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7. Hand and Wrist MCQs

Practice Set 2 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 21

Topic: Nerve & Tendon

A 28-year-old manual laborer presents with medial elbow pain and a snapping sensation during flexion and extension, accompanied by intermittent numbness in his ring and small fingers. Ultrasonography is most likely to demonstrate subluxation of the ulnar nerve along with which other structure?

. Medial head of the triceps
. Lateral head of the triceps
. Long head of the triceps
. Brachialis
. Pronator teres

Correct Answer & Explanation

. Medial head of the triceps

Explanation

Snapping triceps syndrome occurs when the medial head of the triceps subluxates over the medial epicondyle during elbow flexion. It frequently displaces the ulnar nerve concurrently, precipitating cubital tunnel symptoms.

Question 22

Topic: Nerve & Tendon

During surgical decompression for cubital tunnel syndrome, the ulnar nerve is traced distally into the proximal forearm. Which structure bridges the two heads of the flexor carpi ulnaris (FCU) and represents a common site of deep compression?

. Arcade of Struthers
. Medial intermuscular septum
. Osborne's ligament
. Lacertus fibrosus
. Ligament of Struthers

Correct Answer & Explanation

. Osborne's ligament

Explanation

Osborne's ligament (the cubital tunnel retinaculum) forms the roof of the cubital tunnel, bridging the humeral and ulnar heads of the flexor carpi ulnaris. It is a primary site of entrapment for the ulnar nerve.

Question 23

Topic: Nerve & Tendon

When creating the posteromedial portal for elbow arthroscopy, the portal is typically placed superior to the olecranon tip and medial to the triceps tendon. Which nerve is at the greatest risk of injury during the establishment of this portal?

. Radial nerve
. Ulnar nerve
. Median nerve
. Anterior interosseous nerve
. Medial antebrachial cutaneous nerve

Correct Answer & Explanation

. Ulnar nerve

Explanation

The ulnar nerve resides posterior to the medial epicondyle. The posteromedial portal must be created carefully with a 'nick and spread' technique, remaining close to the olecranon to avoid ulnar nerve injury.

Question 24

Topic: Nerve & Tendon

Which nerve is most commonly injured in a distal humerus fracture?

. Radial nerve
. Median nerve
. Axillary nerve
. Ulnar nerve
. Musculocutaneous nerve

Correct Answer & Explanation

. Ulnar nerve

Explanation

The ulnar nerve runs posterior to the medial epicondyle and is vulnerable to injury in distal humerus fractures, particularly supracondylar fractures.

Question 25

Topic: Nerve & Tendon

Which structure is commonly entrapped in a supracondylar humerus fracture in children?

. Brachial artery
. Radial nerve
. Ulnar nerve
. Median nerve
. Cephalic vein

Correct Answer & Explanation

. Brachial artery

Explanation

The brachial artery and median nerve are most at risk for injury or entrapment in displaced supracondylar humerus fractures, potentially leading to Volkmann's ischemic contracture.

Question 26

Topic: 7. Hand and Wrist

Which anatomical structure is commonly involved in De Quervain's tenosynovitis?

. Abductor pollicis longus and Extensor pollicis brevis
. Flexor pollicis longus
. Extensor carpi ulnaris
. Flexor digitorum profundus
. Extensor digitorum communis

Correct Answer & Explanation

. Abductor pollicis longus and Extensor pollicis brevis

Explanation

De Quervain's tenosynovitis affects the tendons of the abductor pollicis longus and extensor pollicis brevis as they pass through the first dorsal compartment of the wrist, leading to pain and swelling at the radial side of the wrist.

Question 27

Topic: 7. Hand and Wrist

Which nerve is compressed in carpal tunnel syndrome?

. Ulnar nerve
. Median nerve
. Radial nerve
. Anterior interosseous nerve
. Axillary nerve

Correct Answer & Explanation

. Median nerve

Explanation

Carpal tunnel syndrome results from compression of the median nerve as it passes through the carpal tunnel in the wrist, leading to numbness, tingling, and weakness in the thumb, index, middle, and radial half of the ring finger.

Question 28

Topic: 7. Hand and Wrist

The main blood supply to the scaphoid bone comes from which artery?

. Radial artery (dorsal carpal branch)
. Ulnar artery
. Median artery
. Anterior interosseous artery
. Posterior interosseous artery

Correct Answer & Explanation

. Radial artery (dorsal carpal branch)

Explanation

The scaphoid bone receives its primary blood supply from branches of the radial artery, particularly the dorsal carpal branch, which enters distally. This tenuous blood supply makes it prone to avascular necrosis after fracture.

