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7. Hand and Wrist MCQs

Practice Set 207 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 4121

Topic: Nerve & Tendon

A cyclist complains of numbness in his small finger and the ulnar half of his ring finger, along with intrinsic muscle weakness.

Which of the following zones of Guyon's canal is most likely compressed if the patient presents with purely motor symptoms (weakness of hypothenar and interossei muscles) with NO sensory deficits?

. Zone 1
. Zone 2
. Zone 3
. Zone 4
. Cubital tunnel

Correct Answer & Explanation

. Zone 1

Explanation

Guyon's canal is divided into three zones. Zone 1 is proximal to the bifurcation and compression causes mixed motor and sensory symptoms. Zone 2 is the deep motor branch, and compression causes pure motor symptoms (weakness of intrinsic muscles). Zone 3 is the superficial sensory branch, and compression causes pure sensory symptoms to the ulnar digits.

Question 4122

Topic: 7. Hand and Wrist

Which of the following cords is primarily responsible for proximal interphalangeal (PIP) joint contracture in Dupuytren's disease?

. Pretendinous cord
. Central cord
. Spiral cord
. Natatory cord
. Lateral cord

Correct Answer & Explanation

. Pretendinous cord

Explanation

The PIP joint contracture in Dupuytren's disease is most commonly caused by the spiral cord (which also displaces the neurovascular bundle centrally and superficially), the central cord, and the lateral cord. The spiral cord is a combination of the pretendinous band, spiral band, lateral digital sheet, and Grayson's ligament. The pretendinous cord primarily causes metacarpophalangeal (MCP) joint contracture.

Question 4123

Topic: Nerve & Tendon

A 40-year-old female presents with severe, lancinating pain in her fingertip, exquisitely sensitive to cold. Examination reveals a bluish discoloration beneath the nail matrix.

Which of the following clinical tests is most specific for diagnosing this condition?

. Tinel's sign
. Allen's test
. Finkelstein's test
. Hildreth's test
. Phalen's test

Correct Answer & Explanation

. Tinel's sign

Explanation

The clinical presentation is classic for a glomus tumor. Hildreth's test is performed by inflating a tourniquet on the proximal arm or digit, which relieves the pain of a glomus tumor due to cessation of blood flow. This test has high specificity. Love's pin test (exquisite point tenderness using a pinhead) and the cold sensitivity test are also characteristic.

Question 4124

Topic: 7. Hand and Wrist

A 25-year-old male struck the tip of his finger while playing basketball and now presents with an inability to actively extend the distal interphalangeal (DIP) joint. Radiographs show a small dorsal avulsion fracture of the distal phalanx involving 20% of the articular surface.

What is the recommended primary treatment?

. Surgical pinning across the DIP joint for 6 weeks
. Open reduction and internal fixation with a mini-screw
. Continuous extension splinting of the DIP joint for 6-8 weeks
. Figure-of-eight splinting of the PIP joint
. Splinting of both the PIP and DIP joints in extension

Correct Answer & Explanation

. Surgical pinning across the DIP joint for 6 weeks

Explanation

For a soft tissue mallet finger or a bony mallet finger involving less than 30-50% of the articular surface without volar subluxation of the distal phalanx, continuous extension splinting of the DIP joint alone for 6-8 weeks is the treatment of choice. The PIP joint should be left free to allow motion. Operative fixation is reserved for larger articular fragments or joints with volar subluxation.

Question 4125

Topic: Nerve & Tendon

A patient complains of numbness in the small finger. On examination, there is weakness of the flexor digitorum profundus to the small finger (FDP) and a positive Froment's sign.

This presentation indicates ulnar nerve compression at what level?

. Guyon's canal
. Cubital tunnel
. Struthers arcade
. Arcade of Frohse
. Carpal tunnel

Correct Answer & Explanation

. Guyon's canal

Explanation

Weakness of the FDP to the small finger indicates that the ulnar nerve compression is proximal to the wrist, typically at the elbow (cubital tunnel syndrome). The motor branches to the FDP and FCU take off in the proximal forearm. Compression at Guyon's canal (wrist) spares the FDP and FCU, presenting with intrinsic muscle weakness (positive Froment's sign) but normal FDP function.

Question 4126

Topic: 7. Hand and Wrist

A patient presents with a throbbing, severe pain in the pulp of the thumb. Examination reveals a tense, swollen, and erythematous thumb pulp.

If surgical drainage is required, which of the following incision techniques is generally avoided due to the risk of neuroma formation and loss of sensation on the working surface?

