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7. Hand and Wrist MCQs

Practice Set 209 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 4161

Topic: 7. Hand and Wrist

A 25-year-old carpenter sustains a laceration to the volar aspect of his right index finger at the level of the proximal phalanx, resulting in a Zone II flexor tendon injury. During surgical repair, preserving the biomechanical efficiency of the tendon is crucial. Which of the following pulley systems are most essential to preserve or reconstruct to prevent significant bowstringing and loss of digital flexion?

. A1 and A3 pulleys
. A2 and A4 pulleys
. A3 and A5 pulleys
. Cruciate pulleys (C1 and C2)
. A1 and A5 pulleys

Correct Answer & Explanation

. A1 and A3 pulleys

Explanation

The A2 and A4 pulleys are the major biomechanical pulleys of the flexor sheath. They arise from the periosteum of the proximal and middle phalanges, respectively. Their preservation or reconstruction is absolutely critical to prevent bowstringing of the flexor tendons, which alters the moment arm and leads to incomplete active flexion and a loss of grip strength. The A1, A3, and A5 pulleys overlay the joints (MCP, PIP, DIP) and are considered minor pulleys.

Question 4162

Topic: 7. Hand and Wrist

A 20-year-old male falls onto an outstretched hand and presents with anatomic snuffbox tenderness. Initial radiographs are negative, but an MRI confirms an occult fracture at the proximal pole of the scaphoid. The patient is warned about the high risk of avascular necrosis. The major blood supply to the scaphoid, which puts the proximal pole at risk, enters from which of the following vessels?

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

Correct Answer & Explanation

. Volar carpal branch of the radial artery

Explanation

The major blood supply to the scaphoid (providing 70-80% of its vascularity, including the entire proximal pole) is retrograde, entering the distal half of the scaphoid dorsally via branches of the dorsal carpal branch of the radial artery. Because the vessels travel from distal to proximal inside the bone, fractures at the waist or proximal pole critically interrupt the blood supply to the proximal fragment, leading to a high rate of avascular necrosis and nonunion.

Question 4163

Topic: 7. Hand and Wrist
A 30-year-old male presents to the emergency department after a high-speed motorcycle accident. He complains of severe wrist pain and numbness in his radial three-and-a-half digits. Lateral radiographs of the wrist demonstrate the lunate completely displaced volar to the radius, while the capitate remains aligned with the radius. According to Mayfield's stages of perilunate instability, what stage does this represent?
. Stage I
. Stage II
. Stage III
. Stage IV
. Stage V

Correct Answer & Explanation

. Stage IV

Explanation

This presentation describes a classic lunate dislocation ('spilled teacup' sign on lateral radiograph), which represents Mayfield Stage IV. The Mayfield classification of perilunate instability progresses sequentially: Stage I involves scapholunate dissociation. Stage II involves lunocapitate dislocation. Stage III involves lunotriquetral disruption (perilunate dislocation). Stage IV involves complete volar enucleation of the lunate from the lunate fossa, pivoting on the short radiolunate ligament.

Question 4164

Topic: Wrist & Carpus

A 60-year-old female presents with sudden inability to flex the interphalangeal (IP) joint of her right thumb. She underwent open reduction and internal fixation of a distal radius fracture with a volar locking plate 6 months ago. What is the most likely surgical error that led to this complication?

. Penetration of screws into the distal radioulnar joint
. Over-contouring of the plate against the radial styloid
. Placement of the volar plate distal to the watershed line
. Failure to repair the pronator quadratus during closure
. Placing screws too dorsally through the second extensor compartment

Correct Answer & Explanation

. Penetration of screws into the distal radioulnar joint

Explanation

Spontaneous rupture of the Flexor Pollicis Longus (FPL) tendon is a known complication of volar plating of the distal radius. This almost invariably occurs when the plate is positioned too far distally, specifically prominent volar to the watershed line of the distal radius. The watershed line is a theoretical margin marking the most distal edge of the flat volar surface of the radius before the articular surface slopes dorsally. Implants placed distal to this line directly irritate the FPL tendon, leading to attrition and eventually rupture.

