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7. Hand and Wrist MCQs

Practice Set 201 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 4001

Topic: Wrist & Carpus

A 25-year-old manual laborer presents with dorsal wrist pain, decreased grip strength, and limited range of motion. Radiographs demonstrate sclerosis and fragmentation of the lunate. Which of the following anatomic variants is most strongly associated with the development of this condition?

. Positive ulnar variance
. Negative ulnar variance
. Madelung deformity
. Scapholunate diastasis
. Ulnar impaction syndrome

Correct Answer & Explanation

. Negative ulnar variance

Explanation

Kienbock's disease (avascular necrosis of the lunate) is strongly associated with negative ulnar variance. A relatively short ulna increases the radiolunate contact stress, predisposing the lunate to microtrauma and ischemia.

Question 4002

Topic: Hand Trauma & Infection

A 40-year-old mechanic presents with severe pain and swelling in his right index finger after a puncture wound 2 days ago. You suspect flexor tenosynovitis. Which of Kanavel's four cardinal signs is considered the most specific, eliciting the earliest and most severe pain?

. Fusiform swelling of the entire digit
. Flexed resting posture of the digit
. Exquisite pain with passive extension of the digit
. Tenderness along the course of the flexor tendon sheath
. Erythema tracking proximally into the palm

Correct Answer & Explanation

. Exquisite pain with passive extension of the digit

Explanation

Kanavel's signs indicate pyogenic flexor tenosynovitis. Pain with passive extension is considered the most sensitive, specific, and often the earliest sign of this infection, as it maximally stretches the inflamed tendon sheath.

Question 4003

Topic: 7. Hand and Wrist

A 21-year-old man sustains a fall onto an outstretched hand and is diagnosed with a proximal pole scaphoid fracture. Why is this specific fracture location at an extraordinarily high risk for developing avascular necrosis and nonunion?

. The proximal pole relies solely on palmar intraosseous vessels
. The blood supply enters distally and flows retrograde to the proximal pole
. Synovial fluid intrinsically inhibits osteoblast migration at the proximal pole
. The proximal pole is devoid of any cartilage covering, impairing diffusion
. The deep branch of the ulnar artery is often transected in this injury pattern

Correct Answer & Explanation

. The blood supply enters distally and flows retrograde to the proximal pole

Explanation

The scaphoid receives its primary blood supply from the dorsal carpal branch of the radial artery, which enters at the distal pole and flows retrograde to the proximal pole. Fractures at the proximal pole sever this retrograde supply, resulting in a high rate of avascular necrosis.

Question 4004

Topic: 7. Hand and Wrist

Biomechanical studies of the flexor tendon sheath in the hand demonstrate that isolated rupture of which two annular pulleys will result in the greatest degree of flexor tendon bowstringing and loss of active interphalangeal joint flexion?

. A1 and A2
. A2 and A3
. A2 and A4
. A3 and A4
. A4 and A5

Correct Answer & Explanation

. A2 and A4

Explanation

The A2 and A4 pulleys arise from the periosteum of the proximal and middle phalanges, respectively. They are the most critical biomechanical pulleys for preventing flexor tendon bowstringing and maintaining the excursion efficiency of digit flexion.

Question 4005

Topic: 7. Hand and Wrist
Scaphoid nonunion advanced collapse (SNAC) progresses through predictable stages of radiocarpal and midcarpal arthritis. Which articulation is classically spared in a stage III SNAC wrist?
. Radioscaphoid joint
. Capitolunate joint
. Radiolunate joint
. Scaphocapitate joint
. Trapeziometacarpal joint

Correct Answer & Explanation

. Radiolunate joint

Explanation

In both SNAC and SLAC wrist patterns, the radiolunate articulation is classically spared from degenerative changes. This is due to the concentric, spherical congruency of the radiolunate joint, which maintains stable load distribution despite altered carpal kinematics.

Question 4006

Topic: 7. Hand and Wrist
A 25-year-old carpenter sustains a volar laceration to his right index finger exactly at the level of the proximal interphalangeal (PIP) joint. Both the FDS and FDP tendons are transected. According to the Verdan classification, which flexor tendon zone is injured?
. Zone I
. Zone II
. Zone III
. Zone IV
. Zone V

Correct Answer & Explanation

. Zone II

Explanation

Zone II (historically termed 'no man's land') extends from the proximal aspect of the A1 pulley (distal palmar crease) to the insertion of the flexor digitorum superficialis (FDS) at the middle phalanx, which includes the region of the PIP joint. Injury here involves both FDS and FDP within the tight fibro-osseous sheath.

Question 4007

Topic: 7. Hand and Wrist

A 45-year-old woman with severe carpal tunnel syndrome undergoes electromyography (EMG). The physician notes a faster than expected conduction velocity in the median nerve in the forearm, and preservation of some intrinsic hand muscle function despite complete distal median nerve block. This finding is most likely explained by which anomalous neural connection?

