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7. Hand and Wrist MCQs

Practice Set 202 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 4021

Topic: 7. Hand and Wrist

A 45-year-old woman presents with classic symptoms of carpal tunnel syndrome. Which of the following electrodiagnostic findings is typically the earliest objective abnormality seen in compressive neuropathy of the median nerve?

. Decreased motor amplitude
. Increased motor latency
. Decreased sensory nerve action potential (SNAP) amplitude
. Increased sensory latency
. Fibrillation potentials in the abductor pollicis brevis

Correct Answer & Explanation

. Increased sensory latency

Explanation

In compressive neuropathies like carpal tunnel syndrome, focal demyelination occurs first. This initial myelin damage leads to a prolongation of sensory latencies before motor fibers are objectively affected.

Question 4022

Topic: 7. Hand and Wrist
A patient sustained a volar laceration over the proximal phalanx of the index finger, resulting in the inability to flex both the PIP and DIP joints. This injury is located in which flexor tendon zone?
. Zone I
. Zone II
. Zone III
. Zone IV
. Zone V

Correct Answer & Explanation

. Zone II

Explanation

Zone II extends from the proximal edge of the A1 pulley to the insertion of the flexor digitorum superficialis tendon. Historically known as "no man's land," injuries here typically involve both the superficialis and profundus tendons within the tight fibro-osseous sheath.

Question 4023

Topic: 7. Hand and Wrist
A 35-year-old carpenter sustains a volar laceration to his index finger at the level of the proximal phalanx, transecting both the flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) tendons. According to the strictly defined flexor tendon zones, which zone is injured?
. Zone I
. Zone II
. Zone III
. Zone IV
. Zone V

Correct Answer & Explanation

. Zone II

Explanation

Zone II, historically called "no man's land," extends from the proximal A1 pulley to the insertion of the FDS on the middle phalanx. Injuries here involve both the FDS and FDP tendons within the narrow fibro-osseous sheath, posing a high risk of postoperative adhesions.

Question 4024

Topic: 7. Hand and Wrist

A 24-year-old male falls on an outstretched hand and sustains a fracture of the scaphoid waist. He is evaluated for surgical fixation due to displacement.

Regarding the vascular anatomy of the scaphoid, which of the following is true?

. The major blood supply enters via the volar tubercle and supplies the proximal pole.
. The proximal pole relies entirely on intraosseous retrograde blood flow.
. The dorsal carpal branch of the ulnar artery supplies the distal pole.
. Avascular necrosis of the proximal pole is rare due to rich collateral circulation.
. The main blood supply enters via the radioscaphocapitate ligament.

Correct Answer & Explanation

. The proximal pole relies entirely on intraosseous retrograde blood flow.

Explanation

The scaphoid receives its primary blood supply from branches of the radial artery. The major dorsal supply (dorsal carpal branch of the radial artery) enters the scaphoid at the dorsal ridge and supplies the proximal 70-80% of the bone via intraosseous retrograde flow. Thus, waist and proximal pole fractures carry a high risk of avascular necrosis of the proximal pole. The volar branch supplies the distal 20-30% of the bone.

Question 4025

Topic: Hand Trauma & Infection

A 35-year-old skier injures his thumb after catching his pole in the snow. Physical examination reveals laxity of the thumb metacarpophalangeal (MCP) joint when stressed in radial deviation with the joint in 30 degrees of flexion. Which of the following anatomic structures prevents spontaneous healing of the injured ligament in a Stener lesion?

. Extensor pollicis longus tendon
. Abductor pollicis brevis tendon
. Adductor pollicis aponeurosis
. Flexor pollicis brevis tendon
. Extensor pollicis brevis tendon

Correct Answer & Explanation

. Adductor pollicis aponeurosis

Explanation

A Stener lesion occurs when the completely avulsed ulnar collateral ligament (UCL) of the thumb MCP joint becomes displaced superficial to the adductor pollicis aponeurosis. This aponeurosis becomes interposed between the ruptured ends of the UCL, preventing spontaneous healing and necessitating surgical repair.

Question 4026

Topic: 7. Hand and Wrist

A 55-year-old manual laborer presents with chronic wrist pain. Radiographs reveal advanced scaphoid nonunion advanced collapse (SNAC).

In the expected progression of SNAC wrist arthritis, which of the following articulations is classically spared?