Question 4165

Topic: Wrist & Carpus
A 45-year-old manual laborer presents with chronic right wrist pain. He has a history of a neglected scaphoid fracture 10 years ago. Radiographs reveal advanced radiocarpal arthritis and capitolunate arthritis. The radiolunate joint is remarkably preserved. Which of the following is the most appropriate surgical intervention?
. Proximal row carpectomy (PRC)
. Scaphoid excision and four-corner fusion
. Radial styloidectomy alone
. Total wrist arthroplasty
. Radioscapholunate (RSL) fusion

Correct Answer & Explanation

. Scaphoid excision and four-corner fusion

Explanation

The patient has Scaphoid Nonunion Advanced Collapse (SNAC) Stage III, characterized by radioscaphoid and capitolunate arthritis, but with sparing of the radiolunate joint. Because the capitate head is arthritic, a proximal row carpectomy (PRC) is contraindicated (as it requires a pristine capitate head to articulate with the lunate fossa). The procedure of choice in an active laborer with SNAC III is scaphoid excision and four-corner fusion (capitate, hamate, lunate, triquetrum), preserving the functional radiolunate joint.

Question 4166

Topic: Hand Trauma & Infection

A 35-year-old mechanic sustains a small puncture wound to his volar right index finger. Two days later, he presents with severe pain and swelling. Which of the following is NOT one of Kanavel's cardinal signs of pyogenic flexor tenosynovitis?

. Fusiform swelling of the digit
. Digit held in a flexed posture
. Severe pain on passive extension of the digit
. Tenderness along the flexor tendon sheath
. Erythema tracking proximally into the palm

Correct Answer & Explanation

. Fusiform swelling of the digit

Explanation

Kanavel's four cardinal signs of pyogenic flexor tenosynovitis include: 1) Fusiform ('sausage') swelling of the entire digit, 2) The digit is held in resting flexion, 3) Exquisite pain with passive extension (often the earliest and most sensitive sign), and 4) Tenderness to palpation along the course of the flexor tendon sheath. Erythema tracking proximally (lymphangitis or palmar spread) is not one of the classic Kanavel's signs.

Question 4167

Topic: 7. Hand and Wrist

During a fasciectomy for Dupuytren's contracture in a 60-year-old male with a severe proximal interphalangeal (PIP) joint contracture, the surgeon must carefully dissect out the neurovascular bundles. Which anatomical structure is primarily responsible for PIP joint contracture and causes the neurovascular bundle to spiral centrally and superficially, putting it at high risk of iatrogenic injury?

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

Correct Answer & Explanation

. Pretendinous band

Explanation

The spiral cord in Dupuytren's disease is responsible for PIP joint contractures and critically alters the normal anatomy of the neurovascular bundle, pulling it centrally and superficially. The spiral cord is formed by the pathological involvement of the pretendinous band, spiral band, lateral digital sheet, and Grayson's ligament. The central cord also causes PIP contracture but does not typically displace the neurovascular bundle.

Question 4168

Topic: 7. Hand and Wrist
A 30-year-old right-hand-dominant male presents with dorsal wrist pain. Radiographs reveal ulnar negative variance and increased sclerosis of the lunate without architectural collapse. MRI confirms Kienböck's disease (Lichtman Stage II). Which of the following is the most widely accepted initial surgical management for this patient?
. Proximal row carpectomy
. Radial shortening osteotomy
. Capitate shortening osteotomy
. Lunate excision and silicone replacement
. Total wrist fusion

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

For Lichtman Stage II (sclerosis, no collapse) and Stage IIIA (collapse, no scaphoid rotation) Kienböck's disease in a patient with ulnar negative variance, joint leveling procedures are the standard of care. A radial shortening osteotomy (or ulnar lengthening) unloads the lunate by shifting compressive forces to the ulnocarpal joint. Salvage procedures like PRC or wrist fusion are reserved for advanced stages (Stage IIIB and IV) with carpal instability or secondary arthritis.

