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7. Hand and Wrist MCQs

Practice Set 208 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 4141

Topic: 7. Hand and Wrist
During a carpal tunnel release, the surgeon must carefully avoid injury to the recurrent motor branch of the median nerve. According to Poisel's classification, what is the most common anatomical relationship of this nerve branch to the transverse carpal ligament?
. Extraligamentous with a recurrent course
. Subligamentous
. Transligamentous
. Pre-ligamentous
. Piercing the ulnar bursa

Correct Answer & Explanation

. Extraligamentous with a recurrent course

Explanation

According to Poisel's classification of the recurrent motor branch of the median nerve: Type I (extraligamentous, taking a recurrent course distal to the ligament) is the most common (~50-80%). Type II is subligamentous (branching within the tunnel and exiting deep to the distal edge). Type III is transligamentous (piercing directly through the TCL), which is the most susceptible to iatrogenic injury.

Question 4142

Topic: Nerve & Tendon

A 42-year-old female presents with severe, paroxysmal pain in her left index fingertip that is exquisitely sensitive to cold temperatures. Examination reveals a bluish hue and pinpoint tenderness beneath the nail plate. Which of the following clinical tests is most specific for diagnosing the suspected lesion?

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

Correct Answer & Explanation

. Finkelstein test

Explanation

The clinical picture is classic for a Glomus tumor (pain, cold sensitivity, pinpoint tenderness). Hildreth's test involves inducing transient ischemia of the digit with a tourniquet; if the pinpoint pain disappears during ischemia and returns upon release, the test is positive. It is highly specific for a glomus tumor.

Question 4143

Topic: 7. Hand and Wrist

A 22-year-old male presents with a nonunion of the proximal pole of the scaphoid 6 months after a fall. What is the primary arterial supply to the proximal pole of the scaphoid that makes it susceptible to avascular necrosis?

. Volar branches of the radial artery
. Dorsal carpal branch of the radial artery
. Ulnar artery through the deep palmar arch
. Anterior interosseous artery
. Palmar carpal branch of the ulnar artery

Correct Answer & Explanation

. Volar branches of the radial artery

Explanation

The scaphoid receives its primary blood supply from the dorsal carpal branch of the radial artery, which enters at the distal third and supplies the proximal pole in a retrograde fashion.

Question 4144

Topic: 7. Hand and Wrist

A 35-year-old basketball player presents with a drooping distal phalanx of his middle finger after a direct blow. Radiographs show a small dorsal avulsion fracture of the distal phalanx involving 15% of the articular surface without subluxation. What is the most appropriate management?

. Surgical fixation with K-wires
. Extension splinting of the DIP joint for 6-8 weeks
. Splinting of both PIP and DIP joints in extension
. Immediate active range of motion
. Surgical repair with a pull-out suture

Correct Answer & Explanation

. Surgical fixation with K-wires

Explanation

Acute mallet finger injuries with <30% articular involvement and no subluxation are treated non-operatively with continuous DIP joint extension splinting for 6-8 weeks. The PIP joint does not need to be immobilized.

Question 4145

Topic: 7. Hand and Wrist
A 40-year-old manual laborer presents with dorsal wrist pain. Imaging demonstrates sclerosis and fragmentation of the lunate, but the scaphoid is properly aligned and the carpal height is maintained. What Lichtman stage does this represent?
. Stage I
. Stage II
. Stage IIIA
. Stage IIIB
. Stage IV

Correct Answer & Explanation

. Stage IIIA

Explanation

Lichtman Stage IIIA is characterized by lunate fragmentation and collapse but maintained carpal height and normal scaphoid alignment. Stage IIIB involves fixed scaphoid rotation and loss of carpal height.

Question 4146

Topic: 7. Hand and Wrist

A 45-year-old female is unable to make an "OK" sign with her thumb and index finger, demonstrating a flattened pinch. Sensation in her hand is completely normal. Which muscle is most likely affected by this isolated nerve palsy?

. Abductor pollicis brevis
. Flexor pollicis longus
. Adductor pollicis
. First dorsal interosseous
. Flexor digitorum superficialis

Correct Answer & Explanation

. Abductor pollicis brevis

Explanation

Anterior interosseous nerve (AIN) palsy presents with inability to flex the IP joint of the thumb (FPL) and DIP joint of the index finger (FDP), resulting in a flattened "OK" sign. The AIN is a pure motor nerve, so sensation is normal.

Question 4147

Topic: Hand Trauma & Infection

In an acute rupture of the ulnar collateral ligament of the thumb MCP joint (skier's thumb), what anatomical structure typically interposes between the torn ligament ends, preventing healing and necessitating surgical repair?