. High lateral incision
. Longitudinal volar midline incision
. J-shaped (hockey-stick) incision
. Volar transverse incision
. Fish-mouth incision

Correct Answer & Explanation

. High lateral incision

Explanation

A felon is an infection of the septated pulp space of the distal phalanx. A 'fish-mouth' incision (a circumferential incision around the tip) is historically associated with painful scars, loss of tactile sensation, and unstable pulp, and is generally avoided. A longitudinal volar midline incision or a high lateral incision that avoids the neurovascular bundles are preferred approaches.

Question 4127

Topic: Nerve & Tendon
A 22-year-old rugby player grabbed an opponent's jersey and felt a pop in his ring finger. He cannot actively flex the distal interphalangeal (DIP) joint. Radiographs reveal a small bony fragment retracted to the level of the proximal interphalangeal (PIP) joint. According to the Leddy and Packer classification, what type of injury is this, and what is its blood supply status?
. Type I, avascular and requires repair within 7-10 days
. Type II, supported by the intact long vinculum, requires repair within a few weeks
. Type III, supported by the short vinculum, can be repaired late
. Type IV, involving a separate bony fragment and tendon avulsion
. Type V, associated with an extra-articular fracture

Correct Answer & Explanation

. Type II, supported by the intact long vinculum, requires repair within a few weeks

Explanation

Jersey finger is an avulsion of the flexor digitorum profundus (FDP) tendon. In the Leddy and Packer classification: Type I retracts to the palm, rupturing both vincula (requires early repair within 7-10 days to prevent contracture and necrosis). Type II retracts to the level of the PIP joint, caught by the intact long vinculum (preserves some blood supply, can be repaired slightly later). Type III is a large bony avulsion caught at the A4 pulley. Type IV is a bony avulsion with simultaneous avulsion of the tendon off the bony fragment.

Question 4128

Topic: 7. Hand and Wrist
A 60-year-old man presents with chronic wrist pain. Radiographs show severe narrowing of the radioscaphoid and capitolunate joints, but the radiolunate joint is preserved. Which of the following surgical procedures is definitively contraindicated in this patient?
. Scaphoid excision and four-corner fusion
. Proximal row carpectomy
. Total wrist arthrodesis
. Total wrist arthroplasty
. Denervation of the wrist

Correct Answer & Explanation

. Proximal row carpectomy

Explanation

The patient has Stage III Scapholunate Advanced Collapse (SLAC) wrist, characterized by arthritis of the radioscaphoid and capitolunate joints with sparing of the radiolunate joint. Proximal row carpectomy (PRC) relies on a preserved, cartilage-covered capitate head to articulate with the lunate fossa of the radius. Because the capitolunate joint is arthritic in Stage III SLAC, PRC is contraindicated. A four-corner fusion with scaphoid excision is the preferred motion-sparing option.

Question 4129

Topic: 7. Hand and Wrist

A 32-year-old male rower presents with pain and swelling approximately 4 to 6 cm proximal to the dorsal wrist joint. Examination reveals localized swelling and crepitus with active wrist flexion and extension. This condition is caused by friction between the muscle bellies and tendons of which two extensor compartments?

. First and Second
. Second and Third
. Third and Fourth
. First and Third
. Fourth and Fifth

Correct Answer & Explanation

. First and Second

Explanation

This is the classic presentation of Intersection Syndrome. It occurs at the point where the muscle bellies of the 1st dorsal compartment (abductor pollicis longus and extensor pollicis brevis) cross over the tendons of the 2nd dorsal compartment (extensor carpi radialis longus and extensor carpi radialis brevis), typically 4-6 cm proximal to Lister's tubercle.

Question 4130

Topic: Nerve & Tendon

A 35-year-old male sustains a high ulnar nerve transection above the elbow. After primary repair, the surgeon decides to perform a distal supercharged nerve transfer to rapidly restore intrinsic hand function before irreversible muscle atrophy occurs. Which of the following nerve transfers is most commonly used for this purpose?

. Anterior interosseous nerve to the deep motor branch of the ulnar nerve
. Extensor carpi radialis brevis branch of radial nerve to the deep motor branch of the ulnar nerve
. Superficial radial nerve to the ulnar sensory nerve
. Brachialis branch of the musculocutaneous nerve to the ulnar nerve
. Palmar cutaneous branch of the median nerve to the ulnar nerve

Correct Answer & Explanation

. Anterior interosseous nerve to the deep motor branch of the ulnar nerve

Explanation

For high ulnar nerve injuries, distal nerve transfers are employed to bypass the long regeneration distance. The transfer of the terminal branch of the anterior interosseous nerve (AIN) (which supplies the pronator quadratus) to the deep motor branch of the ulnar nerve is the most established technique to rapidly reinnervate the intrinsic muscles of the hand.

Question 4131

Topic: 7. Hand and Wrist

A 55-year-old woman with long-standing rheumatoid arthritis presents with an acute inability to actively flex the interphalangeal joint of her thumb. Passive range of motion is full and painless. She has a prominent, soft volar wrist mass. What is the most likely mechanism of this deficit?

