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7. Hand and Wrist MCQs

Practice Set 204 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 4061

Topic: 7. Hand and Wrist

The most common form of congenital syndactyly in the upper extremity typically involves which specific web space, and what is its most common inheritance pattern when familial?

. First web space (thumb and index); X-linked recessive
. Second web space (index and middle); autosomal recessive
. Third web space (middle and ring); autosomal dominant
. Fourth web space (ring and small); autosomal dominant
. Third web space (middle and ring); autosomal recessive

Correct Answer & Explanation

. Third web space (middle and ring); autosomal dominant

Explanation

The most common anatomical location for congenital syndactyly is the third web space, located between the middle and ring fingers. When it occurs as a familial trait, it most frequently follows an autosomal dominant inheritance pattern with variable penetrance.

Question 4062

Topic: Wrist & Carpus

A 65-year-old patient with long-standing rheumatoid arthritis presents with a new inability to actively extend the small and ring fingers at the metacarpophalangeal (MCP) joints. Extension at the PIP joints is preserved, and passive MCP extension is full. This clinical picture (Vaughan-Jackson syndrome) is most often caused by attrition and rupture of the extensor tendons over which specific bony prominence?

. Lister's tubercle
. The distal pole of the scaphoid
. A prominent, dorsally subluxated distal ulna
. The volar rim of the distal radius
. The hook of the hamate

Correct Answer & Explanation

. A prominent, dorsally subluxated distal ulna

Explanation

Vaughan-Jackson syndrome is the sequential, ulnar-to-radial rupture of the extensor digitorum communis (EDC) tendons in rheumatoid arthritis. It is caused by mechanical attrition over a prominent, dorsally subluxated distal ulna head (Caput ulnae syndrome) secondary to destruction of the distal radioulnar joint (DRUJ).

Question 4063

Topic: 7. Hand and Wrist
A 45-year-old male presents with chronic wrist pain and a history of remote trauma. Radiographs reveal advanced scapholunate advanced collapse (SLAC). In the progression to Stage III SLAC wrist, which of the following articulations is newly involved?
. Radioscaphoid
. Radiolunate
. Capitolunate
. Distal radioulnar
. Scaphotrapezial

Correct Answer & Explanation

. Radiolunate

Explanation

SLAC wrist progresses predictably: Stage I involves the radial styloid, Stage II involves the entire radioscaphoid facet, and Stage III involves the capitolunate joint. The radiolunate joint is classically spared due to its concentric spherical articulation.

Question 4064

Topic: 7. Hand and Wrist
Lichtman Stage IIIB Kienbock's disease is distinguished from Stage IIIA by the presence of which of the following radiographic findings?
. Avascular necrosis of the lunate without collapse
. Coronal lunate fracture line
. Fixed scaphoid flexion and carpal height collapse
. Pancarpal arthritis involving the radiolunate joint
. Cystic changes confined to the lunate

Correct Answer & Explanation

. Fixed scaphoid flexion and carpal height collapse

Explanation

Lichtman Stage III Kienbock's disease denotes lunate collapse. Stage IIIA has normal carpal alignment, whereas Stage IIIB is characterized by fixed scaphoid flexion and a decrease in the carpal height ratio, indicating progressive carpal instability.

Question 4065

Topic: 7. Hand and Wrist

A 22-year-old boxer sustains a Bennett fracture. The small volar-ulnar fragment of the thumb metacarpal base is held anatomically in place by which of the following structures?

. Dorsal radial ligament
. Anterior oblique ligament
. Abductor pollicis longus tendon
. Adductor pollicis aponeurosis
. Deep transverse metacarpal ligament

Correct Answer & Explanation

. Anterior oblique ligament

Explanation

In a Bennett fracture, the shaft is pulled proximally and dorsally by the abductor pollicis longus. The volar-ulnar beak fragment remains stabilized in its anatomic position by the strong anterior oblique ligament.

