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7. Hand and Wrist MCQs

Practice Set 215 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 4281

Topic: Wrist & Carpus

A 65-year-old female presents with an inability to flex her thumb interphalangeal joint six months after undergoing volar plate fixation for a distal radius fracture. Radiographs indicate the plate is positioned distally, bridging the watershed line. Which of the following tendons is most likely ruptured?

. Flexor digitorum superficialis to the index finger
. Flexor carpi radialis
. Flexor pollicis longus
. Extensor pollicis longus
. Abductor pollicis longus

Correct Answer & Explanation

. Flexor digitorum superficialis to the index finger

Explanation

Placement of a volar plate distal to the watershed line of the distal radius increases the risk of flexor tendon irritation and rupture. The flexor pollicis longus (FPL) is the most frequently ruptured tendon in this scenario.

Question 4282

Topic: 7. Hand and Wrist
A 34-year-old manual laborer presents with dorsal wrist pain. Radiographs reveal sclerosis and fragmentation of the lunate, with an ulnar variance of minus 3 mm. Advanced imaging confirms stage IIIA Kienböck's disease without carpal collapse. Which of the following is the most appropriate surgical treatment?
. Ulnar shortening osteotomy
. Proximal row carpectomy
. Joint-leveling procedure such as a radial shortening osteotomy
. Total wrist arthrodesis
. Lunate excision and silastic implant arthroplasty

Correct Answer & Explanation

. Joint-leveling procedure such as a radial shortening osteotomy

Explanation

In Stage IIIA Kienböck's disease with ulnar negative variance, joint-leveling procedures (like radial shortening osteotomy) are indicated to mechanically offload the lunate and prevent progression to carpal collapse.

Question 4283

Topic: 7. Hand and Wrist

A 25-year-old male presents with persistent wrist pain 18 months after a fall onto an outstretched hand. Radiographs and subsequent MRI reveal a scaphoid proximal pole nonunion with signs of avascular necrosis, but no evidence of radiocarpal arthritis. What is the most appropriate surgical management?

. Scaphoid excision and four-corner fusion
. Open reduction and internal fixation with non-vascularized iliac crest bone graft
. Open reduction and internal fixation with a vascularized bone graft
. Proximal row carpectomy
. Total wrist arthrodesis

Correct Answer & Explanation

. Scaphoid excision and four-corner fusion

Explanation

Proximal pole scaphoid nonunions with avascular necrosis and no arthritis are best treated with a vascularized bone graft (e.g., 1,2 ICSRA or medial femoral condyle). Non-vascularized grafts have a high failure rate in the setting of AVN.

Question 4284

Topic: 7. Hand and Wrist

Six weeks after completing conservative management in a cast for a non-displaced distal radius fracture, a 55-year-old female experiences a sudden, painless inability to extend her thumb interphalangeal joint. What is the most appropriate surgical treatment?

. Primary end-to-end repair of the extensor pollicis longus tendon
. Tendon transfer using the extensor indicis proprius
. Tendon transfer using the extensor carpi radialis longus
. Interposition tendon grafting using the palmaris longus
. Wrist arthroscopy and extensor compartment synovectomy

Correct Answer & Explanation

. Primary end-to-end repair of the extensor pollicis longus tendon

Explanation

Delayed rupture of the extensor pollicis longus (EPL) tendon is a known complication of non-displaced distal radius fractures. Because the tendon ends are typically attritional and retracted, primary repair is usually impossible, making an EIP to EPL tendon transfer the gold standard.

Question 4285

Topic: Nerve & Tendon

A 45-year-old male presents with weakness in his intrinsic hand muscles and numbness in his small and ring fingers. Froment's sign is positive. Intraoperative exploration of the ulnar nerve at the elbow reveals compression by an anomalous muscle bridging the medial epicondyle and the olecranon. What is the name of this anatomical structure?