Question 29

Topic: Nerve & Tendon

A magnetic resonance image (MRI) of the dominant elbow of a 19-year-old minor league baseball pitcher is presented (pic). He has been unable to pitch for the past 6 weeks secondary to pain. The recommended treatment includes:

. Physical therapy for triceps strengthening
. Physical therapy for pronator strengthening
. Ulnar nerve transpostion
. Radial collateral ligament reconstruction
. Ulnar collateral ligament reconstruction

Correct Answer & Explanation

. Ulnar collateral ligament reconstruction

Explanation

The MRI shows a disruption of the humeral attachment of the ulnar collateral ligament. The ulnar collateral ligament of the elbow is the most frequently observed ligamentous elbow injury in baseball pitchers. Recommended treatment in the throwing athlete is reconstruction of the ulnar collateral ligament with an autogenous palmaris longus graft.

Question 30

Topic: Nerve & Tendon

In a high-level baseball pitcher undergoing ulnar collateral ligament (UCL) reconstruction, which nerve is most intimately at risk of injury and often requires careful decompression or transposition?

. Median nerve
. Radial nerve
. Ulnar nerve
. Musculocutaneous nerve
. Posterior interosseous nerve

Correct Answer & Explanation

. Ulnar nerve

Explanation

The ulnar nerve passes directly behind the medial epicondyle through the cubital tunnel, placing it at high risk during UCL (Tommy John) reconstruction. Surgeons must carefully protect it, and many routinely perform a subcutaneous or submuscular ulnar nerve transposition.

Question 31

Topic: Nerve & Tendon

A 32-year-old male sustains a complete distal biceps tendon rupture. During surgical repair using a single-incision anterior approach, which nerve is at the highest risk of injury?

. Median nerve
. Ulnar nerve
. Lateral antebrachial cutaneous nerve
. Poster interosseous nerve
. Superficial radial nerve

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve

Explanation

The lateral antebrachial cutaneous nerve (LABCN) is the most commonly injured nerve during a single-incision anterior approach for distal biceps repair due to its superficial location and proximity to the surgical field.

Question 32

Topic: Nerve & Tendon

A 28-year-old rugby player grabs an opponent's jersey and feels a sudden "snap" in his ring finger. He is unable to actively flex the DIP joint. What is the most likely diagnosis?

. FDS tendon rupture
. FDP tendon rupture
. A2 pulley rupture
. Central slip rupture
. Sagittal band rupture

Correct Answer & Explanation

. FDP tendon rupture

Explanation

Jersey finger is an avulsion of the Flexor Digitorum Profundus (FDP) tendon. It occurs during forced extension of a flexed DIP joint, leading to an inability to actively flex the DIP.

Question 33

Topic: Hand Trauma & Infection

A 35-year-old carpenter sustains a puncture wound to his right index finger. Two days later, he presents with severe throbbing pain. Which of the following Kanavel signs is typically the earliest clinical indicator of acute infectious flexor tenosynovitis?

. Fusiform swelling of the entire digit
. Flexed resting posture of the digit
. Severe pain with passive extension of the digit
. Tenderness along the entire course of the flexor tendon sheath
. Erythema extending proximal to the palmar crease

Correct Answer & Explanation

. Severe pain with passive extension of the digit

Explanation

Pain out of proportion with passive extension of the involved digit is generally considered the earliest and most sensitive of Kanavel's four classic signs for infectious flexor tenosynovitis. Prompt recognition is critical to prevent tendon necrosis.

Question 34

Topic: Hand Trauma & Infection

A 28-year-old carpenter sustains a puncture wound to the volar aspect of his index finger. Three days later, he presents to the emergency department with a swollen, exquisitely painful finger. Which of the following is NOT one of Kanavel's four cardinal signs of flexor tenosynovitis?

. Flexed resting posture of the digit
. Fusiform swelling of the digit
. Tenderness along the course of the flexor tendon sheath
. Pain with active flexion of the digit
. Pain with passive extension of the digit

Correct Answer & Explanation

. Pain with active flexion of the digit

Explanation

Kanavel's four cardinal signs of flexor tenosynovitis are: flexed resting posture, fusiform (sausage) swelling, exquisite tenderness along the flexor tendon sheath, and severe pain with passive extension. Pain with active flexion is not a defining cardinal sign.

