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7. Hand and Wrist MCQs

Practice Set 203 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 4041

Topic: Nerve & Tendon

A 35-year-old carpenter presents with a sudden inability to perform a tip-to-tip pinch with his thumb and index finger. When attempting an 'OK' sign, he forms a flat pinch due to an inability to flex the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger. Sensation over the hand is completely normal. Which muscle group is affected, and what nerve is implicated?

. Adductor pollicis and first dorsal interosseous; Ulnar nerve
. Flexor pollicis longus and flexor digitorum profundus to the index finger; Anterior interosseous nerve
. Abductor pollicis brevis and opponens pollicis; Recurrent motor branch of the median nerve
. Extensor pollicis longus and extensor indicis proprius; Posterior interosseous nerve
. Flexor digitorum superficialis and flexor carpi radialis; Median nerve

Correct Answer & Explanation

. Flexor pollicis longus and flexor digitorum profundus to the index finger; Anterior interosseous nerve

Explanation

The patient exhibits a classic anterior interosseous nerve (AIN) palsy. The AIN is a pure motor branch of the median nerve that innervates the flexor pollicis longus (FPL), the flexor digitorum profundus (FDP) to the index and long fingers, and the pronator quadratus. Weakness of the FPL and index FDP leads to the characteristic flat pinch, with no sensory deficit.

Question 4042

Topic: Nerve & Tendon

A 40-year-old male with a chronic low ulnar nerve palsy demonstrates severe clawing of his ring and small fingers. During the physical exam, the examiner stabilizes his MCP joints in flexion, and the patient is subsequently able to actively extend the proximal interphalangeal (PIP) joints of those digits. What is this clinical test, and what does a positive result indicate regarding surgical planning?

. Froment's sign; indicates a need for adductor pollicis reconstruction
. Wartenberg's test; indicates intact third palmar interosseous muscle
. Bouvier test; indicates intact extrinsic extensor mechanism to the PIP joints, requiring only an MCP stabilization procedure
. Jeanne's sign; indicates FDP weakness requiring tendon transfer
. Elson test; indicates central slip integrity

Correct Answer & Explanation

. Bouvier test; indicates intact extrinsic extensor mechanism to the PIP joints, requiring only an MCP stabilization procedure

Explanation

The Bouvier test evaluates a claw hand deformity by passively blocking the MCP joints in flexion. If the patient can actively extend the PIP joints, the test is positive, indicating that the extrinsic extensor mechanism (central slip) is competent. This suggests that a simple MCP stabilization procedure (e.g., Zancolli lasso) will successfully correct the claw deformity without the need for a complex PIP extension transfer.

Question 4043

Topic: 7. Hand and Wrist

During an electrodiagnostic evaluation for suspected carpal tunnel syndrome, the neurologist notes an anomalous innervation pattern where motor axons cross from the median nerve to the ulnar nerve in the forearm. This anomaly most commonly innervates which of the following muscles?

. Flexor carpi ulnaris
. First dorsal interosseous
. Abductor pollicis brevis
. Adductor pollicis
. Pronator teres

Correct Answer & Explanation

. First dorsal interosseous

Explanation

The Martin-Gruber anastomosis is an anomalous neural connection in the forearm where motor fibers cross from the median nerve (or AIN) to the ulnar nerve. These fibers typically innervate intrinsic hand muscles normally supplied by the ulnar nerve, with the first dorsal interosseous (FDI) being the most commonly involved muscle.

Question 4044

Topic: 7. Hand and Wrist

A 22-year-old gymnast presents with persistent ulnar-sided wrist pain after a fall. An MRI arthrogram reveals a tear of the triangular fibrocartilage complex (TFCC) directly at its insertion into the fovea at the base of the ulnar styloid. According to the Palmer classification, what type of tear is this, and what is the typical treatment approach?