. Radioscaphoid joint
. Scaphocapitate joint
. Capitolunate joint
. Radiolunate joint
. Trapeziometacarpal joint

Correct Answer & Explanation

. Radiolunate joint

Explanation

The SNAC and SLAC (scapholunate advanced collapse) wrists follow a predictable pattern of progressive arthritis. The radiolunate joint is characteristically spared due to the concentric shape of the lunate fossa and lunate, which prevents abnormal joint loading even in the presence of carpal instability. The progression generally involves the radioscaphoid joint, followed by the scaphocapitate and capitolunate joints.

Question 4027

Topic: 7. Hand and Wrist

During a surgical repair of a Zone II flexor tendon laceration in the index finger, the surgeon must carefully repair both the flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP). At Camper's chiasm, what is the anatomical relationship of the FDS and FDP tendons?

. The FDP tendon bifurcates to allow the FDS to pass through.
. The FDS tendon bifurcates to allow the FDP to pass through to its distal insertion.
. The FDP and FDS tendons merge into a common tendon.
. The FDS tendon inserts solely on the proximal phalanx, bypassing the FDP.
. The FDS and FDP tendons share a single common synovial sheath with no decussation.

Correct Answer & Explanation

. The FDS tendon bifurcates to allow the FDP to pass through to its distal insertion.

Explanation

At Camper's chiasm in Zone II, the flexor digitorum superficialis (FDS) tendon splits (bifurcates) to allow the flexor digitorum profundus (FDP) tendon to pass through and become superficial. The FDS then reconvenes dorsal to the FDP before inserting into the base of the middle phalanx, while the FDP continues to its insertion at the base of the distal phalanx.

Question 4028

Topic: Hand Trauma & Infection

A 42-year-old diabetic male presents with severe swelling, erythema, and pain in his right middle finger after a minor puncture wound. You suspect pyogenic flexor tenosynovitis.

According to Kanavel's criteria, which of the following signs is typically the earliest and most sensitive finding?

. Symmetric swelling of the entire digit (fusiform swelling)
. Exquisite tenderness along the course of the flexor tendon sheath
. A flexed resting posture of the digit
. Exquisite pain with passive extension of the digit
. Erythema tracking proximally into the palm

Correct Answer & Explanation

. Exquisite pain with passive extension of the digit

Explanation

Kanavel's four cardinal signs of pyogenic flexor tenosynovitis are: (1) exquisite pain with passive extension, (2) symmetric (fusiform) swelling of the digit, (3) exquisite tenderness along the course of the flexor sheath, and (4) a flexed resting posture of the digit. Pain with passive extension is widely considered the earliest and most sensitive sign of the condition.

Question 4029

Topic: Nerve & Tendon

A 50-year-old female presents with triggering and pain at the base of her right ring finger. She complains that her finger locks in flexion. The primary site of pathology in typical primary stenosing tenosynovitis (trigger finger) is stenosis at the level of which pulley?

. A1 pulley
. A2 pulley
. A3 pulley
. A4 pulley
. C1 pulley

Correct Answer & Explanation

. A1 pulley

Explanation

Trigger finger (stenosing tenosynovitis) is characterized by catching or locking of the flexor tendon. The pathology primarily involves nodular thickening of the tendon and hypertrophy/stenosis of the first annular (A1) pulley at the level of the metacarpophalangeal (MCP) joint. Surgical release or corticosteroid injection typically targets the A1 pulley.

Question 4030

Topic: 7. Hand and Wrist
A 30-year-old male presents with dorsal wrist pain and decreased grip strength. Radiographs show sclerosis and partial collapse of the lunate. According to the Lichtman classification for Kienböck disease, what distinguishes stage IIIA from stage IIIB?
. Sclerosis of the lunate without collapse
. Presence of carpal tunnel syndrome
. Scaphoid rotation and fixed flexion (carpal instability)
. Extensive radiocarpal and midcarpal arthritis
. Fragmentation of the lunate without collapse

Correct Answer & Explanation

. Scaphoid rotation and fixed flexion (carpal instability)

Explanation

The Lichtman classification for Kienböck disease is based on radiographic findings. Stage III involves lunate collapse. It is divided into IIIA (lunate collapse but normal carpal alignment) and IIIB (lunate collapse with fixed scaphoid rotation/flexion, signifying carpal instability). Stage IV involves secondary radiocarpal or midcarpal arthritic changes.

Question 4031

Topic: 7. Hand and Wrist

A 65-year-old man of Northern European descent is scheduled for fasciectomy for severe Dupuytren contracture of the ring and small fingers. Which of the following pathological cords is responsible for displacing the neurovascular bundle centrally and placing it at highest risk for iatrogenic injury during surgical excision?