. Rupture of the EPL tendon over Lister's tubercle
. Attritional rupture of the FPL tendon over a scaphoid osteophyte
. Anterior interosseous nerve compression by rheumatoid tenosynovitis
. Dislocation of the FPL tendon from its normal retinacular sheath
. Rupture of the FDP tendon to the index finger

Correct Answer & Explanation

. Rupture of the EPL tendon over Lister's tubercle

Explanation

This clinical scenario describes Mannerfelt-Norman syndrome, which is the attritional rupture of the flexor pollicis longus (FPL) tendon over a bony spur protruding from the volar aspect of the scaphoid in patients with rheumatoid arthritis. It is the most common flexor tendon to rupture in the rheumatoid hand. (Vaughan-Jackson syndrome refers to the dorsal rupture of EDC tendons over a prominent ulnar head).

Question 4132

Topic: 7. Hand and Wrist
A 32-year-old jackhammer operator presents with chronic dorsal wrist pain. X-rays reveal sclerosis, fragmentation, and early collapse of the lunate. Carpal height is maintained, and there is no fixed rotation of the scaphoid. MRI confirms avascular necrosis of the lunate. According to the Lichtman classification, what is the stage of this Kienbock's disease?
. Stage I
. Stage II
. Stage IIIA
. Stage IIIB
. Stage IV

Correct Answer & Explanation

. Stage IIIA

Explanation

In the Lichtman classification of Kienbock's disease: Stage I shows normal X-rays but MRI changes. Stage II exhibits lunate sclerosis without collapse. Stage IIIA involves lunate collapse/fragmentation but normal carpal alignment (normal carpal height, normal scaphoid alignment). Stage IIIB involves lunate collapse with fixed scaphoid rotary subluxation and decreased carpal height. Stage IV adds secondary radiocarpal or midcarpal arthritis.

Question 4133

Topic: 7. Hand and Wrist

A 30-year-old male presents with a high radial nerve palsy following a humerus fracture 12 months ago. Nerve exploration was unsuccessful. For the surgical restoration of active wrist extension, which tendon transfer is most commonly utilized and provides the best biomechanical advantage?

. Pronator teres to Extensor carpi radialis brevis
. Flexor carpi ulnaris to Extensor digitorum communis
. Flexor carpi radialis to Extensor pollicis longus
. Palmaris longus to Extensor carpi ulnaris
. Flexor digitorum superficialis to Extensor carpi radialis longus

Correct Answer & Explanation

. Pronator teres to Extensor carpi radialis brevis

Explanation

The pronator teres (PT) to extensor carpi radialis brevis (ECRB) transfer is the workhorse tendon transfer to restore wrist extension in radial nerve palsy. The ECRB is preferred over the ECRL because it inserts more centrally on the third metacarpal, preventing radial deviation during wrist extension.

Question 4134

Topic: Hand Trauma & Infection

A 45-year-old diabetic patient presents with a pyogenic flexor tenosynovitis of his small finger following a puncture wound. Two days later, he develops massive swelling in the thumb and thenar eminence despite having no direct trauma to the thumb. What anatomical structure facilitates this specific spread of infection?

. Midpalmar space
. Thenar space
. Parona's space
. Superficial palmar arch
. Space of Poirier

Correct Answer & Explanation

. Midpalmar space

Explanation

The ulnar bursa (enveloping the small finger flexor tendons) and the radial bursa (enveloping the FPL tendon of the thumb) commonly communicate in the distal forearm via Parona's space (the potential space between the pronator quadratus and the deep flexor tendons). An infection spreading from the small finger to the thumb is known as a 'horseshoe abscess'.

Question 4135

Topic: Wrist & Carpus

A 40-year-old female presents with ulnar-sided wrist pain that worsens with pronation and gripping. Radiographs demonstrate a positive ulnar variance of +4 mm and cystic changes in the lunate and triquetrum. MRI confirms a central perforation of the TFCC but an intact distal radioulnar joint (DRUJ) cartilage. What is the most appropriate surgical intervention?

. Darrach procedure
. Suave-Kapandji procedure
. Ulnar shortening osteotomy
. Proximal row carpectomy
. Wafer procedure (distal ulnar resection)

Correct Answer & Explanation

. Darrach procedure

Explanation

This is a classic presentation of Ulnar Impaction Syndrome. With a positive ulnar variance of +4 mm and preserved DRUJ articular cartilage, an ulnar shortening osteotomy (extra-articular) is the gold standard. It unloads the ulnocarpal joint while tightening the ulnocarpal ligaments. A Wafer procedure is generally reserved for variance of +2 mm or less. Darrach and Suave-Kapandji are salvage procedures for DRUJ arthritis.

