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7. Hand and Wrist MCQs

Practice Set 211 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 4201

Topic: 7. Hand and Wrist
A 1-year-old child presents with a duplicated thumb. Radiographs show a completely duplicated proximal and distal phalanx articulating with a single, broadened metacarpal head. According to the Wassel classification, which type of thumb duplication does this represent?
. Type II
. Type III
. Type IV
. Type V
. Type VI

Correct Answer & Explanation

. Type IV

Explanation

Wassel Type IV is the most common type of thumb duplication, accounting for nearly 50% of cases. It is characterized by duplication of both the proximal and distal phalanges resting on a single, often broadened, metacarpal.

Question 4202

Topic: 7. Hand and Wrist

A 32-year-old weightlifter presents with pain and swelling on the dorsal radial aspect of the distal forearm. The pain is located approximately 4-5 cm proximal to the radial styloid. Crepitus is palpable with wrist flexion and extension. Which two extensor compartments are involved in this condition?

. First and second
. First and third
. Second and third
. Third and fourth
. Second and fourth

Correct Answer & Explanation

. First and second

Explanation

Intersection syndrome is an inflammatory tenosynovitis at the junction where the first dorsal compartment muscle bellies (abductor pollicis longus and extensor pollicis brevis) cross over the tendons of the second dorsal compartment (extensor carpi radialis longus and brevis), typically 4-5 cm proximal to the wrist joint.

Question 4203

Topic: 7. Hand and Wrist
A 22-year-old rugby player felt a pop in his ring finger while grabbing an opponent's jersey. He is unable to actively flex the distal interphalangeal (DIP) joint. Radiographs show a large bony fragment avulsed from the volar base of the distal phalanx, which is retracted just proximal to the DIP joint at the level of the A4 pulley. According to the Leddy and Packer classification, what type of injury is this?
. Type I
. Type II
. Type III
. Type IV
. Type V

Correct Answer & Explanation

. Type III

Explanation

Leddy and Packer Type III jersey finger injuries involve a large bony avulsion that prevents the tendon from retracting proximally past the A4 pulley. Type I retracts into the palm (disrupting both vincula). Type II retracts to the level of the PIP joint.

Question 4204

Topic: 7. Hand and Wrist

A patient with severe chronic carpal tunnel syndrome has profound thenar atrophy and an inability to oppose the thumb. Which of the following tendons is most commonly used in a classic Bunnell or Royle-Thompson transfer to restore thumb opposition (opponensplasty) utilizing a pulley near the pisiform?

. Extensor indicis proprius (EIP)
. Flexor digitorum superficialis (FDS) of the ring finger
. Flexor carpi ulnaris (FCU)
. Abductor digiti minimi (ADM)
. Palmaris longus (PL)

Correct Answer & Explanation

. Extensor indicis proprius (EIP)

Explanation

The FDS of the ring finger is commonly used for opponensplasty. In the Bunnell technique, it is routed around a pulley constructed from the FCU or palmar aponeurosis near the pisiform to redirect its line of pull to replicate the action of the abductor pollicis brevis.

Question 4205

Topic: 7. Hand and Wrist

A 45-year-old aquarium worker presents with a chronic, progressive, nodular swelling along the dorsum of his right hand and forearm for 6 weeks. The lesions are mildly tender. He recalls a minor scratch while cleaning a fish tank. What is the most likely causative organism?

. Sporothrix schenckii
. Staphylococcus aureus
. Mycobacterium marinum
. Pasteurella multocida
. Erysipelothrix rhusiopathiae

Correct Answer & Explanation

. Sporothrix schenckii

Explanation

Mycobacterium marinum is an atypical mycobacterium found in fresh and saltwater environments. Infection typically occurs via minor trauma during aquarium maintenance or handling fish. It presents as a chronic granulomatous infection, often with sporotrichoid (lymphatic) spread up the arm.