Question 4066

Topic: Nerve & Tendon

A patient presents with atrophy of the dorsal interossei and weakness of finger abduction. Sensation over the volar ulnar aspect of the small finger and the hypothenar eminence is completely preserved. The flexor digitorum profundus to the small finger has normal strength. Where is the most likely site of ulnar nerve compression?

. Cubital tunnel
. Zone 1 of Guyon's canal
. Zone 2 of Guyon's canal
. Zone 3 of Guyon's canal
. Arcade of Struthers

Correct Answer & Explanation

. Zone 2 of Guyon's canal

Explanation

Zone 2 of Guyon's canal contains only the deep motor branch of the ulnar nerve. Compression here (e.g., from a hook of hamate fracture) causes isolated intrinsic muscle weakness with preserved sensation.

Question 4067

Topic: 7. Hand and Wrist

During surgical release for Dupuytren's contracture, the neurovascular bundle is noted to be displaced centrally and superficially. Which of the following pathological structures is primarily responsible for this displacement?

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

Correct Answer & Explanation

. Spiral cord

Explanation

The spiral cord contributes to proximal interphalangeal (PIP) joint contracture and characteristically wraps around the neurovascular bundle. As the cord contracts, it pulls the nerve and vessels centrally and superficially, placing them at high risk during surgical dissection.

Question 4068

Topic: Nerve & Tendon

A rugby player sustains a flexor digitorum profundus (FDP) avulsion from the ring finger (Jersey finger). MRI confirms the tendon has retracted completely into the palm (Leddy-Packer Type 1). What is the optimal timeframe for surgical repair?

. Within 7-10 days
. Within 3-4 weeks
. Delayed until full passive motion is restored
. After 6 weeks using a 2-stage tendon graft
. Immediate emergency surgery within 6 hours

Correct Answer & Explanation

. Within 7-10 days

Explanation

Type 1 Jersey fingers involve retraction of the FDP into the palm, which ruptures the vincular blood supply. Repair must be performed within 7-10 days before the tendon undergoes necrosis and irreversible contracture.

Question 4069

Topic: 7. Hand and Wrist

At what age should a complete, simple syndactyly involving the thumb and index finger be surgically released to prevent angular growth deformities?

. 3-6 months
. 12-18 months
. 2-3 years
. 4-5 years
. After skeletal maturity

Correct Answer & Explanation

. 3-6 months

Explanation

Syndactyly of the border digits (thumb-index and ring-small) should be released early, typically at 3-6 months of age. Because these adjacent digits have significant length discrepancies, delayed release leads to progressive tethering and angular deformities.

Question 4070

Topic: 7. Hand and Wrist

A 45-year-old female assembly line worker presents with worsening numbness in her thumb, index, and middle fingers. She notes the symptoms are particularly severe when she repetitively makes a prolonged full fist at work. What anatomic phenomenon most likely contributes to her work-related exacerbation of carpal tunnel syndrome?

. Proximal excursion of the flexor digitorum superficialis muscle belly
. Proximal excursion of the lumbrical muscles
. Distal excursion of the transverse carpal ligament
. Hypertrophy of the palmaris longus
. Dynamic collapse of the hook of the hamate

Correct Answer & Explanation

. Proximal excursion of the lumbrical muscles

Explanation

During full finger flexion, the lumbrical muscles can incur proximally into the carpal tunnel. This proximal excursion increases the volume and pressure within the canal, directly exacerbating carpal tunnel syndrome in workers performing repetitive gripping.

Question 4071

Topic: 7. Hand and Wrist

During primary repair of a Zone II flexor digitorum profundus (FDP) laceration, preservation of the vincula is emphasized to optimize primary tendon healing. The vincula brevia to the FDP is primarily supplied by branches directly originating from which of the following?

. Digital arteries directly
. Superficial palmar arch
. Proper palmar digital arteries via transverse communicating branches
. Common digital arteries directly
. Deep palmar arch via metacarpal arteries

Correct Answer & Explanation

. Proper palmar digital arteries via transverse communicating branches

Explanation

The vincula are supplied by transverse communicating branches of the proper palmar digital arteries. Preserving this intricate blood supply is crucial to prevent tendon necrosis and promote intrinsic healing following Zone II flexor tendon repair.