. Palmer 1A; debridement
. Palmer 1B; surgical repair
. Palmer 1C; ulnar shortening osteotomy
. Palmer 1D; primary closure
. Palmer 2A; wafer procedure

Correct Answer & Explanation

. Palmer 1B; surgical repair

Explanation

A Palmer 1B tear is a traumatic avulsion of the TFCC from its peripheral ulnar insertion (the fovea or base of the ulnar styloid). Because this peripheral zone is well-vascularized, these tears are typically amenable to direct surgical repair, unlike central 1A tears which are avascular and generally treated with debridement.

Question 4045

Topic: Nerve & Tendon

A patient presents with an abducted posture of the small finger at rest and is unable to actively adduct it to the ring finger. This condition (Wartenberg's sign) is caused by the unopposed action of which muscle, due to weakness of which other muscle?

. Unopposed extensor digiti minimi; weakness of the third palmar interosseous
. Unopposed abductor digiti minimi; weakness of the fourth dorsal interosseous
. Unopposed flexor digiti minimi; weakness of the lumbrical
. Unopposed extensor digitorum communis; weakness of the abductor digiti minimi
. Unopposed fourth dorsal interosseous; weakness of the third palmar interosseous

Correct Answer & Explanation

. Unopposed extensor digiti minimi; weakness of the third palmar interosseous

Explanation

Wartenberg's sign is an abducted resting posture of the small finger typically seen in ulnar neuropathy. It results from weakness of the ulnar-innervated third palmar interosseous muscle, which normally adducts the finger, leaving the radial-innervated extensor digiti minimi (EDM) unopposed to exert an abducting force.

Question 4046

Topic: 7. Hand and Wrist

A patient develops a purulent infection spreading from the flexor tendon sheath of the small finger into the palm, which subsequently travels up into the flexor tendon sheath of the thumb. This specific pattern, known as a 'horseshoe abscess,' occurs through an anatomical connection between which two spaces?

. Thenar space and midpalmar space
. Ulnar bursa and radial bursa
. Space of Parona and quadrilateral space
. Superficial palmar arch and deep palmar arch
. Guyon's canal and carpal tunnel

Correct Answer & Explanation

. Ulnar bursa and radial bursa

Explanation

A horseshoe abscess occurs when an infection spreads from the ulnar bursa (the flexor tendon sheath of the small finger) to the radial bursa (the flexor tendon sheath of the thumb). In a large percentage of individuals, these two bursae communicate in the proximal palm/wrist region within the Space of Parona, allowing for rapid spread of pyogenic flexor tenosynovitis.

Question 4047

Topic: 7. Hand and Wrist

A 1-year-old child presents with congenital webbing between two fingers of both hands. Radiographs demonstrate soft tissue connections only, with no bony fusion between the affected digits. Which of the following describes the most common classification and location of this deformity?

. Complex complete syndactyly between index and long fingers
. Simple incomplete syndactyly between long and ring fingers
. Simple complete syndactyly between ring and small fingers
. Complicated syndactyly between thumb and index fingers
. Symbrachydactyly of the central rays

Correct Answer & Explanation

. Simple incomplete syndactyly between long and ring fingers

Explanation

Syndactyly is most commonly found between the long and ring fingers (the third web space). 'Simple' indicates only skin and soft tissue are involved (no bone fusion), while 'complex' involves bony fusion. 'Incomplete' means the webbing does not reach the fingertips. Simple incomplete syndactyly between the long and ring fingers is the most common presentation overall.

Question 4048

Topic: 7. Hand and Wrist
A 45-year-old man presents with chronic wrist pain years after a remote, untreated scaphoid fracture. Radiographs demonstrate a scaphoid nonunion with advanced carpal collapse. There are degenerative changes at the radioscaphoid joint and the scaphocapitate joint, but the radiolunate joint is distinctly preserved. What stage of SNAC (Scaphoid Nonunion Advanced Collapse) wrist is this?
. Stage I
. Stage II
. Stage III
. Stage IV
. Stage V

Correct Answer & Explanation

. Stage III

Explanation

SNAC staging progresses systematically: Stage I involves arthritis isolated to the radial styloid and distal scaphoid pole. Stage II involves arthritis progressing to the scaphocapitate joint. Stage III involves the capitolunate joint. The preservation of the radiolunate joint is a hallmark of SNAC/SLAC pathophysiology, allowing for motion-preserving salvage operations like a four-corner fusion.

