Menu

7. Hand and Wrist MCQs

Practice Set 210 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 4181

Topic: 7. Hand and Wrist

A 22-year-old collegiate baseball player presents with chronic ulnar-sided wrist pain and grip weakness.

A CT scan confirms a nonunion of the hook of the hamate. If left untreated, the unhealed bony fragment is at greatest risk of causing attrition and spontaneous rupture of which of the following tendons?

. Flexor pollicis longus
. Flexor digitorum profundus to the small finger
. Flexor carpi ulnaris
. Extensor digiti minimi
. Flexor digitorum superficialis to the ring finger

Correct Answer & Explanation

. Flexor pollicis longus

Explanation

A nonunion of the hook of the hamate can lead to attritional rupture of the adjacent flexor tendons. Due to its anatomic proximity in the carpal tunnel, the flexor digitorum profundus (FDP) tendon to the small finger (and sometimes the ring finger) is most commonly affected. Excision of the unhealed fragment is the treatment of choice to relieve pain and prevent tendon rupture.

Question 4182

Topic: Nerve & Tendon

A 40-year-old female presents with sudden onset weakness in her right hand.

When asked to make an 'OK' sign, the IP joint of her thumb and the DIP joint of her index finger remain fully extended. She has no sensory deficits. What is the most common anatomic structure responsible for compression of the involved nerve?

. Ligament of Struthers
. Lacertus fibrosus
. Tendinous edge of the deep head of the pronator teres
. Arcade of Frohse
. Osborne's fascia

Correct Answer & Explanation

. Ligament of Struthers

Explanation

The patient demonstrates a classic Anterior Interosseous Nerve (AIN) syndrome, characterized by weakness of the FPL, FDP to the index (and sometimes middle) finger, and pronator quadratus, without sensory loss. The most common site of mechanical compression of the AIN is the tendinous edge of the deep head of the pronator teres. The Arcade of Frohse compresses the PIN, while Osborne's fascia compresses the ulnar nerve.

Question 4183

Topic: 7. Hand and Wrist

A 2-year-old child is undergoing surgical separation of a simple, complete syndactyly of the middle and ring fingers.

When reconstructing the new interdigital web space, the surgeon meticulously designs a dorsal rectangular flap. What is the primary biomechanical rationale for utilizing a flap rather than a linear incision and skin grafting for the web commissure?

. To prevent subsequent 'web creep'
. To avoid injury to the common digital artery bifurcation
. To ensure normal eponychial fold development
. To minimize PIP joint flexion contractures
. To provide superior two-point discrimination to the web space

Correct Answer & Explanation

. To prevent subsequent 'web creep'

Explanation

In syndactyly release, a local flap (typically a dorsal rectangular or volar flap) is essential for reconstructing the deepest part of the commissure. If a straight linear incision and skin graft are used, scar contracture will inevitably pull the web space distally over time as the child grows, a complication known as 'web creep'. Flaps provide supple, unscarred skin that accommodates growth.

Question 4184

Topic: 7. Hand and Wrist
A 25-year-old rugby player presents after violently grabbing an opponent's jersey. His ring finger was forcefully extended while actively flexing. He is unable to actively flex the DIP joint. Radiographs reveal a small bony avulsion fragment that has retracted to the level of the PIP joint. According to the Leddy and Packer classification of 'Jersey finger', which type is this, and what is its associated vascular status?
. Type I; blood supply is completely severed and requires repair within 7-10 days
. Type II; blood supply from the vincula longus is maintained, allowing delayed repair
. Type III; large fragment caught at the A4 pulley, excellent blood supply
. Type IV; simultaneous bony avulsion and tendon pull-off from the fragment
. Type V; bony avulsion with an extra-articular fracture of the distal phalanx

Correct Answer & Explanation

. Type II; blood supply from the vincula longus is maintained, allowing delayed repair

Explanation

This is a Type II Jersey finger (FDP avulsion). In Type II injuries, the tendon retracts to the level of the PIP joint, where it is caught by the intact vincula brevis/longus or chiasm of Camper. Because the vincula provide some blood supply, the tendon does not undergo rapid necrosis, and repair can sometimes be slightly delayed compared to Type I (retracted into palm, complete ischemia, needs repair <10 days). Type III involves a large bony fragment trapped at the A4 pulley.

Question 4185

Topic: 7. Hand and Wrist

A 45-year-old male presents with weakness in extending his fingers and thumb. Sensation in his forearm and hand is entirely normal. When he actively extends his wrist, the hand deviates radially.

Which of the following structures is the most frequent site of compression for the affected nerve?

