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7. Hand and Wrist MCQs

Practice Set 214 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 4261

Topic: Wrist & Carpus

Six months after undergoing volar locked plating for a displaced distal radius fracture, a 55-year-old female reports a sudden inability to actively flex the interphalangeal joint of her thumb. Which of the following is the most likely cause of this complication?

. Rupture of the flexor pollicis longus tendon
. Rupture of the extensor pollicis longus tendon
. Anterior interosseous nerve palsy
. Adhesions of the flexor digitorum profundus
. Failure of the volar locking plate

Correct Answer & Explanation

. Rupture of the flexor pollicis longus tendon

Explanation

Prominence of the plate distal to the watershed line on the volar radius can cause attrition and subsequent rupture of the flexor pollicis longus (FPL) tendon. This is a well-documented complication of volar locked plating.

Question 4262

Topic: 7. Hand and Wrist

A 45-year-old right-hand dominant construction worker presents with chronic wrist pain, weakness, and limited range of motion 6 months after sustaining a distal radius fracture that was treated non-operatively. Radiographs, as depicted, demonstrate a healed distal radius malunion with 25 degrees of dorsal tilt, 8 mm of radial shortening, and a positive ulnar variance.

Given his symptoms and radiographic findings, what is the most appropriate surgical management?

. Ulnar shortening osteotomy alone
. Corrective osteotomy of the distal radius with volar plating and bone graft
. Wrist arthrodesis
. Distal ulna resection (Darrach procedure)
. Continued splinting and physical therapy

Correct Answer & Explanation

. Ulnar shortening osteotomy alone

Explanation

The patient's symptoms are indicative of a symptomatic distal radius malunion with significant dorsal tilt and radial shortening. The most appropriate surgical management to restore anatomy and improve function is a corrective osteotomy of the distal radius. This typically involves opening the osteotomy dorsally or volarly, correcting the angulation and shortening, and securing it with a locking volar plate. Bone graft (autograft or allograft) is often used to fill the osteotomy gap and promote healing. Ulnar shortening osteotomy only addresses ulnar variance and does not correct radial shortening or dorsal tilt. Wrist arthrodesis is a salvage procedure for severe arthritis or instability, not a primary correction for malunion. Darrach procedure addresses distal radioulnar joint (DRUJ) impingement but not the primary deformity. Continued conservative management is unlikely to improve symptoms.

Question 4263

Topic: 7. Hand and Wrist

A 30-year-old male presents with chronic right wrist pain and limited motion following a fall two years prior. Initial radiographs were negative, but subsequent imaging, including the provided X-ray, shows a scaphoid waist nonunion with evidence of proximal pole sclerosis and cystic changes, consistent with avascular necrosis (AVN). There is no signs of capitolunate or radioscaphoid arthritis.

What is the most appropriate surgical intervention for this patient?

. Percutaneous screw fixation alone
. Non-vascularized bone graft with headless compression screw fixation
. Vascularized bone graft with headless compression screw fixation
. Proximal row carpectomy (PRC)
. Wrist arthrodesis

Correct Answer & Explanation

. Percutaneous screw fixation alone

Explanation

For scaphoid nonunion with avascular necrosis (AVN) of the proximal pole, especially without significant secondary arthritis, a vascularized bone graft combined with internal fixation (typically a headless compression screw) is the preferred treatment. The vascularized graft helps revascularize the avascular proximal pole, improving healing rates compared to non-vascularized grafts when AVN is present. Percutaneous fixation alone is for acute, undisplaced fractures. Non-vascularized grafts are used for nonunions without AVN. PRC and wrist arthrodesis are salvage procedures for cases with significant arthritis (SLAC wrist) or failed reconstruction, which are not yet present in this scenario.

Question 4264

Topic: 7. Hand and Wrist

A 55-year-old diabetic patient presents with a 6-month history of progressive right cubital tunnel syndrome. Clinical examination reveals severe intrinsic muscle atrophy in the hand (guttering between metacarpals), complete sensory loss in the ulnar nerve distribution, and a positive Froment's sign. Nerve conduction studies (NCS) and electromyography (EMG) confirm severe ulnar neuropathy at the elbow with evidence of axonal loss and denervation changes in the intrinsic muscles. What is the most appropriate surgical approach for this patient?

