus, flexor digitorum profundus to the index and middle fingers, and pronator quadratus

Explanation

The inability to make the 'OK' sign implies weakness of the flexor pollicis longus (FPL) and flexor digitorum profundus (FDP) to the index finger, resulting in a pinch using the pads of the digits (Mannerfelt's sign). This is characteristic of Anterior Interosseous Nerve (AIN) syndrome. The AIN is a pure motor branch of the median nerve that innervates the FPL, the radial half of the FDP (index and middle fingers), and the pronator quadratus.

Question 3874

Topic: Wrist & Carpus

A 40-year-old female presents with a highly comminuted, un-reconstructable radial head fracture and distal radioulnar joint (DRUJ) instability after a high-energy fall.

What is the primary reason why simple radial head excision is strictly contraindicated in this specific injury pattern?

. It will lead to valgus overstuffing of the radiocapitellar joint
. It will result in proximal migration of the radius and positive ulnar variance
. It will compromise the lateral ulnar collateral ligament repair
. It will prevent the healing of a concomitant coronoid fracture
. It significantly increases the risk of posterior interosseous nerve palsy

Correct Answer & Explanation

. It will result in proximal migration of the radius and positive ulnar variance

Explanation

This patient has an Essex-Lopresti injury, characterized by a radial head fracture, rupture of the interosseous membrane (IOM), and disruption of the DRUJ. The interosseous membrane and the radial head act as the primary and secondary longitudinal stabilizers of the forearm. If the radial head is excised in the setting of an IOM tear, the radius will migrate proximally, resulting in ulnar-positive variance, chronic DRUJ pain, and functional impairment. Radial head arthroplasty is mandatory in this scenario.

Question 3875

Topic: Wrist & Carpus

A 55-year-old female sustains a complex intra-articular fracture of the distal radius. Preoperative CT reveals a small, displaced volar ulnar corner (lunate facet) fragment. Why is fragment-specific fixation of this specific piece considered critical?

. Failure to fix it leads to attritional rupture of the flexor pollicis longus (FPL) tendon
. The fragment acts as an essential buttress; failure to fix it leads to volar subluxation of the radiocarpal joint (carpus)
. It is the primary attachment site of the triangular fibrocartilage complex (TFCC) foveal fibers
. Failure to fix it prevents pronation and supination due to distal radioulnar joint (DRUJ) block
. It contains the vascular supply to the lunate, risking Kienbock's disease if left displaced

Correct Answer & Explanation

. The fragment acts as an essential buttress; failure to fix it leads to volar subluxation of the radiocarpal joint (carpus)

Explanation

The volar ulnar corner of the distal radius (volar lunate facet) contains the attachments of the stout volar radiocarpal ligaments (short radiolunate ligament). This fragment is often small and can easily 'escape' standard volar locking plates. If it is not anatomically reduced and stably fixed (e.g., with a fragment-specific hook plate or wire), the carpus will subluxate volarly with the fragment, leading to catastrophic joint failure and arthritis.

Question 3876

Topic: Wrist & Carpus

A 45-year-old female sustains a volar Barton's fracture of the distal radius. During the injury, the carpus subluxates volarly in conjunction with the distal radius fracture fragment. Which of the following volar extrinsic radiocarpal ligaments is primarily responsible for pulling the carpus volarly with the fractured fragment?

. Radioscaphocapitate and short radiolunate ligaments
. Long radiolunate and radioscapholunate ligaments
. Ulnolunate and ulnotriquetral ligaments
. Volar radioulnar ligament
. Dorsal radiocarpal ligament

Correct Answer & Explanation

. Radioscaphocapitate and short radiolunate ligaments

Explanation

A volar Barton's fracture is a fracture-dislocation where the volar rim of the distal radius shears off, and the carpus translates volarly with it. The carpus follows the volar rim fragment because the stout volar extrinsic ligaments—specifically the radioscaphocapitate (RSC) and the short radiolunate (SRL) ligaments—remain firmly attached to this volar bony fragment.

Question 3877

Topic: Nerve & Tendon

A distal humerus fracture is treated using a posterior approach with an olecranon osteotomy. During the approach, the ulnar nerve is identified and mobilized. The ulnar nerve enters the forearm between the two heads of which muscle?

. Flexor digitorum superficialis
. Pronator teres
. Flexor carpi ulnaris
. Flexor carpi radialis
. Supinator

Correct Answer & Explanation

. Flexor carpi ulnaris

Explanation

The ulnar nerve runs through the cubital tunnel posterior to the medial epicondyle. As it transitions into the proximal forearm, it passes between the humeral and ulnar heads of the flexor carpi ulnaris (FCU) muscle.

Question 3878

Topic: 7. Hand and Wrist

A volar approach to the wrist is performed for carpal tunnel release.

The palmar cutaneous branch of the median nerve must be protected. What is its typical anatomical course in relation to the main median nerve and surrounding structures at the wrist crease?

. It branches 5 cm proximal to the crease and runs ulnar to the palmaris longus.
. It branches 5 cm proximal to the crease and runs between the palmaris longus and flexor carpi radialis.
. It branches at the level of the crease and runs deep to the transverse carpal ligament.
. It branches from the ulnar nerve and crosses the wrist radially.
. It runs deep to the flexor digitorum superficialis tendons.

Correct Answer & Explanation

. It branches 5 cm proximal to the crease and runs between the palmaris longus and flexor carpi radialis.

Explanation

The palmar cutaneous branch of the median nerve typically originates about 5 cm proximal to the wrist crease, on the radial side of the median nerve. It runs distally in the interval between the palmaris longus (PL) and the flexor carpi radialis (FCR), passing superficial to the transverse carpal ligament. Carpal tunnel incisions are placed ulnar to the PL to avoid it.

Question 3879

Topic: 7. Hand and Wrist

A 55-year-old woman is 8 weeks post-ORIF for a distal radius fracture. She presents with severe, burning pain, allodynia, and skin color changes in her hand. Radiographs reveal periarticular osteopenia.

Which of the following is the most established prophylactic measure to prevent this condition?

. Gabapentin 300mg TID
. Vitamin C 500mg daily
. Early aggressive passive stretching
. Prophylactic sympathetic block
. Oral prednisone taper

Correct Answer & Explanation

. Vitamin C 500mg daily

Explanation

Complex Regional Pain Syndrome (CRPS) or Sudeck's atrophy can be prophylactically managed in high-risk groups (like distal radius fractures) with 500mg of daily Vitamin C for 50 days.

Question 3880

Topic: 7. Hand and Wrist

A 50-year-old female presents 8 weeks after a distal radius fracture with severe, burning pain in her hand, hyperhidrosis, and trophic skin changes. Radiographs show patchy periarticular osteopenia.

According to the Budapest criteria for this condition, which clinical presentation is required for diagnosis?

. Bilateral symmetric sensory deficit in a dermatomal pattern
. Elevated systemic inflammatory markers (CRP and ESR)
. At least one symptom in three of four categories (sensory, vasomotor, sudomotor/edema, motor/trophic)
. Immediate, complete pain relief following a diagnostic sympathetic nerve block
. Objective electromyographic evidence of a major peripheral nerve injury

Correct Answer & Explanation

. At least one symptom in three of four categories (sensory, vasomotor, sudomotor/edema, motor/trophic)

Explanation

The clinical diagnosis of Complex Regional Pain Syndrome (CRPS/Algodystrophy) relies on the Budapest criteria. It requires the patient to report at least one symptom in three of four categories: sensory, vasomotor, sudomotor/edema, and motor/trophic, without another diagnosis better explaining the signs.

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