. Leash of Henry
. Fibrous edge of the extensor carpi radialis brevis (ECRB)
. Arcade of Frohse
. Arcade of Struthers
. Distal edge of the supinator

Correct Answer & Explanation

. Leash of Henry

Explanation

The patient has Posterior Interosseous Nerve (PIN) syndrome. The ECRL is supplied by the radial nerve proximal to the PIN branch, so it remains functional, causing radial deviation during wrist extension. The PIN supplies the ECU, EDC, EPL, EPB, and APL. The most common site of PIN compression is the Arcade of Frohse, which is the thickened proximal fibrous edge of the superficial head of the supinator muscle.

Question 4186

Topic: Wrist & Carpus

A 32-year-old gymnast presents with severe ulnar-sided wrist pain after a fall. An MRI confirms a Palmer Class 1B tear of the Triangular Fibrocartilage Complex (TFCC).

Which of the following best describes this specific injury pattern?

. Central articular disc perforation
. Ulnar avulsion with or without an ulnar styloid fracture
. Distal avulsion involving the ulnocarpal ligaments
. Radial avulsion of the TFCC from the sigmoid notch
. Degenerative tear with ulnocarpal impaction syndrome

Correct Answer & Explanation

. Central articular disc perforation

Explanation

The Palmer classification divides TFCC tears into traumatic (Class 1) and degenerative (Class 2). Class 1B refers to an ulnar avulsion (from the fovea/base of the ulnar styloid), which is well-vascularized and highly amenable to primary surgical repair. Class 1A is central (avascular, treated with debridement); Class 1C is distal (ulnocarpal ligaments); Class 1D is a radial avulsion.

Question 4187

Topic: 7. Hand and Wrist

A 65-year-old female presents with severe base of thumb pain and a characteristic 'zig-zag' deformity. Radiographs confirm advanced basal joint (CMC) arthritis.

What is the classic pathoanatomy of the metacarpal and metacarpophalangeal (MCP) joint in this deformity?

. Metacarpal extension and MCP joint flexion
. Metacarpal adduction and MCP joint hyperextension
. Metacarpal abduction and MCP joint hyperextension
. Metacarpal adduction and PIP joint flexion
. Metacarpal flexion and IP joint extension

Correct Answer & Explanation

. Metacarpal extension and MCP joint flexion

Explanation

In advanced trapeziometacarpal (CMC) arthritis, dorsal subluxation of the first metacarpal base leads to metacarpal adduction (a web space contracture). To compensate for the loss of thumb span during grip and pinch, the MCP joint progressively hyperextends, leading to the classic 'zig-zag' deformity (adducted metacarpal, hyperextended MCP). If MCP hyperextension is >30 degrees, it must be addressed surgically (e.g., EPB transfer, capsulodesis, or arthrodesis) during CMC arthroplasty.

Question 4188

Topic: 7. Hand and Wrist

A 28-year-old amateur boxer presents with pain at the base of his left thumb.

Radiographs reveal an intra-articular fracture at the base of the first metacarpal with a small volar-ulnar fragment. While the metacarpal shaft displaces proximally and dorsally, the small volar-ulnar fragment is held in its anatomic position primarily by which of the following ligaments?

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

Correct Answer & Explanation

. Dorsal radial ligament

Explanation

This is a Bennett fracture. The small volar-ulnar fragment remains attached to the trapezium via the strong anterior oblique ligament (AOL). The main metacarpal shaft is pulled proximally, dorsally, and radially by the deforming forces of the Abductor Pollicis Longus (APL), Extensor Pollicis Longus (EPL), and Adductor Pollicis.

Question 4189

Topic: 7. Hand and Wrist

During a regional fasciectomy for Dupuytren's disease, the surgeon must carefully dissect the neurovascular bundle to avoid iatrogenic injury.

The spiral cord is notorious for causing PIP joint contractures and altering normal digital anatomy. How does the spiral cord characteristically displace the neurovascular bundle?

. Central and volar to the cord
. Lateral and dorsal to the cord
. Medial and dorsal to the cord
. Proximal and ulnar to the cord
. It does not displace the neurovascular bundle

Correct Answer & Explanation

. Central and volar to the cord

Explanation

In Dupuytren's disease, the spiral cord originates from the pre-tendinous band, spiral band, lateral digital sheet, and Grayson's ligament. As it contracts, it courses deep (dorsal) to the neurovascular bundle proximally, but then 'spirals' around it to attach distally. This mechanism displaces the neurovascular bundle central (towards the midline) and volar (superficial), placing it at extremely high risk of transection during skin incision and dissection.

Question 4190

Topic: Nerve & Tendon

A 32-year-old postpartum female undergoes a surgical release of the first dorsal compartment for refractory De Quervain's tenosynovitis.

Failure to recognize which of the following anatomic variations is the most common cause of incomplete symptom relief following this procedure?