. In-situ decompression of the ulnar nerve at the cubital tunnel
. Medial epicondylectomy
. Subcutaneous anterior transposition of the ulnar nerve
. Submuscular anterior transposition of the ulnar nerve
. Conservative management with nocturnal splinting and activity modification

Correct Answer & Explanation

. In-situ decompression of the ulnar nerve at the cubital tunnel

Explanation

In cases of severe cubital tunnel syndrome with advanced symptoms like intrinsic muscle atrophy, significant sensory loss, and severe axonal loss on NCS/EMG, a more robust decompression and protection of the ulnar nerve is generally recommended. Submuscular anterior transposition offers the most comprehensive decompression and places the nerve in a protective environment away from repetitive stretch and compression at the epicondyle. While in-situ decompression or medial epicondylectomy can be effective for milder to moderate cases, severe neuropathy warrants a more definitive solution to optimize recovery and prevent further deterioration. Conservative management is ineffective for severe, progressive cases.

Question 4265

Topic: 7. Hand and Wrist

A 35-year-old patient sustains a clean laceration to the palmar aspect of the ring finger at the level of the proximal phalanx (Zone II), resulting in complete transection of both the flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS) tendons. Primary repair is performed within 6 hours. Which of the following post-operative rehabilitation protocols is generally considered most appropriate and evidence-based for optimizing outcomes in this injury?

. Complete immobilization in a dorsal blocking splint for 6 weeks, then gradual active range of motion.
. Early passive protected motion (e.g., modified Kleinert protocol).
. Early active protected motion (e.g., modified Duran or similar active protocols).
. Delayed active motion, commencing at 3 weeks post-operatively.
. Immediate unrestricted active motion to prevent stiffness.

Correct Answer & Explanation

. Complete immobilization in a dorsal blocking splint for 6 weeks, then gradual active range of motion.

Explanation

For flexor tendon repairs, particularly in Zone II, early controlled motion protocols have demonstrated superior outcomes compared to prolonged immobilization. Among these, early active protected motion protocols (such as modified Duran, modified Washington, or similar techniques) are increasingly favored. These protocols involve carefully prescribed active flexion and extension exercises within a protective splint, which helps to minimize adhesion formation, promote tendon gliding, and reduce joint stiffness, without increasing the risk of rupture compared to early passive protocols, assuming good patient compliance and a strong repair. Early passive protected motion (e.g., modified Kleinert) is also acceptable and widely used but may not achieve the same gliding potential as active protocols. Complete immobilization leads to significant stiffness and adhesions. Immediate unrestricted motion would place the repair at high risk of rupture.

Question 4266

Topic: 7. Hand and Wrist

A 21-year-old male falls on an outstretched hand and presents with anatomic snuffbox tenderness. Imaging confirms an acute, displaced fracture of the proximal pole of the scaphoid.

What is the most appropriate surgical approach for this specific fracture pattern, and why?

. Volar approach to avoid the radial artery
. Dorsal approach to optimize trajectory and preserve volar blood supply
. Volar approach to directly visualize the radioscaphocapitate ligament
. Dorsal approach to visualize the median nerve
. Percutaneous volar approach to minimize scarring

Correct Answer & Explanation

. Volar approach to avoid the radial artery

Explanation

Proximal pole scaphoid fractures are best approached dorsally to allow for accurate screw trajectory (perpendicular to the fracture) while preserving the tenuous retrograde blood supply entering distally.

Question 4267

Topic: 7. Hand and Wrist
A 30-year-old carpenter presents with progressive, activity-related dorsal wrist pain. Radiographs reveal sclerosis, fragmentation, and collapse of the lunate (Kienböck's disease stage IIIA), with an ulnar variance of -3 mm. What is the most appropriate primary surgical intervention?
. Proximal row carpectomy
. Total wrist arthrodesis
. Radial shortening osteotomy
. Vascularized bone graft from the distal radius
. Ulnar lengthening osteotomy

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

In Kienböck's disease with ulnar negative variance and an intact lunate cartilage shell without secondary osteoarthritis (Stage IIIA), a joint-leveling procedure such as a radial shortening osteotomy is indicated to offload the lunate.

Question 4268

Topic: 7. Hand and Wrist

A 65-year-old osteoporotic female presents with a distal radius fracture featuring a displaced volar intra-articular fragment (Volar Barton's fracture).

If this fracture is treated with a dorsal spanning plate instead of a volar buttress plate, what is the most likely mechanism of failure?

. Inability to resist volar shear forces
. Extensor pollicis longus rupture
. Loss of radial inclination
. Carpal tunnel syndrome
. Distal radioulnar joint instability

Correct Answer & Explanation

. Inability to resist volar shear forces

Explanation

A Volar Barton's fracture is a shear fracture. It must be neutralized with a volar buttress plate; treating it from the dorsal side alone is biomechanically insufficient to resist the volar shear forces.