Question 4206

Topic: Wrist & Carpus
A 50-year-old man presents with chronic radial-sided wrist pain. Radiographs reveal scapholunate dissociation with advanced arthritic changes involving the radioscaphoid joint and the capitolunate joint, but the radiolunate joint is spared. What is the appropriate SLAC stage and recommended surgical treatment?
. Stage I SLAC; Radial styloidectomy
. Stage II SLAC; Proximal row carpectomy
. Stage III SLAC; Four-corner arthrodesis
. Stage IV SLAC; Total wrist arthrodesis
. Stage II SLAC; Scaphocapitate fusion

Correct Answer & Explanation

. Stage III SLAC; Four-corner arthrodesis

Explanation

This is Stage III SLAC (Scapholunate Advanced Collapse), characterized by progressive arthritis involving the radioscaphoid and capitolunate joints, while the radiolunate joint is uniquely spared. Four-corner arthrodesis (with scaphoid excision) is the standard treatment. Proximal row carpectomy is contraindicated due to capitate head arthritis.

Question 4207

Topic: 7. Hand and Wrist

A 60-year-old patient requires a radial forearm free flap for reconstruction. An Allen's test is performed to assess the collateral circulation of the hand. After occluding both the radial and ulnar arteries and having the patient clench the fist to exsanguinate the hand, the examiner releases pressure on the ulnar artery. Normal return of color should occur within approximately:

. 1 to 2 seconds
. 5 to 7 seconds
. 10 to 15 seconds
. 20 to 25 seconds
. 30 to 45 seconds

Correct Answer & Explanation

. 1 to 2 seconds

Explanation

In a standard Allen's test, normal capillary refill and return of palmar blush via collateral circulation from the ulnar artery should occur within 5 to 7 seconds. A delay greater than 10-14 seconds indicates poor collateral circulation and is a contraindication to harvesting a radial forearm flap.

Question 4208

Topic: Hand Trauma & Infection

A 35-year-old skier falls while holding a ski pole and presents with thumb MCP joint pain. Examination reveals 40 degrees of radial deviation laxity in full extension with no solid endpoint. An MRI confirms a complete tear of the ulnar collateral ligament (UCL). Which anatomic structure prevents nonoperative healing of this lesion?

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

Correct Answer & Explanation

. Adductor pollicis aponeurosis

Explanation

A Stener lesion occurs when the torn UCL of the thumb becomes displaced superficial to the adductor pollicis aponeurosis. This prevents the ligament from apposing its anatomical insertion, requiring surgical repair.

Question 4209

Topic: Nerve & Tendon

A 42-year-old basketball player jammed his finger 4 weeks ago. He now presents with a PIP joint flexion posture and DIP joint hyperextension. Which of the following is the primary pathophysiologic mechanism for this deformity?

. Rupture of the terminal extensor tendon
. Rupture of the central slip and volar subluxation of the lateral bands
. Attenuation of the volar plate
. Rupture of the FDP tendon
. Injury to the sagittal band

Correct Answer & Explanation

. Rupture of the terminal extensor tendon

Explanation

A Boutonniere deformity results from a rupture of the central slip, allowing the lateral bands to subluxate volar to the PIP joint axis of rotation. This biomechanical shift causes PIP flexion and DIP hyperextension.

Question 4210

Topic: 7. Hand and Wrist
A 45-year-old laborer complains of chronic radial-sided wrist pain 10 years after an untreated scaphoid waist fracture. Radiographs show a scaphoid nonunion with radioscaphoid arthritis and capitolunate arthritis, but the radiolunate joint is spared. What is the most appropriate surgical treatment?
. Proximal row carpectomy (PRC)
. Scaphoid excision and four-corner fusion
. Total wrist arthrodesis
. Radial styloidectomy
. Scaphoid nonunion repair with vascularized bone graft

Correct Answer & Explanation

. Scaphoid excision and four-corner fusion

Explanation

This patient has Stage III SNAC wrist (capitolunate arthritis with preserved radiolunate joint). A four-corner fusion with scaphoid excision is indicated because PRC is contraindicated when capitate arthritis is present.