. Multiple slips of the abductor pollicis longus (APL)
. A separate fibro-osseous subsheath for the extensor pollicis brevis (EPB)
. Aberrant course of the superficial radial nerve
. Inadvertent release of the extensor pollicis longus (EPL)
. Anomalous insertion of the brachioradialis

Correct Answer & Explanation

. Multiple slips of the abductor pollicis longus (APL)

Explanation

The most common reason for failed surgical release in De Quervain's tenosynovitis is the failure to recognize and release a separate fibro-osseous subsheath containing the Extensor Pollicis Brevis (EPB) tendon. While the APL frequently has multiple slips, they typically run in the main compartment. The EPB is housed in a separate subsheath in up to 40% of patients.

Question 4191

Topic: 7. Hand and Wrist
A 40-year-old industrial worker sustains a severe crush amputation of multiple digits in a mechanical press. Which of the following is considered an absolute contraindication to replantation of an amputated part?
. Amputation in a child
. Amputation of the thumb
. Ischemia time of 8 hours for a digit
. Crush injury with multiple level amputations
. Clean guillotine amputation through the proximal phalanx

Correct Answer & Explanation

. Crush injury with multiple level amputations

Explanation

Absolute contraindications to replantation include severe crush injuries with multiple level amputations, prolonged warm ischemia time (>12 hours for digits, >6 hours for major muscle-containing parts), and patients with severe life-threatening concomitant injuries. Amputations in children, thumb amputations, and multiple digit amputations are generally considered strong indications for replantation.

Question 4192

Topic: 7. Hand and Wrist

A 35-year-old carpenter sustains a volar oblique amputation of his thumb pulp, resulting in a 1.5 x 1.5 cm defect with exposed distal phalanx bone.

Which of the following local flaps is the most appropriate single-stage option for restoring durable, sensate coverage to the volar thumb while minimizing joint contracture?

. Cross-finger flap
. Thenar flap
. Moberg volar advancement flap
. Reverse radial forearm flap
. First dorsal metacarpal artery (kite) flap

Correct Answer & Explanation

. Cross-finger flap

Explanation

The Moberg volar advancement flap is the ideal choice for volar thumb defects up to 1.5 - 2 cm. It involves elevating the entire volar skin of the thumb along with both neurovascular bundles, preserving excellent sensibility. A unique feature of the thumb's blood supply (distinct dorsal supply) allows this flap to survive without causing dorsal necrosis. A thenar flap requires two stages and risks PIP joint contracture in adults. Cross-finger flaps are insensate unless specifically innervated.

Question 4193

Topic: 7. Hand and Wrist

A 45-year-old mechanic presents with pain and cold intolerance in the ring and small fingers of his dominant right hand. Allen's test shows delayed capillary refill on the ulnar aspect. Angiography reveals occlusion of the ulnar artery distal to the pisiform. What is the most common anatomical site of compression or injury leading to this condition?

. Against the hook of the hamate
. At the arcade of Struthers
. Deep to the pronator teres
. Between the two heads of flexor carpi ulnaris
. At the superficial palmar arch

Correct Answer & Explanation

. Against the hook of the hamate

Explanation

This patient has Hypothenar Hammer Syndrome, which is characterized by thrombosis or aneurysm of the ulnar artery. The ulnar artery is vulnerable to repetitive blunt trauma as it passes over the hook of the hamate superficial to the flexor retinaculum in Guyon's canal.

Question 4194

Topic: 7. Hand and Wrist
A 35-year-old manual laborer presents with dorsal wrist pain. Radiographs reveal sclerosis of the lunate without collapse, and MRI shows diffuse decreased T1 signal in the lunate. Ulnar variance is negative. What is the most appropriate initial surgical management if conservative treatment fails?
. Proximal row carpectomy
. Scaphocapitate fusion
. Radial shortening osteotomy
. Total wrist arthrodesis
. Lunate excision and silastic replacement

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

This patient has Lichtman Stage II Kienbรถck's disease (sclerosis without collapse) with ulnar minus variance. A joint leveling procedure, such as a radial shortening osteotomy, is the preferred surgical treatment to decompress the lunate and potentially arrest disease progression.

Question 4195

Topic: 7. Hand and Wrist
A 28-year-old carpenter suffers a clean amputation of the index finger at the level of the proximal phalanx. During replantation, what is the generally accepted sequence of structure repair?
. Bone, extensor tendon, flexor tendon, arteries, nerves, veins
. Bone, arteries, veins, extensor tendon, flexor tendon, nerves
. Arteries, veins, bone, flexor tendon, extensor tendon, nerves
. Flexor tendon, extensor tendon, bone, arteries, nerves, veins
. Veins, arteries, nerves, bone, extensor tendon, flexor tendon

Correct Answer & Explanation

. Bone, extensor tendon, flexor tendon, arteries, nerves, veins

Explanation

The standard sequence for digit replantation is summarized by the mnemonic BEFANV: Bone, Extensor tendon, Flexor tendon, Arteries, Nerves, Veins. Bone fixation provides a stable framework, followed by tendon repairs, which can tolerate the manipulation required before delicate microvascular anastomoses.

