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7. Hand and Wrist MCQs

Practice Set 196 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 3901

Topic: Nerve & Tendon

An elderly patient with a highly comminuted intra-articular distal humerus fracture undergoes total elbow arthroplasty with an ulnar nerve transposition. Which blood vessel, which reliably supplies the ulnar nerve in the cubital tunnel, must be carefully managed to avoid nerve ischemia?

. Radial collateral artery
. Middle collateral artery
. Superior ulnar collateral artery
. Recurrent interosseous artery
. Deep brachial artery

Correct Answer & Explanation

. Superior ulnar collateral artery

Explanation

The superior ulnar collateral artery reliably travels with the ulnar nerve posterior to the medial intermuscular septum and serves as its primary blood supply in the cubital tunnel. Its careful preservation during neurolysis minimizes ischemic ulnar neuropathy.

Question 3902

Topic: Nerve & Tendon

During an olecranon osteotomy approach for open reduction and internal fixation of a complex intra-articular distal humerus fracture, which nerve must be routinely identified and protected or transposed?

. Median nerve
. Radial nerve
. Ulnar nerve
. Anterior interosseous nerve
. Musculocutaneous nerve

Correct Answer & Explanation

. Ulnar nerve

Explanation

The ulnar nerve courses directly posterior to the medial epicondyle in the cubital tunnel. It must be carefully identified, mobilized, and often anteriorly transposed to avoid iatrogenic injury during a posterior olecranon osteotomy approach to the distal humerus.

Question 3903

Topic: Nerve & Tendon

During a medial approach to the humerus for vascular exploration, the medial intermuscular septum is encountered. The ulnar nerve passes from the anterior to the posterior compartment by piercing this septum. Which vascular structure typically accompanies the ulnar nerve through this septum?

. Radial collateral artery
. Superior ulnar collateral artery
. Inferior ulnar collateral artery
. Middle collateral artery
. Anterior ulnar recurrent artery

Correct Answer & Explanation

. Superior ulnar collateral artery

Explanation

The superior ulnar collateral artery originates from the brachial artery and reliably pierces the medial intermuscular septum alongside the ulnar nerve to enter the posterior compartment of the arm.

Question 3904

Topic: 7. Hand and Wrist

A 28-year-old man presents with a pathologic fracture of the proximal phalanx of the ring finger after jamming his hand. Radiographs reveal an expansile, lucent lesion.

What is the most appropriate definitive management?

. Ray amputation
. Neoadjuvant chemotherapy followed by curettage
. Immediate curettage and bone grafting
. Immobilization until fracture heals followed by curettage and bone grafting
. Wide local excision

Correct Answer & Explanation

. Immobilization until fracture heals followed by curettage and bone grafting

Explanation

For enchondromas of the hand presenting with a pathologic fracture, initial treatment is allowing the fracture to heal. Definitive management with intralesional curettage and bone grafting is performed subsequently.

Question 3905

Topic: 7. Hand and Wrist

A 35-year-old presents with a painless, swollen ring finger. Radiographs show a centrally located, lytic lesion in the proximal phalanx with stippled calcifications.

What is the most appropriate initial management?

. Curettage and bone grafting immediately
. Observation and reassurance
. Wide local excision
. Neoadjuvant chemotherapy
. Ray amputation

Correct Answer & Explanation

. Observation and reassurance

Explanation

This is a classic presentation of an asymptomatic enchondroma in the hand. Asymptomatic, incidentally found enchondromas should be observed; surgical intervention is reserved for symptomatic lesions or pathologic fractures.

Question 3906

Topic: 7. Hand and Wrist

A 24-year-old male presents with multiple asymmetric nodular deformities of the hands and feet, along with multiple dark-blue soft tissue masses. Genetic testing would most likely reveal a somatic mutation in which of the following genes?

. EXT1
. GNAS
. IDH1
. RB1
. TP53

Correct Answer & Explanation

. IDH1

Explanation

This patient has Maffucci syndrome, characterized by multiple enchondromas and soft-tissue hemangiomas. It is caused by somatic mutations in the IDH1 or IDH2 genes.

Question 3907

Topic: 7. Hand and Wrist

A 30-year-old right-hand-dominant carpenter presents with acute pain in his right ring finger after a minor twisting injury. Radiographs show a well-circumscribed, lucent lesion in the proximal phalanx with a pathologic fracture.

What is the most appropriate initial management for this patient?

. Immediate curettage and bone grafting
. Ray amputation
. Immobilization until fracture healing, followed by curettage and grafting
. Neoadjuvant chemotherapy followed by wide excision
. Intralesional corticosteroid injection

Correct Answer & Explanation

. Immobilization until fracture healing, followed by curettage and grafting

Explanation

The patient has a pathologic fracture through an enchondroma of the hand. The standard standard of care is to allow the fracture to heal with immobilization first, followed by elective curettage and bone grafting to prevent recurrence.