Question 4211

Topic: 7. Hand and Wrist
A 22-year-old rugby player grasped an opponent's jersey and felt a pop in his left ring finger. He cannot actively flex the DIP joint. Imaging shows a bony fragment avulsed from the distal phalanx retracted to the level of the PIP joint. Which Leddy-Packer classification type is this injury?
. Type I
. Type II
. Type III
. Type IV
. Type V

Correct Answer & Explanation

. Type II

Explanation

Leddy-Packer Type II injuries involve the FDP tendon retracting to the level of the PIP joint, held in place by the long vinculum. Type I retracts to the palm, and Type III is a large bony fragment restricted at the A4 pulley.

Question 4212

Topic: 7. Hand and Wrist
A 28-year-old carpenter presents with dorsal wrist pain. Radiographs show sclerosis of the lunate with no collapse (Lichtman Stage II). Ulnar variance is determined to be negative 3 mm. What is the most appropriate surgical intervention?
. Proximal row carpectomy
. Total wrist arthrodesis
. Radial shortening osteotomy
. Lunate excision and silastic replacement
. Capitate shortening osteotomy

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

In early-stage Kienbock's disease (Stage I, II, IIIA) with ulnar minus variance, joint-leveling procedures like a radial shortening osteotomy unload the lunate and promote revascularization.

Question 4213

Topic: 7. Hand and Wrist

During a fasciectomy for Dupuytren's contracture in a 65-year-old man, the surgeon must carefully dissect the neurovascular bundles. Which of the following pathological cords is primarily responsible for displacing the neurovascular bundle centrally and superficially in the digit?

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

Correct Answer & Explanation

. Pretendinous cord

Explanation

The spiral cord displaces the neurovascular bundle centrally and superficially, placing it at high risk of iatrogenic injury during excision. It is formed by the pretendinous band, spiral band, lateral digital sheet, and Grayson's ligament.

Question 4214

Topic: 7. Hand and Wrist

A 55-year-old female with long-standing rheumatoid arthritis suddenly loses the ability to actively flex the IP joint of her right thumb. Examination shows no active FPL function. What is the most likely location of the attritional tendon rupture?

. Lister's tubercle
. The hook of the hamate
. The volar aspect of the distal radius at the scaphoid fossa (Mannerfelt lesion)
. The A1 pulley
. The pisiform

Correct Answer & Explanation

. Lister's tubercle

Explanation

A Mannerfelt-Vainio lesion is an attritional rupture of the flexor pollicis longus (FPL) tendon caused by a bony spur on the volar aspect of the distal radius, typically near the scaphoid fossa in rheumatoid patients.

Question 4215

Topic: Nerve & Tendon

A patient sustains a complete transection of the median nerve at the elbow. Unexpectedly, the patient retains motor function in the first dorsal interosseous (FDI) muscle, but electrodiagnostic testing reveals the ulnar nerve is intact at the elbow. Which of the following anatomical variants explains this finding?

. Riche-Cannieu anastomosis
. Martin-Gruber anastomosis
. Marinacci communication
. Berrettini anastomosis
. Linburg-Comstock anomaly

Correct Answer & Explanation

. Riche-Cannieu anastomosis

Explanation

A Martin-Gruber anastomosis is a motor connection in the forearm from the median nerve to the ulnar nerve. It often carries fibers that innervate the intrinsic hand muscles, allowing partial function despite proximal median nerve injury.

Question 4216

Topic: Hand Trauma & Infection

A 24-year-old male presents with a swollen, erythematous MCP joint of his right ring finger after an altercation where he punched another individual in the mouth. What is the most appropriate empiric antibiotic regimen to cover the typical pathogens, including Eikenella corrodens?