Question 4136

Topic: 7. Hand and Wrist

In the surgical treatment of Dupuytren's contracture, a specific pathological cord is responsible for flexing the PIP joint and simultaneously displacing the neurovascular bundle centrally and superficially, placing it at high risk of transection. Which of the following normal fascial structures is NOT a precursor to this cord?

. Pretendinous band
. Spiral band
. Lateral digital sheet
. Grayson's ligament
. Cleland's ligament

Correct Answer & Explanation

. Pretendinous band

Explanation

The spiral cord is responsible for PIP contracture and central/superficial displacement of the neurovascular bundle. It forms from four structures: the pretendinous band, the spiral band, the lateral digital sheet, and Grayson's ligament. Cleland's ligament is located dorsal to the neurovascular bundle and is NOT involved in the pathogenesis of Dupuytren's disease.

Question 4137

Topic: 7. Hand and Wrist

A 25-year-old carpenter suffers a fingertip amputation of his index finger. The amputation is volar-oblique, exposing 4 mm of the distal phalanx. Which of the following is the most appropriate soft tissue coverage option to provide durable, sensate padding?

. V-Y advancement flap (Atasoy)
. Cross-finger flap
. Moberg advancement flap
. Thenar flap
. Split-thickness skin graft

Correct Answer & Explanation

. V-Y advancement flap (Atasoy)

Explanation

A cross-finger flap is the ideal choice for a volar-oblique amputation of a digit (excluding the thumb) with exposed bone, as it brings in thick, durable tissue from the dorsum of an adjacent finger. A V-Y (Atasoy) flap is better for transverse or dorsal-oblique amputations. A Moberg flap is strictly used for the thumb due to its unique independent dorsal blood supply.

Question 4138

Topic: 7. Hand and Wrist

A 30-year-old skier presents with severe pain and weakness of pinch in the right thumb following a fall on an outstretched hand with a ski pole. Examination shows 45 degrees of radial deviation of the MCP joint with no firm endpoint. A Stener lesion is suspected. What defines the anatomy of a Stener lesion?

. The torn ulnar collateral ligament (UCL) is displaced deep to the adductor pollicis aponeurosis.
. The torn ulnar collateral ligament (UCL) is displaced superficial to the adductor pollicis aponeurosis.
. The adductor pollicis tendon is interposed between the intact UCL and the metacarpal head.
. The volar plate is avulsed and interposed within the MCP joint.
. The radial collateral ligament is displaced superficial to the abductor pollicis brevis.

Correct Answer & Explanation

. The torn ulnar collateral ligament (UCL) is displaced deep to the adductor pollicis aponeurosis.

Explanation

A Stener lesion occurs in complete ruptures of the thumb UCL. The torn end of the ligament flips back and displaces superficial to the adductor pollicis aponeurosis. Because the aponeurosis is interposed between the ligament and its bony insertion, non-operative healing is impossible, and surgical repair is mandated.

Question 4139

Topic: 7. Hand and Wrist
A 35-year-old male presents with wrist pain 10 years after an untreated fall. Radiographs show a scaphoid nonunion. There is joint space narrowing of the radioscaphoid joint and the capitolunate joint, but the radiolunate joint is perfectly preserved. What stage of Scaphoid Nonunion Advanced Collapse (SNAC) does this represent?
. Stage I
. Stage II
. Stage III
. Stage IV
. Stage V

Correct Answer & Explanation

. Stage III

Explanation

SNAC staging describes the progressive pattern of arthritis following a scaphoid nonunion. Stage I involves the radial styloid and distal scaphoid fragment. Stage II involves the scaphocapitate joint. Stage III involves the capitolunate joint. Stage IV is pancarpal arthritis. The radiolunate joint is characteristically spared due to the conformal nature of the radiolunate articulation.

Question 4140

Topic: Wrist & Carpus

Six weeks following a non-displaced distal radius fracture treated successfully with a short arm cast, a 58-year-old female presents with a sudden inability to actively lift her thumb into extension. Which tendon is the standard choice for transfer to restore this lost function?

. Extensor indicis proprius (EIP)
. Extensor carpi radialis longus (ECRL)
. Palmaris longus (PL)
. Flexor digitorum superficialis (FDS) of the ring finger
. Abductor pollicis longus (APL)

Correct Answer & Explanation

. Extensor indicis proprius (EIP)

Explanation

The patient has experienced an attritional rupture of the Extensor Pollicis Longus (EPL) tendon, a well-known complication of non-displaced distal radius fractures (due to ischemia or mechanical wear at Lister's tubercle). The Extensor Indicis Proprius (EIP) transfer is the gold standard procedure to restore independent thumb extension.

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