Question 3908

Topic: 7. Hand and Wrist

A 32-year-old right-hand-dominant male presents with sudden pain in his right ring finger after a mild twisting injury. Radiographs demonstrate a pathologic fracture through a centrally located, lytic, expansile lesion with stippled calcifications in the proximal phalanx. What is the most appropriate management strategy?

. Immediate wide local resection and structural bone grafting
. Immobilization to allow fracture healing, followed by elective intralesional curettage and bone grafting
. Immediate intralesional curettage and bone grafting with K-wire fixation
. Ray amputation of the affected digit
. Administration of neoadjuvant chemotherapy followed by curettage

Correct Answer & Explanation

. Immobilization to allow fracture healing, followed by elective intralesional curettage and bone grafting

Explanation

Enchondromas are the most common primary bone tumors of the hand. When complicated by a pathologic fracture, the standard management is immobilization to allow fracture healing, followed by elective intralesional curettage and grafting to prevent recurrence.

Question 3909

Topic: 7. Hand and Wrist

A 55-year-old right-hand dominant female presents with numbness and tingling in her thumb, index, middle, and radial half of the ring finger, particularly at night. Phalen's test is positive. What is the most likely diagnosis?

. Ulnar nerve entrapment at the elbow
. Radial nerve palsy
. Carpal tunnel syndrome
. Cervical radiculopathy (C6/C7)
. De Quervain's tenosynovitis

Correct Answer & Explanation

. Carpal tunnel syndrome

Explanation

The symptoms described (numbness and tingling in the median nerve distribution - thumb, index, middle, and radial half of the ring finger, worse at night) along with a positive Phalen's test (flexing wrists for 60 seconds reproduces symptoms) are classic for carpal tunnel syndrome, caused by compression of the median nerve at the wrist. Ulnar nerve entrapment would affect the small finger and ulnar half of the ring finger. Radial nerve palsy affects motor function (wrist drop) and sensation on the dorsal hand. Cervical radiculopathy might have similar dermatomal symptoms but often includes neck pain and upper extremity weakness, and Phalen's test would not be positive. De Quervain's tenosynovitis affects the thumb extensors and abductors.

Question 3910

Topic: 7. Hand and Wrist
What is the hallmark radiographic finding in osteonecrosis of the lunate (Kienböck's disease)?
. Loss of carpal height and sclerosis of the lunate
. Cystic changes in the scaphoid
. Increased joint space at the radiocarpal joint
. Fracture of the triquetrum
. Increased ulnar variance

Correct Answer & Explanation

. Loss of carpal height and sclerosis of the lunate

Explanation

Kienböck's disease is avascular necrosis of the lunate bone. The hallmark radiographic findings progress through stages but typically involve increasing sclerosis, fragmentation, and collapse of the lunate, leading to loss of carpal height. Cystic changes in the scaphoid might be seen in degenerative conditions, but not specific to Kienböck's. Increased joint space is atypical. Fracture of the triquetrum is a separate injury. Increased ulnar variance (ulna longer than radius) is a potential predisposing factor but not a direct sign of lunate osteonecrosis itself.

Question 3911

Topic: 7. Hand and Wrist

A 28-year-old female presents with pain, numbness, and weakness in her shoulder and arm. Examination reveals atrophy of the intrinsic hand muscles (e.g., thenar eminence) and a positive Adson's test. What is the most likely diagnosis?

. Rotator cuff tear
. Cervical radiculopathy (C8/T1)
. Carpal tunnel syndrome
. Thoracic outlet syndrome
. Ulnar nerve entrapment at the elbow

Correct Answer & Explanation

. Thoracic outlet syndrome

Explanation

The constellation of symptoms including pain, numbness, weakness in the arm, intrinsic hand muscle atrophy, and a positive Adson's test (diminished radial pulse with arm abduction, extension, and external rotation, and head rotation towards the affected side) is highly suggestive of Thoracic Outlet Syndrome (TOS), specifically the neurogenic type affecting the brachial plexus. Rotator cuff tears cause shoulder pain and weakness, but not typically hand atrophy or positive Adson's. Cervical radiculopathy (C8/T1) can cause similar neurological symptoms, but Adson's test is specific for TOS. Carpal tunnel syndrome affects the median nerve at the wrist. Ulnar nerve entrapment affects the ulnar nerve distribution.

Question 3912

Topic: 7. Hand and Wrist

A 50-year-old female administrative assistant reports numbness and tingling in her thumb, index, middle, and radial half of the ring finger, especially at night and with repetitive tasks. Phalen's test and Tinel's sign at the wrist are positive. What is the initial MOST appropriate non-surgical management?