Question 4269

Topic: 7. Hand and Wrist

A 28-year-old male falls from a roof. His lateral wrist radiograph demonstrates a 'spilled teacup' sign, with the capitate displaced dorsally to the lunate.

Which peripheral nerve is at the highest acute risk of compression in this clinical scenario?

. Superficial branch of the radial nerve
. Deep branch of the ulnar nerve
. Posterior interosseous nerve
. Median nerve
. Anterior interosseous nerve

Correct Answer & Explanation

. Superficial branch of the radial nerve

Explanation

This describes a perilunate/lunate dislocation. The volarly displaced lunate severely compromises the carpal tunnel, placing the median nerve at acute risk for compression and necessitating emergent reduction.

Question 4270

Topic: Hand Trauma & Infection

A 32-year-old mechanic presents with an infected index finger after a puncture wound. Which of the following is NOT one of Kanavel's cardinal signs for acute pyogenic flexor tenosynovitis?

. Severe pain with passive extension of the digit
. Flexed resting posture of the digit
. Fusiform (sausage) swelling of the digit
. Tenderness along the entire flexor tendon sheath
. Erythema tracking proximally up the volar forearm

Correct Answer & Explanation

. Severe pain with passive extension of the digit

Explanation

Kanavel's signs include: flexed posture, fusiform swelling, tenderness over the flexor sheath, and pain with passive extension. Erythema tracking proximally indicates lymphangitis, not tenosynovitis.

Question 4271

Topic: Hand Trauma & Infection

A 35-year-old skier falls while holding his pole, sustaining a hyperabduction injury to the thumb. Clinical examination reveals gross laxity of the metacarpophalangeal (MCP) joint to valgus stress. A Stener lesion is suspected. What anatomical structure prevents spontaneous healing of the torn ulnar collateral ligament (UCL) in this lesion?

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

Correct Answer & Explanation

. Extensor pollicis brevis tendon

Explanation

A Stener lesion occurs when the torn UCL displaces superficial to the adductor pollicis aponeurosis. The aponeurosis physically blocks the ligament from returning to its insertion site, mandating surgical repair.

Question 4272

Topic: Nerve & Tendon
A 20-year-old rugby player presents with the inability to actively flex the DIP joint of his ring finger after grabbing an opponent's jersey. Radiographs show a small bony avulsion fragment localized at the level of the PIP joint. What is the correct classification and recommended timeline for repair?
. Leddy-Packer Type I; repair within 7-10 days
. Leddy-Packer Type I; repair at 4 weeks
. Leddy-Packer Type II; repair within 3-4 weeks
. Leddy-Packer Type III; repair at 6 weeks
. Leddy-Packer Type IV; non-operative management

Correct Answer & Explanation

. Leddy-Packer Type II; repair within 3-4 weeks

Explanation

This is a Leddy-Packer Type II 'Jersey Finger' (avulsion retracts to the PIP level, held by the intact vinculum longum). Blood supply is preserved enough to allow repair up to 3-4 weeks post-injury.

Question 4273

Topic: Wrist & Carpus

A 60-year-old female undergoes volar locking plate fixation for a displaced distal radius fracture. Six months postoperatively, she presents with an inability to actively flex the interphalangeal joint of her thumb. What is the most likely cause?

. Extensor pollicis longus (EPL) rupture from dorsal screw prominence
. Flexor pollicis longus (FPL) rupture from plate placement distal to the watershed line
. Anterior interosseous nerve (AIN) neuropraxia
. Adhesions of the flexor digitorum profundus (FDP)
. Failure of the fracture fixation

Correct Answer & Explanation

. Extensor pollicis longus (EPL) rupture from dorsal screw prominence

Explanation

Placement of a volar plate distal to the watershed line increases the risk of flexor tendon irritation and rupture. The Flexor Pollicis Longus (FPL) is the most commonly ruptured tendon due to its anatomical proximity to the prominent distal edge of the plate.

Question 4274

Topic: 7. Hand and Wrist

A 40-year-old male presents with severe wrist and elbow pain after falling from a ladder. Radiographs reveal a comminuted, unsalvageable radial head fracture. Wrist examination demonstrates DRUJ instability. Which of the following is absolutely contraindicated?

. Radial head excision alone
. Radial head replacement with a metallic prosthesis
. Open reduction internal fixation of the DRUJ
. Interosseous membrane reconstruction
. Distal radius osteotomy

Correct Answer & Explanation

. Radial head excision alone

Explanation

This patient has an Essex-Lopresti injury (radial head fracture, interosseous membrane tear, and DRUJ disruption). Radial head excision alone is contraindicated as it removes the primary restraint to proximal radial migration, leading to chronic wrist pain and ulnar impaction.