Question 4072

Topic: 7. Hand and Wrist
A 62-year-old man presents with chronic wrist pain and limited range of motion. Radiographs demonstrate scapholunate advanced collapse (SLAC) with arthritic changes involving the radioscaphoid and capitolunate joints, while the radiolunate joint remains widely spaced and pristine. According to the Watson classification, what is the stage of this patient's SLAC wrist, and what is the primary biomechanical reason the radiolunate joint is spared?
. Stage II; concentric radiolunate articulation
. Stage III; concentric radiolunate articulation
. Stage III; robust volar radiolunate ligament
. Stage IV; robust volar radiolunate ligament
. Stage II; robust dorsal radiocarpal ligament

Correct Answer & Explanation

. Stage III; robust volar radiolunate ligament

Explanation

Stage III SLAC arthritis involves the capitolunate joint in addition to the radioscaphoid joint. The radiolunate joint is classically spared because its concentric, spherical articulation avoids the sheer forces that rapidly degrade the elliptical scaphoid fossa.

Question 4073

Topic: 7. Hand and Wrist

In a patient with advanced trapeziometacarpal (CMC) joint arthritis of the thumb, progressive attenuation of a specific primary stabilizing ligament leads to the characteristic dorsoradial subluxation of the metacarpal base. Which of the following ligaments is historically referred to as the 'beak' ligament and is directly implicated in this subluxation?

. Dorsal radial ligament
. Anterior oblique ligament
. Posterior oblique ligament
. Ulnar collateral ligament
. Intermetacarpal ligament

Correct Answer & Explanation

. Anterior oblique ligament

Explanation

The anterior oblique ligament (AOL), also known as the volar beak ligament, is historically considered the primary stabilizer against dorsoradial subluxation of the thumb CMC joint. Attenuation of the AOL leads to classical basal joint arthritis patterns.

Question 4074

Topic: 7. Hand and Wrist
A 32-year-old carpenter presents with persistent dorsal wrist pain. Imaging confirms avascular necrosis of the lunate (Kienbock disease). Radiographs show complete lunate collapse and a fixed flexed posture of the scaphoid (cortical ring sign), but no degenerative carpal arthritic changes are noted. Which of the following is the most appropriate surgical management?
. Radial shortening osteotomy
. Proximal row carpectomy
. Scaphocapitate fusion
. Total wrist arthrodesis
. Lunate excision alone

Correct Answer & Explanation

. Scaphocapitate fusion

Explanation

This patient has Lichtman Stage IIIB Kienbock disease, characterized by lunate collapse with fixed scaphoid rotation and no carpal arthritis. Scaphocapitate or STT fusion addresses the fixed scaphoid instability and mechanically unloads the collapsed lunate.

Question 4075

Topic: Nerve & Tendon
A 22-year-old rugby player grabs an opponent's jersey and sustains an isolated hyperextension injury to his ring finger distal interphalangeal (DIP) joint. Imaging demonstrates an avulsed bony fragment located at the level of the proximal interphalangeal (PIP) joint. What Leddy-Packer type is this injury, and what is its vincular status?
. Type I; completely disrupted vincula
. Type II; preserved vincula longa
. Type III; preserved vincula brevia
. Type IV; completely disrupted vincula
. Type II; preserved vincula brevia

Correct Answer & Explanation

. Type II; preserved vincula longa

Explanation

This is a Type II jersey finger, where the FDP tendon retracts to the level of the PIP joint and is arrested by the intact vincula longa. Because some blood supply is preserved, repair can often be safely delayed for up to a few weeks, unlike Type I injuries.

Question 4076

Topic: Nerve & Tendon

A 45-year-old woman presents with a chronic, untreated mallet finger of the middle digit. She has progressively developed a severe swan neck deformity. What is the primary pathomechanical cause of this secondary deformity?