. Corticosteroid injection into the carpal tunnel
. Surgical carpal tunnel release
. Ergonomic workplace adjustments and night splinting
. Oral NSAIDs and physical therapy
. Nerve conduction studies and EMG

Correct Answer & Explanation

. Ergonomic workplace adjustments and night splinting

Explanation

This clinical picture is classic for Carpal Tunnel Syndrome (CTS). The initial, conservative management of CTS, particularly for mild to moderate symptoms, involves ergonomic workplace adjustments to reduce repetitive strain and night splinting to maintain the wrist in a neutral position, thereby reducing pressure on the median nerve. While corticosteroid injections can provide temporary relief, they are not the first-line and durable solution. Surgery is for failed conservative management or severe cases. NSAIDs are less effective for nerve compression. NCS/EMG is a diagnostic confirmation tool, not a treatment.

Question 3913

Topic: 7. Hand and Wrist

A new mother complains of pain along the radial side of her wrist and at the base of her thumb, exacerbated by lifting her baby. Finkelstein's test is positive. What tendons are primarily affected?

. Flexor pollicis longus and Flexor digitorum profundus
. Extensor carpi radialis longus and brevis
. Abductor pollicis longus and Extensor pollicis brevis
. Extensor pollicis longus and Extensor polensor indicis
. Flexor carpi radialis and Palmaris longus

Correct Answer & Explanation

. Abductor pollicis longus and Extensor pollicis brevis

Explanation

De Quervain's tenosynovitis is an inflammatory condition affecting the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons, as they pass through the first dorsal compartment of the wrist. Finkelstein's test specifically exacerbates pain by stretching these tendons. This condition is common in new mothers due to repetitive lifting with wrist ulnar deviation and thumb abduction.

Question 3914

Topic: Nerve & Tendon

A 58-year-old female complains of her ring finger catching or locking in a flexed position, especially in the morning. She often has to manually extend it, sometimes with a painful snap. What is the MOST appropriate initial treatment for this condition?

. Surgical release of the A1 pulley
. Corticosteroid injection into the flexor tendon sheath
. Night splinting in extension
. Oral NSAIDs and hand therapy
. Observation and reassurance

Correct Answer & Explanation

. Corticosteroid injection into the flexor tendon sheath

Explanation

This patient has classic symptoms of trigger finger (stenosing tenosynovitis). The initial treatment of choice is typically a corticosteroid injection into the flexor tendon sheath at the A1 pulley, which often provides significant and sometimes permanent relief. If conservative measures fail, or if symptoms recur, surgical release of the A1 pulley is highly effective. Oral NSAIDs and hand therapy are generally less effective as standalone treatments. Night splinting and observation are also less likely to resolve the mechanical catching.

Question 3915

Topic: 7. Hand and Wrist

A 20-year-old male falls onto an outstretched hand while snowboarding. He complains of radial wrist pain. Physical examination reveals tenderness in the anatomical snuffbox and pain with scaphoid compression. Initial X-rays are negative for fracture. What is the MOST appropriate next step in management?

. Discharge with instructions to return if pain worsens
. MRI of the wrist
. CT scan of the wrist
. Immobilize in a thumb spica cast and repeat X-rays in 10-14 days
. Wrist splint and oral NSAIDs

Correct Answer & Explanation

. Immobilize in a thumb spica cast and repeat X-rays in 10-14 days

Explanation

Given the classic mechanism of injury and physical exam findings suggestive of a scaphoid fracture, even with negative initial X-rays, the risk of misdiagnosis and subsequent non-union is high. The MOST appropriate next step is to immobilize the wrist in a thumb spica cast and repeat X-rays in 10-14 days, at which point a fracture line may become visible due to bone resorption. Alternatively, if definitive diagnosis is desired sooner, an MRI is highly sensitive for occult scaphoid fractures. Discharging the patient or just a wrist splint is inadequate for suspected scaphoid fracture.

Question 3916

Topic: Nerve & Tendon

A 35-year-old male jams his finger while playing basketball, resulting in an inability to actively extend the distal interphalangeal (DIP) joint of his right ring finger. The finger appears to be in slight flexion at the DIP joint. What is the MOST likely diagnosis and initial management?

. Boutonniere deformity; surgical repair
. Swan neck deformity; splinting
. Mallet finger; continuous DIP joint extension splinting
. Jersey finger; surgical repair
. Distal phalanx fracture; casting

Correct Answer & Explanation

. Mallet finger; continuous DIP joint extension splinting

Explanation

This is a classic presentation of a mallet finger, which is a rupture or avulsion of the extensor tendon at its insertion on the distal phalanx, resulting in an inability to actively extend the DIP joint. The initial management is typically continuous splinting of the DIP joint in extension (without hyperextension of the PIP joint) for 6-8 weeks to allow the tendon to heal. Surgical repair is reserved for specific cases like large bony avulsions or failed conservative management. Boutonniere and Swan neck deformities are different and chronic. Jersey finger involves the flexor digitorum profundus.