Question 4169

Topic: 7. Hand and Wrist

A 25-year-old athlete undergoes wrist arthroscopy for chronic ulnar-sided wrist pain after a twisting injury. A peripheral (Palmer class 1B) tear of the triangular fibrocartilage complex (TFCC) is identified and repaired. The vascular supply to this reparable zone of the TFCC is primarily derived from which of the following?

. Anterior interosseous artery only
. Branches of the ulnar artery and anterior interosseous artery
. Branches of the radial artery and posterior interosseous artery
. The superficial palmar arch
. The deep palmar arch

Correct Answer & Explanation

. Anterior interosseous artery only

Explanation

The blood supply to the TFCC is limited to its peripheral 10% to 25%. This vascularity comes primarily from the dorsal and palmar radiocarpal branches of the ulnar artery, as well as branches of the anterior interosseous artery. Because only the peripheral portion is vascularized, only peripheral tears (Palmer 1B, 1C) are amenable to surgical repair, while central tears (Palmer 1A) require debridement.

Question 4170

Topic: 7. Hand and Wrist
A 55-year-old female with severe, conservative-refractory basilar thumb arthritis (Eaton-Littler Stage III) is undergoing a Ligament Reconstruction and Tendon Interposition (LRTI) arthroplasty. During this procedure, the trapezium is excised. Which tendon is classically harvested (either entirely or split) to reconstruct the anterior oblique ligament and provide the interpositional anchovy?
. Extensor pollicis brevis (EPB)
. Abductor pollicis longus (APL)
. Flexor carpi radialis (FCR)
. Flexor carpi ulnaris (FCU)
. Palmaris longus (PL)

Correct Answer & Explanation

. Flexor carpi radialis (FCR)

Explanation

The classic LRTI procedure, popularized by Burton and Pellegrini, utilizes a split (or entire) Flexor Carpi Radialis (FCR) tendon. The harvested slip is passed through a drill hole in the base of the first metacarpal to reconstruct the anterior oblique ligament (beak ligament) to prevent proximal and dorsal migration, and the remaining tendon is rolled into an 'anchovy' and interposed into the void left by the trapeziectomy.

Question 4171

Topic: Nerve & Tendon

A surgeon is performing a release of the first dorsal compartment for De Quervain's tenosynovitis. To avoid recurrence of symptoms, it is critical to identify and release all tendon slips. The surgeon must specifically look for a separate fascial subcompartment that frequently houses which of the following tendons?

. Abductor pollicis longus (APL)
. Extensor pollicis longus (EPL)
. Extensor pollicis brevis (EPB)
. Extensor carpi radialis longus (ECRL)
. Extensor indicis proprius (EIP)

Correct Answer & Explanation

. Abductor pollicis longus (APL)

Explanation

In De Quervain's tenosynovitis, the first dorsal compartment contains the APL and EPB tendons. Anatomical variations are very common. A separate subcompartment exists in approximately 40% to 60% of patients and almost exclusively houses the Extensor Pollicis Brevis (EPB) tendon. Failure to identify and release this EPB subcompartment is the leading cause of surgical failure and recurrent symptoms.

Question 4172

Topic: 7. Hand and Wrist
A 45-year-old male is undergoing nerve conduction studies. The electromyographer notes that the compound muscle action potential (CMAP) recorded at the hypothenar eminence is significantly larger when stimulating the ulnar nerve at the wrist compared to stimulating the ulnar nerve at the elbow. This finding is indicative of which of the following common anatomical variants?
. Riche-Cannieu anastomosis
. Berrettini anastomosis
. Martin-Gruber anastomosis
. Marinacci communication
. Hypothenar motor branch variation

Correct Answer & Explanation

. Martin-Gruber anastomosis

Explanation

The Martin-Gruber anastomosis is a motor connection in the forearm where branches from the median nerve (usually via the anterior interosseous nerve) cross over to join the ulnar nerve. Because these motor fibers travel with the median nerve at the elbow but the ulnar nerve at the wrist, stimulating the ulnar nerve at the wrist captures both native ulnar fibers and the crossed median fibers, resulting in a larger CMAP compared to stimulating the ulnar nerve at the elbow.