. Clindamycin
. Cephalexin
. Amoxicillin-clavulanate
. Trimethoprim-sulfamethoxazole
. Erythromycin

Correct Answer & Explanation

. Clindamycin

Explanation

Human bites (fight bites) require coverage for staph, strep, anaerobes, and Eikenella corrodens. Amoxicillin-clavulanate (Augmentin) provides excellent empiric oral coverage.

Question 4217

Topic: 7. Hand and Wrist

A 9-month-old infant is evaluated for syndactyly of the long and ring fingers. The digits share skin and soft tissue, but radiographs show no bony fusion. What is the most appropriate timing and surgical approach for release?

. Release at 12-18 months of age using dorsal and volar zigzag flaps
. Release at 3 months of age using straight line incisions
. Release at 5 years of age using a skin graft only
. Release at 6 months of age using straight line incisions and Z-plasties
. Wait until skeletal maturity to prevent growth disturbance

Correct Answer & Explanation

. Release at 12-18 months of age using dorsal and volar zigzag flaps

Explanation

Simple syndactyly of the long/ring fingers is typically released around 12 to 18 months of age to allow for adequate hand function development. Zigzag incisions with full-thickness skin grafting are standard to prevent scar contractures.

Question 4218

Topic: Nerve & Tendon

A 45-year-old avid cyclist presents with isolated weakness of finger abduction and adduction. He has normal sensation over his small and ring fingers, and normal function of the hypothenar muscles. In which zone of Guyon's canal is the ulnar nerve compressed?

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

Correct Answer & Explanation

. Zone 1

Explanation

Guyon's Canal Zone 2 contains only the deep motor branch of the ulnar nerve after the hypothenar motor branches have exited. Compression here causes isolated weakness of the interossei and lumbricals, sparing hypothenar function and sensation.

Question 4219

Topic: 7. Hand and Wrist
A 35-year-old manual laborer presents with dorsal wrist pain. Radiographs demonstrate sclerosis of the lunate with a coronal fracture and early collapse, but without carpal instability or secondary osteoarthritis. The patient has ulnar-neutral variance. Which Lichtman stage does this represent, and what is the most appropriate surgical treatment?
. Stage II / immobilization in a short arm cast
. Stage IIIA / radial shortening osteotomy
. Stage IIIB / proximal row carpectomy
. Stage IV / total wrist arthrodesis
. Stage IIIA / capitate shortening osteotomy

Correct Answer & Explanation

. Stage IIIA / radial shortening osteotomy

Explanation

This describes Lichtman Stage IIIA Kienböck's disease, characterized by lunate collapse without fixed scaphoid rotation or carpal instability. Radial shortening osteotomy decreases mechanical loading on the lunate and is highly effective in ulnar-negative or neutral variance wrists.

Question 4220

Topic: Wrist & Carpus

A 65-year-old female presents 6 weeks after non-operative management of a nondisplaced distal radius fracture. She reports suddenly losing the ability to actively extend her thumb interphalangeal joint. Which tendon transfer is considered the gold standard for restoring this function?

. Flexor Carpi Radialis (FCR) to Extensor Pollicis Longus (EPL)
. Extensor Indicis Proprius (EIP) to Extensor Pollicis Longus (EPL)
. Palmaris Longus (PL) to Extensor Pollicis Longus (EPL)
. Extensor Carpi Radialis Longus (ECRL) to Extensor Pollicis Longus (EPL)
. Abductor Pollicis Longus (APL) to Extensor Pollicis Longus (EPL)

Correct Answer & Explanation

. Flexor Carpi Radialis (FCR) to Extensor Pollicis Longus (EPL)

Explanation

Extensor pollicis longus (EPL) rupture is a known complication of nondisplaced distal radius fractures due to ischemia or attrition at Lister's tubercle. The Extensor Indicis Proprius (EIP) to EPL transfer is the preferred reconstruction because it matches the excursion and vector of the EPL.

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