Question 4049

Topic: 7. Hand and Wrist

A 55-year-old female presents with the inability to actively flex her thumb interphalangeal joint 6 months after open reduction and internal fixation of a distal radius fracture with a volar locking plate. Radiographs show the plate is positioned distally, slightly over the watershed line. Which complication is most likely responsible for her current presentation?

. Attritional rupture of the flexor pollicis longus tendon
. Iatrogenic laceration of the median nerve
. Extensor pollicis longus rupture due to prominent dorsal screws
. Intracompartmental pressure elevation resulting in ischemic contracture
. Hardware loosening and fracture displacement blocking tendon excursion

Correct Answer & Explanation

. Attritional rupture of the flexor pollicis longus tendon

Explanation

Placement of a volar locking plate distal to the watershed line of the distal radius places the flexor tendons, most notably the flexor pollicis longus (FPL) tendon, at high risk for attritional wear and subsequent rupture. Extensor pollicis longus (EPL) ruptures are more commonly associated with prominent dorsal screws or un-displaced distal radius fractures managed nonoperatively.

Question 4050

Topic: 7. Hand and Wrist
A 32-year-old construction worker presents with central dorsal wrist pain. Radiographs reveal sclerosis and fragmentation of the lunate with a negative ulnar variance of 3 mm, but no carpal collapse. According to Lichtman's classification of Kienbock's disease, what is the most appropriate surgical intervention?
. Proximal row carpectomy
. Four-corner fusion
. Radial shortening osteotomy
. Lunate excision and prosthetic replacement
. Scaphoid-trapezium-trapezoid (STT) fusion

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

This patient has Lichtman Stage IIIA Kienbock's disease (lunate sclerosis/fragmentation without fixed carpal collapse) in the setting of ulnar negative variance. A joint-leveling procedure, such as a radial shortening osteotomy, unloads the lunate and is the treatment of choice. Proximal row carpectomy or intercarpal fusions are reserved for later stages (IIIB or IV) where carpal collapse or osteoarthritis has occurred.

Question 4051

Topic: 7. Hand and Wrist
A 45-year-old male presents with chronic wrist pain. Radiographs show a scaphoid nonunion with advanced collapse (SNAC). There is significant osteoarthritis at the radioscaphoid and capitolunate joints, but the radiolunate joint space is well preserved. Which of the following is the most appropriate surgical treatment?
. Total wrist arthrodesis
. Proximal row carpectomy
. Scaphoid excision and four-corner arthrodesis
. Radial styloidectomy
. Vascularized bone grafting of the scaphoid

Correct Answer & Explanation

. Scaphoid excision and four-corner arthrodesis

Explanation

This is a SNAC stage III wrist, defined by radioscaphoid and capitolunate arthritis. The radiolunate joint is characteristically spared. Because the capitate head is arthritic, a proximal row carpectomy (which articulates the capitate in the lunate fossa) is contraindicated. Scaphoid excision with four-corner fusion is the procedure of choice as it relies on the preserved radiolunate articulation.

Question 4052

Topic: Nerve & Tendon

A 28-year-old basketball player jams his finger and presents with a swollen proximal interphalangeal (PIP) joint. Over the next 3 weeks, he develops a characteristic Boutonniere deformity. What is the primary pathoanatomy leading to the progressive hyperextension of the distal interphalangeal (DIP) joint in this deformity?