. Arcade of Struthers
. Osborne's ligament
. Anconeus epitrochlearis
. Ligament of Struthers
. Lacertus fibrosus

Correct Answer & Explanation

. Arcade of Struthers

Explanation

The anconeus epitrochlearis is an anomalous muscle present in a small percentage of the population that can cause cubital tunnel syndrome. It replaces the Osborne ligament, forming a muscular roof over the ulnar nerve at the elbow.

Question 4286

Topic: Hand Trauma & Infection

A 30-year-old male sustains a forced hyperabduction injury to his thumb metacarpophalangeal (MCP) joint while skiing. MRI confirms a complete tear of the ulnar collateral ligament (UCL) with the adductor aponeurosis interposed between the ruptured ligament and its anatomical insertion. What is this lesion called, and what is the indicated management?

. Segond lesion, indicating conservative management
. Stener lesion, indicating the need for surgical repair
. Stener lesion, indicating successful conservative management in a thumb spica cast
. Gamekeeper's lesion, requiring immediate MCP joint arthrodesis
. Volar plate avulsion, necessitating a dorsal blocking splint

Correct Answer & Explanation

. Segond lesion, indicating conservative management

Explanation

A Stener lesion occurs when the torn UCL displaces superficial to the adductor aponeurosis, preventing anatomical healing. It is an absolute indication for surgical repair.

Question 4287

Topic: 7. Hand and Wrist

A 68-year-old male with pre-existing cervical spondylosis falls forward and strikes his chin, causing a hyperextension injury to his neck. On examination, he has motor strength of 2/5 in his hands and 4/5 in his lower extremities. What is the most likely diagnosis?

. Anterior cord syndrome
. Posterior cord syndrome
. Central cord syndrome
. Brown-Sequard syndrome
. Conus medullaris syndrome

Correct Answer & Explanation

. Anterior cord syndrome

Explanation

Central cord syndrome most commonly occurs in elderly patients with pre-existing cervical spondylosis who sustain a hyperextension injury. It presents with motor weakness that is proportionally greater in the upper extremities than the lower extremities.

Question 4288

Topic: 7. Hand and Wrist
In Lichtman's classification of Kienböck disease, what specific finding differentiates Stage IIIA from Stage IIIB?
. Sclerosis of the lunate without fragmentation
. Fragmentation of the lunate without carpal collapse
. Fixed scaphoid rotary subluxation and carpal height collapse
. The development of radiocarpal osteoarthritis
. The presence of multiple subchondral lunate cysts

Correct Answer & Explanation

. Fixed scaphoid rotary subluxation and carpal height collapse

Explanation

Lichtman's classification for Kienböck disease (avascular necrosis of the lunate) divides stage III into IIIA and IIIB. Both stages feature lunate fragmentation and collapse. However, Stage IIIA maintains normal carpal alignment, while Stage IIIB is defined by fixed scaphoid rotary subluxation and a decrease in carpal height ratio. Stage IV involves widespread radiocarpal and midcarpal secondary arthritis.

Question 4289

Topic: Nerve & Tendon

A patient presents with progressive weakness of the interosseous muscles and an inability to cross their index and middle fingers. Sensory examination reveals normal two-point discrimination over the entire little finger and the ulnar half of the ring finger. A focal compressive lesion is suspected. In which anatomical location is the lesion most likely located?

. The cubital tunnel
. Zone 1 of Guyon's canal
. Zone 2 of Guyon's canal
. Zone 3 of Guyon's canal
. The Arcade of Struthers

Correct Answer & Explanation

. The cubital tunnel

Explanation

This patient has an isolated motor deficit of the ulnar nerve without sensory deficits. Guyon's canal is divided into three zones. Zone 1 contains the combined motor and sensory branches; compression here causes mixed symptoms. Zone 2 contains only the deep motor branch; compression here causes isolated weakness of the ulnar innervated intrinsic muscles. Zone 3 contains only the superficial sensory branch; compression here causes isolated sensory deficits. Cubital tunnel syndrome typically causes both motor and sensory findings.