Question 4196

Topic: Hand Trauma & Infection

A patient presents with a swollen, painful ring finger 3 days after sustaining a puncture wound. Which of the following is NOT one of Kanavel's cardinal signs of pyogenic flexor tenosynovitis?

. Fusiform swelling of the digit
. Flexed resting posture of the digit
. Tenderness along the flexor tendon sheath
. Erythema extending to the palmar crease
. Pain on passive extension of the digit

Correct Answer & Explanation

. Fusiform swelling of the digit

Explanation

Kanavel's four cardinal signs of pyogenic flexor tenosynovitis include: 1) fusiform swelling of the digit, 2) flexed resting posture, 3) tenderness along the flexor tendon sheath, and 4) pain on passive extension. Erythema extending to the palmar crease is not one of Kanavel's specific signs.

Question 4197

Topic: Wrist & Carpus
A 40-year-old man presents with chronic wrist pain. Radiographs demonstrate a scaphoid nonunion with arthritic changes involving the entire scaphoid fossa of the radius, but the capitolunate joint and radiolunate joint are preserved. What is the stage of Scaphoid Nonunion Advanced Collapse (SNAC) and the most appropriate surgical treatment?
. Stage I SNAC; Radial styloidectomy and scaphoid fixation
. Stage II SNAC; Proximal row carpectomy or four-corner fusion
. Stage III SNAC; Total wrist arthrodesis
. Stage I SNAC; Four-corner fusion
. Stage II SNAC; Total wrist arthroplasty

Correct Answer & Explanation

. Stage II SNAC; Proximal row carpectomy or four-corner fusion

Explanation

SNAC Stage II involves radioscaphoid arthritis extending beyond the radial styloid to include the entire scaphoid fossa. The radiolunate and midcarpal joints are spared. Acceptable surgical treatments for Stage II include proximal row carpectomy (PRC) or scaphoid excision with four-corner arthrodesis.

Question 4198

Topic: Nerve & Tendon

A 35-year-old male presents with a low ulnar nerve palsy and a claw deformity of the ring and small fingers. When the examiner stabilizes the metacarpophalangeal (MCP) joints in slight flexion, the patient is able to actively extend the proximal interphalangeal (PIP) joints. This physical examination finding indicates:

. A positive Froment sign
. A positive Wartenberg sign
. A negative Bouvier test
. A positive Bouvier test
. A positive Jeanne sign

Correct Answer & Explanation

. A positive Froment sign

Explanation

A positive Bouvier test occurs when blocking the MCP joints in slight flexion allows the extrinsic extensor apparatus to fully extend the PIP joints. This indicates that the central slip and extensor mechanism are intact, and simply restoring MCP flexion (e.g., via a Zancolli lasso or other intrinsic minus correction) will correct the clawing.

Question 4199

Topic: 7. Hand and Wrist

A 25-year-old basketball player presents with a finger deformity 4 weeks after jamming his finger. He has flexion of the proximal interphalangeal (PIP) joint and extension of the distal interphalangeal (DIP) joint. This deformity is primarily caused by rupture or attenuation of which of the following structures?

. Terminal extensor tendon
. Central slip of the extensor tendon
. Flexor digitorum superficialis
. Volar plate
. Sagittal band

Correct Answer & Explanation

. Terminal extensor tendon

Explanation

The patient has a Boutonniere deformity. It is caused by an injury to the central slip of the extensor tendon at its insertion on the base of the middle phalanx. This allows the lateral bands to subluxate volarly below the axis of rotation of the PIP joint, causing PIP flexion and DIP extension.

Question 4200

Topic: 7. Hand and Wrist

A 55-year-old female with long-standing rheumatoid arthritis presents with a prominent ulnar head, dorsal swelling over the wrist, and inability to actively extend her small and ring fingers. The tenodesis effect is absent (fingers do not extend with passive wrist flexion). What is the underlying cause of her inability to extend the fingers?

. Posterior interosseous nerve compression at the Arcade of Frohse
. Volar subluxation of the metacarpophalangeal joints
. Rupture of the extensor tendons over the distal ulna
. Ulnar nerve entrapment at Guyon's canal
. Rupture of the central slip

Correct Answer & Explanation

. Posterior interosseous nerve compression at the Arcade of Frohse

Explanation

This presentation is typical of Vaughan-Jackson syndrome, an attritional rupture of the extensor tendons starting from the ulnar side (extensor digiti minimi, then extensor digitorum communis to the small and ring fingers) caused by a prominent, unstable, and arthritic ulnar head (caput ulnae syndrome). The absent tenodesis effect confirms tendon rupture rather than nerve palsy.

Test Yourself

Switch to an interactive, timed exam simulation to truly master this topic.

On this Page