. Pretendinous cord
. Central cord
. Spiral cord
. Natatory cord
. Retrovascular cord

Correct Answer & Explanation

. Spiral cord

Explanation

In Dupuytren's disease, the spiral cord is notorious for displacing the neurovascular bundle centrally and superficially as it contracts. The spiral cord is formed by the coalescence of the pretendinous band, spiral band, lateral digital sheet, and Grayson's ligament. This distorted anatomy places the digital nerve at high risk for transection during surgical fasciectomy.

Question 4032

Topic: 7. Hand and Wrist
A 22-year-old male fell onto his extended, ulnarly deviated wrist. A lateral radiograph reveals a perilunate dislocation. According to Mayfield's stages of perilunate instability, a Stage III injury indicates a complete disruption of which specific ligamentous interval?
. Scapholunate interosseous ligament
. Lunotriquetral interosseous ligament
. Dorsal radiocarpal ligament
. Volar radioscaphocapitate ligament
. Ulnocarpal complex

Correct Answer & Explanation

. Lunotriquetral interosseous ligament

Explanation

Mayfield's stages of perilunate instability follow a sequential pattern of ligamentous failure from radial to ulnar around the lunate: Stage I: Scapholunate dissociation. Stage II: Capitate dislocation (space of Poirier disruption). Stage III: Lunotriquetral disruption (resulting in perilunate dislocation). Stage IV: Lunate dislocation (dorsal radiocarpal ligament disruption, lunate falls volarly into the carpal tunnel).

Question 4033

Topic: Wrist & Carpus

A 45-year-old female sustains a comminuted intra-articular distal radius fracture.

The presence of a separate volar marginal fragment of the lunate facet (volar Barton's variant) is highly important to identify because:

. It invariably requires excision and proximal row carpectomy.
. It is easily captured by standard dorsal spanning plates.
. It acts as a critical stabilizer to prevent volar subluxation of the carpus.
. It indicates an associated distal radioulnar joint (DRUJ) dislocation.
. It is non-articular and can be managed non-operatively.

Correct Answer & Explanation

. It acts as a critical stabilizer to prevent volar subluxation of the carpus.

Explanation

The volar marginal fragment of the lunate facet is critical for the stability of the radiocarpal joint. The short radiolunate ligament originates from this fragment, and if it remains displaced, the entire carpus may subluxate volarly. Standard volar locking plates may not adequately capture small, very distal volar ulnar corner fragments, sometimes necessitating fragment-specific fixation.

Question 4034

Topic: 7. Hand and Wrist

A 30-year-old male presents with a deformity of his index finger 4 weeks after a jamming injury while playing basketball. Examination reveals the proximal interphalangeal (PIP) joint in fixed flexion and the distal interphalangeal (DIP) joint in hyperextension. This deformity is due to rupture of which structure?

. Terminal extensor tendon
. Central slip of the extensor mechanism
. Flexor digitorum profundus (FDP) tendon
. Volar plate
. Sagittal band

Correct Answer & Explanation

. Central slip of the extensor mechanism

Explanation

The patient has a Boutonniere deformity. It is caused by an injury/rupture to the central slip of the extensor tendon at its insertion on the base of the middle phalanx. The lateral bands subsequently subluxate volarly below the axis of rotation of the PIP joint, acting as flexors of the PIP and causing hyperextension at the DIP joint.

Question 4035

Topic: Nerve & Tendon

A 40-year-old cyclist complains of numbness and tingling in the small and ulnar half of the ring finger. He also has weakness in finger abduction and adduction. Examination reveals normal sensation on the dorsum of the ulnar hand.

This clinical presentation is most consistent with compression of the ulnar nerve in Guyon's canal at which specific zone?

. Zone 1
. Zone 2
. Zone 3
. Cubital tunnel
. Arcade of Struthers

Correct Answer & Explanation

. Zone 1

Explanation

Compression in Guyon's canal Zone 1 involves the main ulnar nerve before it bifurcates, causing both motor (intrinsic weakness) and sensory (volar small/ring finger) deficits. Importantly, the dorsal ulnar cutaneous nerve branches off approximately 5 cm proximal to the wrist, so dorsal sensation is spared in Guyon's canal lesions. If it were Zone 2 (deep motor branch), there would be no sensory deficit. If Zone 3 (superficial sensory), there would be no motor deficit.