Question 3917

Topic: Nerve & Tendon

A 45-year-old male laborer presents with gradual onset of pain, stiffness, and snapping in his right index finger, particularly worse in the morning. He notes that the finger occasionally gets 'stuck' in a flexed position and requires passive extension to straighten. What is the most likely diagnosis?

. De Quervain's tenosynovitis
. Carpal tunnel syndrome
. Flexor tendinitis (trigger finger)
. Ganglion cyst
. Rheumatoid arthritis

Correct Answer & Explanation

. Flexor tendinitis (trigger finger)

Explanation

The classic symptoms of trigger finger (stenosing tenosynovitis) include pain, stiffness, and a palpable nodule or catching/locking sensation during finger flexion and extension, often worse in the morning. This is caused by inflammation and thickening of the flexor tendon sheath, particularly at the A1 pulley, leading to difficulty for the tendon to glide smoothly. De Quervain's affects the first dorsal compartment of the wrist. Carpal tunnel syndrome involves median nerve compression. Ganglion cysts are typically localized masses. Rheumatoid arthritis would involve multiple joints and systemic symptoms.

Question 3918

Topic: 7. Hand and Wrist

A 38-year-old female presents with progressive pain, swelling, and crepitus in her dominant wrist. Radiographs reveal diffuse carpal collapse, scaphoid non-union, and radioscaphoid arthritis. She is a non-smoker. What is the most appropriate surgical intervention for significant pain and dysfunction?

. Scaphoid non-union repair with bone graft
. Proximal row carpectomy (PRC)
. Scapholunate ligament reconstruction
. Four-corner fusion (Scapholunate advanced collapse - SLAC wrist reconstruction)
. Total wrist arthroplasty

Correct Answer & Explanation

. Four-corner fusion (Scapholunate advanced collapse - SLAC wrist reconstruction)

Explanation

The description of diffuse carpal collapse, scaphoid non-union, and radioscaphoid arthritis in a wrist indicates advanced scapholunate advanced collapse (SLAC wrist) or scaphoid non-union advanced collapse (SNAC wrist). For established arthritis of the radioscaphoid joint and midcarpal instability, a four-corner fusion (fusion of the capitate, hamate, triquetrum, and lunate) with scaphoid excision is a well-established and durable surgical option that preserves some wrist motion while alleviating pain. A proximal row carpectomy (PRC) is another option, but often contraindicated with capitolunate arthritis. Scaphoid non-union repair is not sufficient once arthritis has developed. Scapholunate reconstruction is for earlier stages before significant arthritis. Total wrist arthroplasty is typically reserved for severe, global arthritis and lower demand patients.

Question 3919

Topic: 7. Hand and Wrist

What is the primary vascular supply to the scaphoid bone, making it susceptible to avascular necrosis after fracture?

. Radial artery, volar carpal branch
. Ulnar artery, dorsal carpal branch
. Radial artery, dorsal carpal branch
. Median artery, palmar branch
. Anterior interosseous artery

Correct Answer & Explanation

. Radial artery, dorsal carpal branch

Explanation

The primary blood supply to the scaphoid bone is via branches of the radial artery, specifically the dorsal carpal branch (or dorsal carpal artery). These vessels enter the scaphoid distally and dorsally, providing a retrograde blood supply to the proximal pole. This retrograde flow makes the proximal pole particularly vulnerable to avascular necrosis (AVN) following a scaphoid waist fracture, as its blood supply can be disrupted. The volar carpal branch supplies the distal scaphoid but does not typically reach the proximal pole.

Question 3920

Topic: Nerve & Tendon

What is the primary indication for surgical intervention in patients with carpal tunnel syndrome?

. Intermittent numbness and tingling in the median nerve distribution
. Difficulty with fine motor tasks and dropping objects
. Positive Phalen's and Tinel's signs
. Thenar muscle atrophy and persistent sensory deficit
. Night pain unresponsive to splinting

Correct Answer & Explanation

. Thenar muscle atrophy and persistent sensory deficit

Explanation

While all options represent symptoms of carpal tunnel syndrome, thenar muscle atrophy and persistent sensory deficit (indicating severe nerve compression and potential irreversible damage) are considered primary indications for surgical release. These signs suggest chronic and severe median nerve compression. While other symptoms like night pain unresponsive to splinting or difficulty with fine motor tasks are strong indications for surgery, thenar atrophy signifies advanced disease. Intermittent numbness and positive provocative signs alone can often be managed conservatively initially.

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