Question 4173

Topic: 7. Hand and Wrist

A 22-year-old male punches a wall and sustains a fracture of the fifth metacarpal neck (Boxer's fracture). He has no rotational deformity of the digit. According to standard orthopedic principles, what is the maximum acceptable volar angulation for this specific fracture before reduction and internal fixation are strongly recommended?

. 10 degrees
. 30 degrees
. 40 degrees
. 70 degrees
. 90 degrees

Correct Answer & Explanation

. 10 degrees

Explanation

The 5th carpometacarpal (CMC) joint has the greatest compensatory mobility of all the metacarpals (approx. 20-30 degrees of AP motion). Because of this extensive mobility, the 5th metacarpal neck can tolerate significant volar angulation—typically up to 70 degrees—without significant functional impairment, provided there is no rotational malalignment (no digital crossing). The 2nd and 3rd metacarpals, which are relatively fixed, can only tolerate 10-15 degrees.

Question 4174

Topic: Nerve & Tendon

A 32-year-old avid cyclist presents with profound weakness of finger abduction and adduction. He has a positive Froment's sign. However, his hypothenar muscles (abductor digiti minimi) possess normal strength, and his sensation over the volar small finger is completely intact. In which zone of Guyon's canal is the ulnar nerve most likely compressed?

. Zone 1
. Zone 2
. Zone 3
. Zone 4
. Zone 5

Correct Answer & Explanation

. Zone 1

Explanation

Guyon's canal is divided into three zones. Zone 1 is proximal to the bifurcation; compression here causes mixed motor and sensory deficits (involving hypothenar muscles). Zone 2 encompasses the deep motor branch after it bifurcates; compression here causes pure motor deficits. Furthermore, if the compression is distal to the hypothenar motor branches within Zone 2, it spares the hypothenar muscles but paralyzes the interossei and lumbricals (as in this cyclist). Zone 3 surrounds the superficial sensory branch; compression here causes pure sensory deficits.

Question 4175

Topic: Wrist & Carpus

In Scapholunate Advanced Collapse (SLAC) of the wrist, a predictable and sequential pattern of articular degeneration occurs. Despite severe arthritis at the radioscaphoid and capitolunate joints, the radiolunate joint is almost universally spared. What anatomical and biomechanical characteristic of the radiolunate joint explains this sparing?

. The lunate has no direct ligamentous attachments to the radius.
. The lunate articular surface is entirely covered by the TFCC.
. The radiolunate articulation is perfectly spherical and concentric.
. The radiolunate joint is elliptical, preventing rotation.
. The lunate relies exclusively on the radioscaphocapitate ligament for stability.

Correct Answer & Explanation

. The lunate has no direct ligamentous attachments to the radius.

Explanation

In SLAC wrist, the radiolunate joint is famously spared from osteoarthritis. This is because the articulation between the lunate and the lunate fossa of the distal radius is spherical and concentric. Even when the lunate rotates dorsally (DISI deformity) due to scapholunate ligament incompetence, the spherical geometry maintains a congruent joint surface with evenly distributed loads. In contrast, the radioscaphoid joint is elliptical; when the scaphoid flexes, point loading occurs, leading to rapid cartilage breakdown.

Question 4176

Topic: 7. Hand and Wrist

A 24-year-old basketball player presents with a 'jammed' finger. On examination, the proximal interphalangeal (PIP) joint is fixed in flexion, and the distal interphalangeal (DIP) joint is held in hyperextension. This boutonniere deformity is initiated by an injury to the central slip of the extensor tendon. Which secondary biomechanical alteration is the direct cause of the DIP hyperextension?

. Dorsal subluxation of the lateral bands
. Volar subluxation of the lateral bands
. Rupture of the oblique retinacular ligament
. Contracture of the terminal tendon
. Avulsion of the deep transverse metacarpal ligament

Correct Answer & Explanation

. Dorsal subluxation of the lateral bands

Explanation

A Boutonniere deformity begins with a rupture or attenuation of the central slip of the extensor apparatus at its insertion on the middle phalanx, leading to PIP flexion. This loss of dorsal restraint allows the lateral bands to subluxate volarly (palmar to the axis of rotation of the PIP joint). Once volar, they act as PIP flexors. As they displace volarly and proximally, they increase tension on the terminal tendon, directly causing hyperextension of the DIP joint.