Question 4036

Topic: 7. Hand and Wrist

Which of the following intrinsic hand muscles is typically innervated by the median nerve?

. Adductor pollicis
. Palmar interossei
. First and second lumbricals
. Third and fourth lumbricals
. Opponens digiti minimi

Correct Answer & Explanation

. First and second lumbricals

Explanation

The median nerve typically innervates the "LOAF" muscles in the hand: First and second Lumbricals, Opponens pollicis, Abductor pollicis brevis, and the superficial head of the Flexor pollicis brevis. The adductor pollicis, interossei, 3rd/4th lumbricals, and hypothenar muscles are innervated by the ulnar nerve.

Question 4037

Topic: 7. Hand and Wrist
A 14-month-old child presents with an extra digit on the radial side of the thumb (preaxial polydactyly). Radiographs demonstrate that both the proximal and distal phalanges are duplicated, but they articulate with a single, normally formed first metacarpal. According to the Wassel classification, which type is this?
. Type II
. Type III
. Type IV
. Type V
. Type VI

Correct Answer & Explanation

. Type III

Explanation

The Wassel classification is used for thumb duplication (preaxial polydactyly). Type IV is the most common (accounting for roughly 50% of cases) and involves complete duplication of both the proximal and distal phalanges, articulating with a single, common first metacarpal. Type I = bifid distal phalanx. Type II = duplicated distal phalanx. Type III = bifid proximal phalanx. Type IV = duplicated proximal and distal phalanges. Type V = bifid metacarpal. Type VI = duplicated metacarpal.

Question 4038

Topic: Wrist & Carpus

A hand surgeon is evaluating a patient with a suspected triangular fibrocartilage complex (TFCC) tear. When considering potential for spontaneous healing or surgical repair of a TFCC tear, the surgeon must account for its vascular supply. Which portion of the TFCC is considered vascularized and capable of healing?

. The central articular disc
. The entire complex is completely avascular
. The peripheral 10% to 25%
. The central 50%
. The radial insertion site at the sigmoid notch

Correct Answer & Explanation

. The peripheral 10% to 25%

Explanation

The blood supply to the triangular fibrocartilage complex (TFCC) originates from branches of the ulnar artery and anterior interosseous artery, penetrating only the peripheral 10% to 25% (the capsular attachments). The central portion and the radial insertion (sigmoid notch) are avascular and receive nutrition via synovial fluid diffusion. Therefore, only peripheral tears (e.g., Palmer Class 1B) are amenable to direct surgical repair, whereas central tears (Palmer Class 1A) typically require debridement due to poor healing potential.

Question 4039

Topic: 7. Hand and Wrist
A 30-year-old manual laborer presents with chronic dorsal wrist pain. Radiographs reveal sclerosis and collapse of the lunate, but the overall carpal height is maintained, and there is no fixed scaphoid rotation. The patient's radiographic evaluation also demonstrates an ulnar negative variance of 3 mm. Which of the following is the most appropriate surgical management?
. Proximal row carpectomy
. Scaphocapitate fusion
. Radial shortening osteotomy
. Lunate excision and silicone replacement
. Wrist arthrodesis

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

The patient has Kienböck's disease, Lichtman Stage IIIA (lunate collapse without fixed scaphoid rotation or carpal collapse). Given the significant ulnar negative variance, a joint-leveling procedure such as a radial shortening osteotomy is the most appropriate treatment to decrease load across the radiolunate joint and halt disease progression.

Question 4040

Topic: 7. Hand and Wrist

A 9-year-old boy presents to the emergency department after his long finger was crushed in a door. Examination reveals a clinically deformed distal phalanx with the nail plate avulsed proximally, resting dorsal to the eponychial fold. Radiographs show a displaced Salter-Harris I fracture of the distal phalanx. What is the most appropriate management?

. Closed reduction and splinting in extension
. Splinting in flexion and oral antibiotics
. Nail plate removal, thorough debridement, fracture reduction, nail bed repair, and antibiotics
. Distal phalanx amputation
. Percutaneous pinning without nail removal

Correct Answer & Explanation

. Nail plate removal, thorough debridement, fracture reduction, nail bed repair, and antibiotics

Explanation

This presentation describes a Seymour fracture, which is an open juxta-epiphyseal fracture of the distal phalanx with a concurrent nail bed injury and soft tissue interposition (typically the germinal matrix). Standard of care to prevent severe infection (osteomyelitis) and growth arrest requires nail plate removal, irrigation, fracture reduction, repair of the nail bed, and antibiotic administration.

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