. Riche-Cannieu anastomosis
. Martin-Gruber anastomosis
. Marinacci communication
. Berrettini branch
. Bouvier's connection

Correct Answer & Explanation

. Martin-Gruber anastomosis

Explanation

The Martin-Gruber anastomosis is a common anatomical variant involving a communication between the median nerve and ulnar nerve in the forearm. Motor fibers crossing from median to ulnar can bypass a distal median nerve lesion at the wrist, preserving intrinsic hand function and altering EMG findings. Riche-Cannieu is in the palm (deep ulnar to median recurrent).

Question 4008

Topic: 7. Hand and Wrist

A 25-year-old rugby player sustained a closed avulsion of the flexor digitorum profundus (FDP) from the distal phalanx of the ring finger (Jersey finger). The tendon has retracted entirely into the palm (Leddy-Packer Type I). What is the maximum recommended timeframe for surgical repair to prevent permanent loss of tendon excursion due to complete loss of vascular supply?

. 24 hours
. 7 to 10 days
. 3 weeks
. 6 weeks
. 3 months

Correct Answer & Explanation

. 7 to 10 days

Explanation

A Leddy-Packer Type I Jersey finger involves avulsion of the FDP tendon with retraction into the palm. This disrupts both the short and long vincula, eliminating the tendon's blood supply. Repair must be performed within 7 to 10 days before the tendon undergoes irreversible necrosis, myostatic contracture, and cannot be mobilized back to the distal phalanx.

Question 4009

Topic: 7. Hand and Wrist
During the post-operative rehabilitation of a flexor tendon repair in the hand, which phase of tendon healing is characterized by the highest risk of iatrogenic rupture due to a marked decrease in tensile strength?
. Inflammatory phase (days 1-3)
. Early proliferative phase (days 5-21)
. Late proliferative phase (days 21-28)
. Remodeling phase (months 1-3)
. Maturation phase (months 3-6)

Correct Answer & Explanation

. Early proliferative phase (days 5-21)

Explanation

The early proliferative phase (specifically the period from approximately 5 days to 3 weeks post-repair) is the period of highest risk for gap formation or rupture. During this time, the initial inflammatory response softens the tissue, and the newly deposited collagen (type III) is immature and lacks sufficient tensile strength before active remodeling reinforces the repair.

Question 4010

Topic: 7. Hand and Wrist

A 22-year-old male sustains a displaced proximal pole scaphoid fracture. The risk of avascular necrosis is extremely high due to the scaphoid's retrograde blood supply. Which artery provides the primary blood supply to the proximal pole?

. Palmar carpal branch of the radial artery
. Superficial palmar arch
. Dorsal carpal branch of the radial artery
. Anterior interosseous artery
. Ulnar artery deep branch

Correct Answer & Explanation

. Dorsal carpal branch of the radial artery

Explanation

The major blood supply to the scaphoid is retrograde, arising from the dorsal carpal branch of the radial artery, which enters at the waist and supplies the proximal pole. Fractures at the proximal pole thus have a high rate of nonunion and avascular necrosis.

Question 4011

Topic: 7. Hand and Wrist

During an electrodiagnostic study, a patient's median nerve is stimulated at the elbow and wrist, recording over the abductor pollicis brevis, showing normal amplitude. However, when recording over the first dorsal interosseous (FDI), stimulating the median nerve at the elbow produces a compound muscle action potential (CMAP), but stimulating it at the wrist does not. Which anatomical variant explains this finding?

. Riche-Harnieu anastomosis
. Martin-Gruber anastomosis
. Marinacci communication
. Berrettini anastomosis
. Linburg-Comstock anomaly

Correct Answer & Explanation

. Martin-Gruber anastomosis

Explanation

The Martin-Gruber anastomosis is a common motor crossover from the median nerve to the ulnar nerve in the forearm. When present, median nerve stimulation at the elbow will capture these crossover fibers to ulnar-innervated muscles like the FDI, whereas wrist stimulation will not.

Question 4012

Topic: Nerve & Tendon

A patient presents with an inability to form an 'OK' sign with their thumb and index finger. Examination reveals weakness in flexing the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger. Which of the following muscles is additionally denervated in this syndrome?

. Flexor carpi radialis
. Flexor digitorum superficialis
. Pronator teres
. Pronator quadratus
. Abductor pollicis brevis

Correct Answer & Explanation

. Pronator quadratus

Explanation

The patient has Anterior Interosseous Nerve (AIN) syndrome. The AIN is a pure motor branch of the median nerve that innervates the flexor pollicis longus (FPL), the radial half of the flexor digitorum profundus (FDP to the index and middle fingers), and the pronator quadratus.

Question 4013

Topic: 7. Hand and Wrist

During an open carpal tunnel release, the surgeon must be careful to avoid injuring the recurrent motor branch of the median nerve. Through which of the following muscles does the transmuscular variant of this nerve pass?

. Flexor pollicis brevis
. Abductor pollicis brevis
. Opponens pollicis
. Adductor pollicis
. Lumbrical

Correct Answer & Explanation

. Flexor pollicis brevis

Explanation

The recurrent motor branch of the median nerve usually takes an extraligamentous course. In its transmuscular variant, it pierces the flexor retinaculum or the flexor pollicis brevis muscle.