Question 4177

Topic: Nerve & Tendon

A 45-year-old construction worker presents with pain, cold intolerance, and pale discoloration of his ring and small fingers. An Allen test demonstrates delayed capillary refill when the ulnar artery is assessed.

Angiography confirms thrombosis of the ulnar artery in Guyon's canal. Which of the following anatomic structures acts as the 'anvil' against which the ulnar artery is repeatedly traumatized in this condition?

. Scaphoid tubercle
. Hook of hamate
. Pisiform
. Trapezium ridge
. Lister's tubercle

Correct Answer & Explanation

. Scaphoid tubercle

Explanation

This patient has Hypothenar Hammer Syndrome, which results from repetitive blunt trauma to the hypothenar eminence. This causes intimal injury, thrombosis, or aneurysm of the ulnar artery as it passes through Guyon's canal. The hook of the hamate acts as the bony 'anvil' that the artery is compressed against. The pisiform forms the ulnar border of Guyon's canal but does not typically act as the anvil.

Question 4178

Topic: 7. Hand and Wrist

A 25-year-old female presents with acute pain and swelling in her ring finger after a minor twisting injury.

Radiographs demonstrate a pathologic fracture through a centrally located lytic lesion in the proximal phalanx with stippled calcifications. What is the most appropriate definitive management for the underlying lesion once the fracture is addressed?

. Observation alone as it will heal with the fracture
. Marginal excision and ray amputation
. Curettage and bone grafting
. Neoadjuvant chemotherapy followed by wide resection
. Radiation therapy

Correct Answer & Explanation

. Observation alone as it will heal with the fracture

Explanation

The presentation and radiographic findings (lytic lesion with stippled 'popcorn' calcifications in a proximal phalanx) are diagnostic of an enchondroma, the most common primary bone tumor in the hand. Unlike non-ossifying fibromas or simple bone cysts in children, enchondromas do not reliably resolve after a pathologic fracture. The standard definitive treatment is intralesional curettage and bone grafting, which can be done acutely or after the fracture has healed.

Question 4179

Topic: Hand Trauma & Infection

A 28-year-old male presents 48 hours after a puncture wound to the volar aspect of his index finger.

His finger is erythematous, swollen, and held in a flexed posture. According to Kanavel's criteria for acute suppurative flexor tenosynovitis, which of the following signs is considered the earliest and most sensitive indicator of the infection?

. Fusiform (sausage-like) swelling of the digit
. Flexed resting posture of the digit
. Tenderness extending along the flexor tendon sheath
. Exquisite pain with passive extension of the digit
. Erythema tracking proximally into the palm

Correct Answer & Explanation

. Fusiform (sausage-like) swelling of the digit

Explanation

Kanavel's four cardinal signs of flexor tenosynovitis are: (1) fusiform swelling, (2) flexed resting posture, (3) tenderness along the flexor sheath, and (4) pain with passive extension. Of these, pain with passive extension is considered the earliest, most reliable, and most sensitive sign of the condition.

Question 4180

Topic: 7. Hand and Wrist
A 55-year-old male with chronic wrist pain is diagnosed with Scapholunate Advanced Collapse (SLAC) arthritis. In the natural radiographic progression of SLAC wrist, which of the following joints is characteristically preserved from degenerative changes, even in Stage III disease?
. Radioscaphoid joint
. Capitolunate joint
. Scaphocapitate joint
. Radiolunate joint
. Scaphotrapezial joint

Correct Answer & Explanation

. Radiolunate joint

Explanation

In SLAC wrist, the sequence of arthritic changes follows a predictable pattern: Stage I involves the radial styloid and distal scaphoid; Stage II involves the entire radioscaphoid fossa; Stage III involves the capitolunate joint. The radiolunate joint is characteristically spared due to the spherical shape of the lunate and the intact short radiolunate ligament, which prevents abnormal kinematics at this articulation.

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