. Volar subluxation of the lateral bands
. Attenuation of the central slip insertion
. Proximal retraction of the extensor mechanism concentrating force on the central slip
. Contracture of the oblique retinacular ligament
. Rupture of the volar plate at the PIP joint

Correct Answer & Explanation

. Proximal retraction of the extensor mechanism concentrating force on the central slip

Explanation

Chronic disruption of the terminal tendon allows the entire extensor mechanism to migrate proximally. This migration concentrates the extensor forces entirely onto the central slip, causing secondary hyperextension of the PIP joint and a swan neck deformity.

Question 4077

Topic: 7. Hand and Wrist

During the surgical exploration of a flexor tendon laceration in Zone II of the hand, it is critical to handle the tendons delicately. The primary nutritional supply to the flexor digitorum profundus (FDP) within this fibro-osseous digital sheath is known to be derived from which of the following mechanisms?

. Synovial fluid diffusion
. Direct arterial branches from the common digital arteries
. Direct branches from the superficial palmar arch
. The long and short vincula exclusively
. Peritendinous capillary networks

Correct Answer & Explanation

. Synovial fluid diffusion

Explanation

While the vincula (longa and brevia) provide some segmental blood supply to the dorsal aspect of the flexor tendons, the primary source of nutrition for the flexor tendons within the relatively avascular digital sheaths (Zone II) is via imbibition and diffusion from the surrounding synovial fluid.

Question 4078

Topic: 7. Hand and Wrist

A 48-year-old typist complains of night-time awakening with numbness and tingling in her thumb, index, and long fingers. Which of the following clinical tests or signs is considered the most sensitive modality for detecting early sensory nerve fiber compression in Carpal Tunnel Syndrome?

. Phalen's maneuver
. Semmes-Weinstein monofilament testing
. Tinel's sign at the wrist crest
. Static two-point discrimination
. Electromyography (EMG)

Correct Answer & Explanation

. Semmes-Weinstein monofilament testing

Explanation

Semmes-Weinstein monofilament testing assesses thresholds of touch/pressure sensation, mediated by slowly adapting nerve fibers. It is considered the most sensitive clinical physical exam test for detecting early nerve compression in carpal tunnel syndrome, turning positive before changes in two-point discrimination (which measures innervation density) occur.

Question 4079

Topic: Wrist & Carpus

In an effort to prevent the development of Complex Regional Pain Syndrome (CRPS) following a conservatively managed distal radius fracture, the American Academy of Orthopaedic Surgeons (AAOS) recommends which of the following oral prophylactic therapies?

. Gabapentin 300 mg daily for 21 days
. Vitamin C 500 mg daily for 50 days
. Ibuprofen 400 mg every 8 hours for 14 days
. Prednisone taper over 10 days
. Amitriptyline 25 mg nightly for 30 days

Correct Answer & Explanation

. Gabapentin 300 mg daily for 21 days

Explanation

The daily administration of 500 mg of Vitamin C for 50 days following a distal radius fracture has been shown to significantly reduce the risk of developing CRPS, primarily through its antioxidant and free radical scavenging properties.

Question 4080

Topic: Nerve & Tendon

A patient presents with a deep forearm laceration. On physical examination, they are completely unable to flex the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger (unable to make an 'OK' sign). Which of the following nerve branches and corresponding muscles are paralyzed?

. Recurrent motor branch of median nerve: Opponens pollicis, Abductor pollicis brevis
. Anterior interosseous nerve: Flexor pollicis longus, Flexor digitorum profundus (index/middle), Pronator quadratus
. Posterior interosseous nerve: Extensor pollicis longus, Extensor indicis proprius
. Ulnar nerve: Flexor digitorum profundus (ring/small), Adductor pollicis
. Superficial radial nerve: Brachioradialis, Extensor carpi radialis longus

Correct Answer & Explanation

. Recurrent motor branch of median nerve: Opponens pollicis, Abductor pollicis brevis

Explanation

The inability to make the 'OK' sign implies loss of flexion at the IP joint of the thumb and DIP joint of the index finger. These movements are controlled by the Flexor Pollicis Longus (FPL) and the radial half of the Flexor Digitorum Profundus (FDP), both innervated by the Anterior Interosseous Nerve (AIN).

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