Question 4014

Topic: 7. Hand and Wrist
A 30-year-old carpenter sustains a volar laceration over the proximal phalanx of his index finger, transecting both the FDS and FDP tendons. According to the Verdan classification, which zone of flexor tendon injury does this represent?
. 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 (distal palmar crease) to the insertion of the flexor digitorum superficialis. Injuries here are notoriously difficult to treat due to adhesions between both tendons in the tight fibro-osseous sheath.

Question 4015

Topic: Wrist & Carpus

A 24-year-old male sustains a displaced proximal pole scaphoid fracture. The primary blood supply at highest risk of disruption enters the scaphoid at which anatomic location?

. Volar tubercle
. Dorsal ridge
. Proximal pole
. Distal pole articular surface
. Scapholunate ligament insertion

Correct Answer & Explanation

. Dorsal ridge

Explanation

The primary blood supply to the scaphoid is retrograde, entering via branches of the radial artery at the dorsal ridge. Proximal pole fractures therefore carry a high risk of avascular necrosis.

Question 4016

Topic: Nerve & Tendon

During an in-situ decompression of the ulnar nerve for cubital tunnel syndrome, the surgeon releases the fascial band spanning the two heads of the flexor carpi ulnaris muscle. What is the eponym for this anatomic structure?

. Ligament of Struthers
. Arcade of Frohse
. Osborne ligament
. Lacertus fibrosus
. Arcade of Struthers

Correct Answer & Explanation

. Osborne ligament

Explanation

Osborne's ligament forms the roof of the cubital tunnel and connects the olecranon and medial epicondylar heads of the flexor carpi ulnaris. It is a primary site of ulnar nerve compression.

Question 4017

Topic: 7. Hand and Wrist

A 50-year-old female presents with severe, longstanding symptoms of carpal tunnel syndrome, including noticeable thenar atrophy. Electromyography (EMG) and nerve conduction velocities (NCV) are ordered. Which of the following findings on these studies indicates the most severe degree of axonal nerve injury and suggests a poorer prognosis for complete functional recovery?

. Prolonged sensory latency
. Decreased sensory conduction velocity
. Prolonged distal motor latency
. Decreased compound muscle action potential (CMAP) amplitude
. Fibrillation potentials in the abductor pollicis brevis

Correct Answer & Explanation

. Fibrillation potentials in the abductor pollicis brevis

Explanation

Fibrillation potentials and positive sharp waves on EMG indicate active muscle denervation resulting from axonal loss. This represents advanced, severe nerve compression (Wallerian degeneration) and portends a poorer prognosis for complete functional recovery compared to mere demyelination, which typically presents as prolonged latencies and decreased conduction velocities without EMG denervation changes.

Question 4018

Topic: Hand Trauma & Infection

Kanavel's signs are classically used to clinical diagnose pyogenic flexor tenosynovitis of the hand. Which of the following is considered the earliest and most reliable of these signs?

. Fusiform swelling of the entire digit
. Flexed resting posture of the digit
. Tenderness strictly localized along the flexor tendon sheath
. Severe pain with passive extension of the digit
. Erythema of the volar aspect of the finger

Correct Answer & Explanation

. Severe pain with passive extension of the digit

Explanation

The four Kanavel signs are: 1) flexed resting posture, 2) fusiform (sausage) swelling, 3) tenderness along the flexor tendon sheath, and 4) excruciating pain with passive extension. Pain with passive extension is historically considered the earliest and most reliable clinical hallmark of pyogenic flexor tenosynovitis.

Question 4019

Topic: Nerve & Tendon

A cyclist presents with numbness in the volar aspect of his small finger and the ulnar half of his ring finger, alongside profound weakness of the interosseous muscles. Sensation on the dorsal ulnar aspect of the hand is completely preserved. According to the zoning of Guyon's canal, which zone is most likely the site of ulnar nerve compression?

. Zone 1
. Zone 2
. Zone 3
. The cubital tunnel
. The Arcade of Struthers

Correct Answer & Explanation

. Zone 1

Explanation

Guyon's canal is divided into 3 zones. Zone 1 is proximal to the nerve's bifurcation and contains both motor and sensory fascicles; compression here causes mixed motor and sensory deficits in the volar digits. Zone 2 contains only the deep motor branch, and Zone 3 contains only the superficial sensory branch. Dorsal sensation is spared because the dorsal sensory branch of the ulnar nerve branches off roughly 5-8 cm proximal to the wrist crease, completely bypassing Guyon's canal. Thus, volar sensory loss plus motor loss indicates Zone 1 compression.

Question 4020

Topic: 7. Hand and Wrist
A carpenter suffers a sharp laceration to the palmar aspect of the proximal phalanx, transecting both the flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) tendons. This injury is located in which flexor tendon zone, historically deemed 'no man's land'?
. Zone I
. Zone II
. Zone III
. Zone IV
. Zone V

Correct Answer & Explanation

. Zone II

Explanation

Zone II extends from the distal palmar crease to the middle of the middle phalanx, a tight fibro-osseous sheath where both the FDS and FDP travel together. It was historically called 'no man's land' due to the high propensity for postoperative adhesions and historically poor functional outcomes.

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