. Volar subluxation of the lateral bands
. Rupture of the terminal extensor tendon
. Attenuation of the triangular ligament and dorsal subluxation of lateral bands
. Rupture of the sagittal band at the metacarpophalangeal joint
. Contracture of the oblique retinacular ligament (ORL)

Correct Answer & Explanation

. Attenuation of the triangular ligament and dorsal subluxation of lateral bands

Explanation

A Boutonniere deformity is initiated by a disruption of the central slip. As the central slip fails, the triangular ligament stretches, allowing the lateral bands to subluxate volar to the axis of rotation of the PIP joint. They then act as flexors of the PIP joint, and their increased proximal pull on the terminal tendon causes secondary hyperextension of the DIP joint.

Question 4053

Topic: Nerve & Tendon

During the surgical release of a trigger thumb, the A1 pulley is divided to relieve triggering. Which adjacent structure is at greatest risk of iatrogenic injury if the surgical approach and dissection are placed too far radially?

. Radial proper digital nerve of the thumb
. Ulnar proper digital nerve of the thumb
. Recurrent motor branch of the median nerve
. Flexor pollicis longus tendon
. Superficial branch of the radial nerve

Correct Answer & Explanation

. Radial proper digital nerve of the thumb

Explanation

The radial proper digital nerve of the thumb crosses obliquely over the flexor tendon sheath at the level of the metacarpophalangeal flexion crease near the A1 pulley. It is highly susceptible to iatrogenic injury if the incision or deep dissection for a trigger thumb release extends too far radially.

Question 4054

Topic: Nerve & Tendon

A patient with severe carpal tunnel syndrome exhibits profound thenar atrophy but normal sensation over the dorsum of the hand. Electromyography reveals normal motor function of the first dorsal interosseous muscle, but paradoxically normal thenar function on proximal nerve stimulation due to a Martin-Gruber anastomosis. Where does this specific neural connection occur anatomically?

. In the forearm between the median nerve and the ulnar nerve
. In the palm between the recurrent motor branch of the median nerve and deep ulnar nerve
. In the upper arm between the musculocutaneous and median nerves
. In the wrist, as a sensory connection between ulnar and median nerves
. In the digital web spaces between common digital nerves

Correct Answer & Explanation

. In the forearm between the median nerve and the ulnar nerve

Explanation

The Martin-Gruber anastomosis is an anomalous crossing of nerve fibers from the median nerve (or its anterior interosseous branch) to the ulnar nerve in the proximal forearm. It typically carries motor fibers. In contrast, the Riche-Cannieu anastomosis occurs in the palm between the recurrent branch of the median nerve and the deep motor branch of the ulnar nerve.

Question 4055

Topic: Nerve & Tendon

A cyclist presents with isolated weakness in finger abduction and adduction. Sensation is perfectly intact in the ring and small fingers, and over the hypothenar eminence. Compression of the ulnar nerve in Guyon's canal is diagnosed. In which anatomical zone of Guyon's canal is the compression located?

. Zone 1
. Zone 2
. Zone 3
. Proximal to the canal entirely
. Distal to the hook of the hamate

Correct Answer & Explanation

. Zone 3

Explanation

Guyon's canal is divided into three zones. Zone 1 is proximal to the nerve bifurcation and contains mixed motor and sensory fibers. Zone 2 contains only the deep motor branch, which innervates the interossei and lumbricals (abduction/adduction). Zone 3 contains the superficial sensory branch. Isolated motor deficit indicates Zone 2 compression.

Question 4056

Topic: 7. Hand and Wrist
A 60-year-old female presents with pain at the base of her thumb. Radiographs demonstrate advanced trapeziometacarpal joint destruction, subchondral sclerosis, and greater than 1/3 radial subluxation of the first metacarpal base. The scaphotrapezial (ST) joint is perfectly preserved. According to the Eaton-Littler classification, what stage is this disease?
. Stage I
. Stage II
. Stage III
. Stage IV
. Stage V

Correct Answer & Explanation

. Stage III

Explanation

Eaton-Littler Stage III is characterized by significant joint space narrowing, osteophytes >2 mm, and prominent subluxation of the trapeziometacarpal joint, but with a normal scaphotrapezial (ST) joint. Stage IV involves pantrapezial arthritis (specifically progression to involve the ST joint).