. Adductor pollicis aponeurosis
. Abductor pollicis brevis tendon
. Extensor pollicis longus tendon
. Flexor pollicis brevis muscle
. Volar plate

Correct Answer & Explanation

. Adductor pollicis aponeurosis

Explanation

A Stener lesion occurs when the torn ulnar collateral ligament displaces superficial to the adductor pollicis aponeurosis. This prevents proper apposition of the ligament ends and is an indication for surgical repair.

Question 4148

Topic: 7. Hand and Wrist

During evaluation of a patient with suspected carpal tunnel syndrome, the examiner places the wrist in maximum flexion for 60 seconds to reproduce paresthesias in the median nerve distribution. What is the name of this provocative test?

. Tinel's sign
. Phalen's test
. Durkan's test
. Froment's sign
. Finkelstein's test

Correct Answer & Explanation

. Tinel's sign

Explanation

Phalen's test involves placing the wrists in maximum flexion for 60 seconds to reproduce carpal tunnel symptoms. Durkan's test relies on direct compression over the carpal tunnel.

Question 4149

Topic: Hand Trauma & Infection

A 32-year-old male presents with a swollen, erythematous, and exquisitely painful index finger after a puncture wound. Which of the following is NOT one of Kanavel's cardinal signs of flexor tenosynovitis?

. Fusiform swelling of the digit
. Pain with active extension of the digit
. Flexed posture of the digit
. Pain with passive extension of the digit
. Tenderness along the flexor tendon sheath

Correct Answer & Explanation

. Fusiform swelling of the digit

Explanation

Kanavel's four cardinal signs are: fusiform swelling, flexed posture, exquisite pain with passive extension, and tenderness along the flexor sheath. Pain on active extension is not considered a cardinal sign.

Question 4150

Topic: 7. Hand and Wrist
A 28-year-old male presents with dorsal radial wrist pain following a fall onto an outstretched hand. Radiographs show a widened scapholunate interval (>3 mm) on the AP view and a dorsal tilt of the lunate on the lateral view. What specific deformity is present?
. Volar intercalated segment instability (VISI)
. Dorsal intercalated segment instability (DISI)
. Perilunate dislocation
. Lunate dislocation
. Midcarpal instability

Correct Answer & Explanation

. Dorsal intercalated segment instability (DISI)

Explanation

A scapholunate ligament tear allows the scaphoid to flex and the lunate to extend, leading to Dorsal Intercalated Segment Instability (DISI). The lunate tilts dorsally, yielding a scapholunate angle >60 degrees.

Question 4151

Topic: 7. Hand and Wrist

In the surgical management of Dupuytren's contracture, which fascial structure is typically spared from involvement and helps protect the neurovascular bundle during dissection?

. Spiral cord
. Pretendinous band
. Natatory ligament
. Cleland's ligament
. Grayson's ligament

Correct Answer & Explanation

. Spiral cord

Explanation

Cleland's ligaments are located dorsal to the neurovascular bundles and are generally spared in Dupuytren's disease. Grayson's ligaments are volar to the NV bundles and are frequently involved.

Question 4152

Topic: 7. Hand and Wrist
A 55-year-old female presents with base of thumb pain. Radiographs reveal Eaton-Littler Stage III trapeziometacarpal osteoarthritis. She has failed conservative management. Which surgical procedure is considered the gold standard for long-term pain relief and functional improvement?
. CMC joint arthrodesis
. Trapeziometacarpal joint denervation
. Trapeziectomy with or without ligament reconstruction and tendon interposition (LRTI)
. Metacarpal osteotomy
. Total joint arthroplasty

Correct Answer & Explanation

. Trapeziectomy with or without ligament reconstruction and tendon interposition (LRTI)

Explanation

Trapeziectomy with or without LRTI is the standard surgical treatment for advanced (Stage III/IV) thumb CMC arthritis. It provides excellent long-term pain relief while preserving functional motion.

Question 4153

Topic: Nerve & Tendon

A patient presents with a finger deformity characterized by PIP joint flexion and DIP joint hyperextension. What is the primary anatomic defect responsible for this deformity?

. Rupture of the terminal extensor tendon
. Attenuation or rupture of the central slip
. Volar plate rupture at the PIP joint
. Contracture of the oblique retinacular ligament
. Rupture of the flexor digitorum superficialis

Correct Answer & Explanation

. Rupture of the terminal extensor tendon

Explanation

A Boutonniere deformity is caused by the attenuation or rupture of the central slip of the extensor apparatus at the PIP joint. This allows the lateral bands to subluxate volarly and become flexors of the PIP and extensors of the DIP.

Question 4154

Topic: 7. Hand and Wrist

A full-term infant is born with complete simple syndactyly of the long and ring fingers. When is the optimal time for surgical release to prevent angular deformity and optimize functional outcome?