Question 4275

Topic: Nerve & Tendon

During an in situ ulnar nerve decompression at the elbow, the surgeon must release multiple potential sites of compression. Which of the following is the most proximal site of potential ulnar nerve entrapment?

. Arcade of Struthers
. Medial intermuscular septum
. Osborne's fascia
. Fascia of the flexor carpi ulnaris (FCU)
. Ligament of Struthers

Correct Answer & Explanation

. Arcade of Struthers

Explanation

The Arcade of Struthers is a fascial band located approximately 8 cm proximal to the medial epicondyle and represents the most proximal potential site for ulnar nerve entrapment at the elbow. Note that the Ligament of Struthers is associated with median nerve compression.

Question 4276

Topic: 7. Hand and Wrist

A 32-year-old carpenter presents with chronic dorsal wrist pain. Radiographs demonstrate Kienbock's disease with sclerosis of the lunate, no lunate collapse, and ulnar minus variance. What is the most appropriate surgical treatment?

. Proximal row carpectomy
. Radial shortening osteotomy
. Lunate excision and silastic replacement
. Total wrist arthrodesis
. Ulnar shortening osteotomy

Correct Answer & Explanation

. Proximal row carpectomy

Explanation

In early Kienbock's disease (Lichtman Stage I or II) without lunate collapse and with negative ulnar variance, a joint-leveling procedure such as a radial shortening osteotomy unloads the lunate to halt disease progression.

Question 4277

Topic: Nerve & Tendon

A 42-year-old female presents with chronic lateral elbow pain. She has point tenderness 4 cm distal to the lateral epicondyle. Pain is exacerbated by resisted extension of the middle finger with the elbow extended. What is the most likely site of nerve compression?

. Arcade of Frohse
. Osborne's ligament
. Ligament of Struthers
. Arcade of Struthers
. Lacertus fibrosus

Correct Answer & Explanation

. Arcade of Frohse

Explanation

The patient's presentation is consistent with radial tunnel syndrome. The most common site of compression of the posterior interosseous nerve (PIN) in radial tunnel syndrome is the Arcade of Frohse, the proximal fascial edge of the supinator muscle.

Question 4278

Topic: Nerve & Tendon

A 48-year-old female presents with numbness in her thumb, index, and middle fingers. Phalen's test is negative, but she has a positive Tinel's sign in the proximal forearm. She also reports pain in the proximal forearm with resisted forearm pronation. Which condition is most likely?

. Carpal tunnel syndrome
. Anterior interosseous nerve syndrome
. Pronator teres syndrome
. Cubital tunnel syndrome
. Cervical radiculopathy

Correct Answer & Explanation

. Carpal tunnel syndrome

Explanation

Pronator teres syndrome is a proximal median nerve entrapment characterized by vague volar forearm pain and paresthesias in the median nerve distribution. It is differentiated from carpal tunnel syndrome by a negative Phalen's test and pain with resisted pronation.

Question 4279

Topic: Nerve & Tendon

A 45-year-old weightlifter presents with a sudden 'pop' and ecchymosis in his right antecubital fossa. A reverse Popeye sign is noted. He undergoes a single-incision anterior approach for distal biceps tendon repair. Which of the following neurologic structures is at the highest risk of injury during this specific surgical approach?

. Posterior interosseous nerve
. Lateral antebrachial cutaneous nerve
. Median nerve
. Ulnar nerve
. Superficial radial nerve

Correct Answer & Explanation

. Posterior interosseous nerve

Explanation

The lateral antebrachial cutaneous nerve is the most commonly injured structure during a single-incision anterior approach for distal biceps repair due to its superficial course laterally. The posterior interosseous nerve is more at risk during a two-incision approach.

Question 4280

Topic: 7. Hand and Wrist
A 40-year-old male presents with chronic wrist pain. Radiographs reveal a scaphoid nonunion with advanced radioscaphoid arthritis and narrowing of the capitolunate joint space, but preservation of the radiolunate articulation. Which of the following is the most appropriate surgical intervention?
. Proximal row carpectomy
. Radial styloidectomy
. Scaphoid excision and four-corner fusion
. Total wrist arthrodesis
. Scaphoid open reduction and internal fixation with bone grafting

Correct Answer & Explanation

. Scaphoid excision and four-corner fusion

Explanation

The clinical scenario describes a Stage III Scaphoid Nonunion Advanced Collapse (SNAC) wrist, featuring capitolunate arthritis. Proximal row carpectomy is contraindicated when capitate arthrosis is present, making four-corner fusion the treatment of choice.

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