Question 4057

Topic: Wrist & Carpus
In the progressive sequence of perilunate instability described by Mayfield, what specific anatomical disruption defines Stage II?
. Scapholunate interosseous ligament dissociation
. Lunotriquetral interosseous ligament dissociation
. Dorsal radiocarpal ligament rupture
. Volar radiolunate ligament failure
. Capitolunate articulation disruption

Correct Answer & Explanation

. Lunotriquetral interosseous ligament dissociation

Explanation

Mayfield's stages of perilunate instability follow a progressive pattern around the lunate: Stage I involves scapholunate dissociation. Stage II involves disruption of the capitolunate articulation as force propagates through the space of Poirier, leading to dorsal capitate dislocation. Stage III is lunotriquetral dissociation, and Stage IV is complete lunate dislocation.

Question 4058

Topic: Wrist & Carpus

A 25-year-old elite gymnast presents with ulnar-sided wrist pain and instability of the distal radioulnar joint (DRUJ). An MRI reveals a traumatic avulsion of the triangular fibrocartilage complex (TFCC) from its bony insertion at the ulnar fovea. What is the correct Palmer classification for this specific injury?

. Class 1A
. Class 1B
. Class 1C
. Class 1D
. Class 2A

Correct Answer & Explanation

. Class 1B

Explanation

The Palmer classification divides TFCC tears into traumatic (Class 1) and degenerative (Class 2). Class 1A is a central slit/perforation. Class 1B is an ulnar-sided avulsion from the fovea or base of the ulnar styloid (often causing DRUJ instability). Class 1C is a distal avulsion from the carpus, and Class 1D is a radial-sided avulsion from the sigmoid notch.

Question 4059

Topic: 7. Hand and Wrist

In the surgical treatment of Dupuytren's contracture, release of the spiral cord is often necessary to correct proximal interphalangeal (PIP) joint flexion deformities. Which of the following normal fascial structures collectively form the pathological spiral cord?

. Pretendinous band, spiral band, lateral digital sheet, and Grayson's ligament
. Natatory ligament, superficial transverse metacarpal ligament, and Cleland's ligament
. Superficial transverse metacarpal ligament and central pretendinous band
. Cleland's ligament, lateral digital sheet, and oblique retinacular ligament
. Transverse retinacular ligament and Grayson's ligament

Correct Answer & Explanation

. Pretendinous band, spiral band, lateral digital sheet, and Grayson's ligament

Explanation

The spiral cord is formed by the pathological thickening of four normal structures: the pretendinous band, the spiral band, the lateral digital sheet, and Grayson's ligament. Cleland's ligaments, which are located dorsal to the neurovascular bundle, do not become involved in Dupuytren's disease. The spiral cord is notorious for displacing the neurovascular bundle centrally and proximally.

Question 4060

Topic: Hand Trauma & Infection

A patient presents with a swollen, painful index finger 3 days after a minor puncture wound to the volar crease. Which of the following is NOT one of Kanavel's four cardinal signs of suppurative flexor tenosynovitis?

. Fusiform swelling of the entire digit
. Tenderness along the entire course of the flexor tendon sheath
. Severe pain on active flexion of the digit
. Digit held in a semi-flexed resting posture
. Severe pain on passive extension of the digit

Correct Answer & Explanation

. Severe pain on active flexion of the digit

Explanation

Kanavel's four cardinal signs are: 1) fusiform swelling (sausage digit), 2) digit held in slightly flexed posture, 3) tenderness along the flexor tendon sheath, and 4) severe pain with passive extension. Pain on passive extension stretches the inflamed sheath and is typically the earliest and most reliable sign. Active flexion pain is not a formal Kanavel sign.

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