. Within the first 3 months of life
. At 6 to 12 months of age
. At 12 to 18 months of age
. Between 3 and 4 years of age
. Prior to starting primary school

Correct Answer & Explanation

. Within the first 3 months of life

Explanation

Simple syndactyly release is typically performed between 12 and 18 months of age to optimize pinch development while minimizing anesthetic risks. Border digits (thumb/index, ring/small) require earlier release (6 months) to prevent growth tethering.

Question 4155

Topic: 7. Hand and Wrist

A cyclist complains of numbness in his ring and small fingers and weakness in hand grip. Examination reveals clawing of the ring and small fingers. Compression of the ulnar nerve is suspected in Guyon's canal. Which of the following forms the floor of Guyon's canal?

. Volar carpal ligament
. Transverse carpal ligament
. Pisohamate ligament
. Flexor retinaculum
. Hook of the hamate

Correct Answer & Explanation

. Volar carpal ligament

Explanation

The floor of Guyon's canal is formed by the transverse carpal ligament (flexor retinaculum) and the pisohamate ligament. The roof is formed by the volar carpal ligament.

Question 4156

Topic: 7. Hand and Wrist

A patient presents with median nerve distribution paresthesias. Which clinical finding best differentiates Pronator Syndrome from Carpal Tunnel Syndrome?

. Weakness of the abductor pollicis brevis
. Positive Tinel's sign at the wrist
. Paresthesias in the radial three and a half digits
. Sensory loss over the thenar eminence
. Night pain awakening the patient

Correct Answer & Explanation

. Weakness of the abductor pollicis brevis

Explanation

The palmar cutaneous branch of the median nerve supplies sensation to the thenar eminence and branches off proximal to the carpal tunnel. Therefore, thenar sensation is spared in Carpal Tunnel Syndrome but decreased in Pronator Syndrome.

Question 4157

Topic: 7. Hand and Wrist
A 45-year-old heavy laborer presents with chronic wrist pain. Radiographs demonstrate advanced arthritis of the radioscaphoid and capitolunate joints, while the radiolunate joint is entirely spared. Which of the following is the most appropriate surgical management?
. Proximal row carpectomy
. Scaphoid excision and four-corner arthrodesis
. Radial styloidectomy
. Total wrist arthrodesis
. Scaphoid open reduction and internal fixation

Correct Answer & Explanation

. Scaphoid excision and four-corner arthrodesis

Explanation

This patient has Stage III Scapholunate Advanced Collapse (SLAC). Proximal row carpectomy is contraindicated due to capitate head arthritis; four-corner arthrodesis removes the arthritic capitolunate joint while preserving the healthy radiolunate joint.

Question 4158

Topic: 7. Hand and Wrist

A 55-year-old female with severe rheumatoid arthritis presents with an inability to actively extend her small and ring fingers. Passive extension is full, and tenodesis effect demonstrates intact extensor tendons proximal to the wrist. What is the most likely etiology of this presentation?

. Caput ulnae syndrome causing Vaughan-Jackson lesion
. Mannerfelt syndrome causing flexor tendon attrition
. Posterior interosseous nerve (PIN) entrapment
. Triggering of rheumatoid nodules at the A1 pulley
. Spontaneous rupture of the extensor retinaculum

Correct Answer & Explanation

. Caput ulnae syndrome causing Vaughan-Jackson lesion

Explanation

Vaughan-Jackson syndrome involves the sequential rupture of the extensor tendons (starting from EDM, then EDC to the ring finger) due to attrition over a dorsally subluxated, arthritic distal ulna (caput ulnae).

Question 4159

Topic: 7. Hand and Wrist

During surgical fasciectomy for a complex Dupuytren's contracture of the proximal interphalangeal (PIP) joint, the surgeon must identify and protect the neurovascular bundle, which is often displaced by the spiral cord. Which of the following structures does NOT contribute to the formation of the spiral cord?

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

Correct Answer & Explanation

. Grayson's ligament

Explanation

The spiral cord is composed of the pretendinous band, spiral band, lateral digital sheet, and Grayson's ligament. Cleland's ligaments remain dorsal to the neurovascular bundle and are spared in Dupuytren's disease.

Question 4160

Topic: Nerve & Tendon

A 32-year-old cyclist presents with weakness in his hand after a long-distance race. Examination reveals weak finger abduction and adduction, and a positive Froment's sign. Sensation over the entire little finger and the ulnar half of the ring finger is completely normal. In which zone of Guyon's canal is the compression most likely located?

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

Correct Answer & Explanation

. Zone 1

Explanation

Zone 2 of Guyon's canal contains only the deep motor branch of the ulnar nerve. Compression here (e.g., from a ganglion cyst or hook of hamate fracture) causes isolated motor weakness of the ulnar-innervated intrinsics with spared sensation.

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