Question 35

Topic: Nerve & Tendon

A 21-year-old collegiate baseball pitcher undergoes ulnar collateral ligament (UCL) reconstruction using a palmaris longus autograft. Which of the following technical factors is most associated with postoperative ulnar neuropathy?

. Routine submuscular ulnar nerve transposition
. Use of a figure-of-eight graft weave
. Drilling the ulnar tunnel anterior to the sublime tubercle
. Failure to address the medial antebrachial cutaneous nerve
. Over-tensioning of the graft at 90 degrees of flexion

Correct Answer & Explanation

. Routine submuscular ulnar nerve transposition

Explanation

Routine ulnar nerve transposition during UCL reconstruction increases the risk of postoperative ulnar neuropathy compared to in situ decompression. Current trends favor leaving the nerve undisturbed unless significant preoperative neuropathy exists.

Question 36

Topic: 7. Hand and Wrist

A 24-year-old manual laborer presents with a scaphoid waist nonunion demonstrating sclerosis at the fracture margins but no avascular necrosis or carpal collapse. What is the gold standard surgical management?

. Vascularized distal radius bone graft and screw fixation
. Non-vascularized iliac crest bone graft and screw fixation
. Proximal row carpectomy
. Four-corner fusion
. Scaphoid excision and partial wrist fusion

Correct Answer & Explanation

. Non-vascularized iliac crest bone graft and screw fixation

Explanation

For a scaphoid waist nonunion without avascular necrosis or significant carpal collapse, non-vascularized structural bone grafting (e.g., iliac crest) with rigid internal screw fixation is the treatment of choice. Vascularized grafts are reserved for cases with proximal pole avascular necrosis.

Question 37

Topic: 7. Hand and Wrist

In the natural progression of Scapholunate Advanced Collapse (SLAC) wrist, which joint or articulation is classically spared until the latest stages of the disease?

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

Correct Answer & Explanation

. Radiolunate joint

Explanation

In SLAC wrist, the radiolunate joint is classically spared because the lunate fossa is spherical and maintains a concentric articulation with the lunate. This prevents early degenerative changes compared to the elliptical scaphoid fossa.

Question 38

Topic: Wrist & Carpus

Following open reduction and internal fixation of a distal radius fracture with a volar locking plate, a patient develops an inability to actively flex the interphalangeal joint of the thumb 6 months postoperatively. What technical error is most likely responsible?

. Placement of the plate proximal to the watershed line
. Placement of the plate distal to the watershed line
. Penetration of screws into the dorsal radiocarpal joint
. Over-reduction of the volar tilt
. Failure to repair the pronator quadratus

Correct Answer & Explanation

. Placement of the plate distal to the watershed line

Explanation

Placement of a volar plate distal to the watershed line of the distal radius can cause mechanical irritation and subsequent attrition rupture of the flexor pollicis longus (FPL) tendon.

Question 39

Topic: Nerve & Tendon

When evaluating the biomechanical constructs for Ulnar Collateral Ligament (UCL) reconstruction of the elbow, the "docking" technique compared to the traditional figure-of-eight technique has been shown to:

. Require a larger ulnar bone tunnel
. Have an increased risk of ulnar nerve injury
. Result in inferior maximum load to failure
. Reduce the number of holes drilled in the medial epicondyle to one
. Decrease the tension on the flexor-pronator mass

Correct Answer & Explanation

. Reduce the number of holes drilled in the medial epicondyle to one

Explanation

The docking technique simplifies humeral fixation by using a single main tunnel in the medial epicondyle where the graft ends are "docked" and tied over a bone bridge, thereby reducing stress risers.

Question 40

Topic: 7. Hand and Wrist

A 19-year-old collegiate quarterback sustains a scaphoid waist fracture. Which blood vessel provides the primary retrograde vascular supply to the proximal pole of the scaphoid, predisposing it to avascular necrosis?

. Volar carpal branch of the radial artery
. Dorsal carpal branch of the radial artery
. Superficial palmar arch
. Princeps pollicis artery
. Ulnar artery via the deep palmar arch

Correct Answer & Explanation

. Dorsal carpal branch of the radial artery

Explanation

The scaphoid receives 70-80% of its blood supply via the dorsal carpal branch of the radial artery, which enters the scaphoid at the dorsal ridge and supplies the proximal pole in a retrograde fashion.

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