Question 4290

Topic: 7. Hand and Wrist

A 45-year-old woman is scheduled for an open carpal tunnel release. The surgeon is mindful of the anatomical variations of the recurrent motor branch of the median nerve to avoid iatrogenic injury. According to the Lanz classification, which of the following represents the most common anatomical course of the recurrent motor branch?

. Extraligamentous with recurrent branching
. Subligamentous with recurrent branching
. Transligamentous branching through the flexor retinaculum
. Ulnar-sided branching from the median nerve
. High division of the median nerve proximal to the carpal tunnel

Correct Answer & Explanation

. Extraligamentous with recurrent branching

Explanation

According to the Lanz classification of the median nerve at the wrist, the most common course of the recurrent motor branch is extraligamentous with recurrent branching (Group 1, occurring in approximately 46-90% of individuals). In this pattern, the branch arises distal to the transverse carpal ligament and curls back to innervate the thenar musculature.

Question 4291

Topic: Wrist & Carpus

A 62-year-old woman is treated in a short arm cast for a minimally displaced, extra-articular fracture of the distal radius. Four weeks later, her cast is removed, but she suddenly loses the ability to actively extend her thumb interphalangeal joint. She has no sensory deficits. What is the most likely etiology of this complication?

. Iatrogenic injury to the radial nerve from cast compression
. Avascular necrosis of the scaphoid leading to mechanical block
. Attritional rupture of the extensor pollicis longus (EPL) tendon
. Compression of the posterior interosseous nerve (PIN) by fracture callus
. Unrecognized associated radiocarpal dislocation

Correct Answer & Explanation

. Iatrogenic injury to the radial nerve from cast compression

Explanation

EPL tendon rupture is a well-documented complication following nondisplaced or minimally displaced distal radius fractures treated conservatively. It occurs due to localized ischemia within the third dorsal compartment (a watershed area for the tendon as it angles around Lister's tubercle), compounded by mechanical attrition from the fracture hematoma or callus.

Question 4292

Topic: 7. Hand and Wrist

In flexor tendon injury topography, Bunnell's historic "no man's land" of the hand corresponds to Zone II. This zone is anatomically defined as the region between which of the following structures?

. Distal palmar crease to the FDS tendon insertion
. FDS insertion to the FDP insertion
. Carpal tunnel to the distal palmar crease
. Musculotendinous junction to the carpal tunnel
. A1 pulley to the A3 pulley

Correct Answer & Explanation

. Distal palmar crease to the FDS tendon insertion

Explanation

Flexor tendon Zone II, historically known as "no man's land" due to poor surgical outcomes prior to modern techniques, extends from the A1 pulley (approximately at the distal palmar crease) to the insertion of the flexor digitorum superficialis (FDS) tendon on the middle phalanx. Both FDS and FDP travel tightly together in the fibro-osseous sheath here.

Question 4293

Topic: Nerve & Tendon

During an anterior transposition of the ulnar nerve at the elbow, the surgeon dissects proximally to resect the medial intermuscular septum, preventing nerve kinking. Which artery, traveling with the ulnar nerve in the posterior compartment of the arm, provides its primary blood supply and must be carefully managed?

. Radial collateral artery
. Middle collateral artery
. Superior ulnar collateral artery
. Inferior ulnar collateral artery
. Anterior ulnar recurrent artery

Correct Answer & Explanation

. Radial collateral artery

Explanation

The superior ulnar collateral artery branches from the brachial artery and pierces the medial intermuscular septum to enter the posterior compartment of the arm. It travels closely with the ulnar nerve and provides its primary extrinsic vascular supply in this region. The inferior ulnar collateral artery also contributes but typically anastomoses more distally.

Question 4294

Topic: Wrist & Carpus
A 45-year-old manual laborer presents with progressive wrist pain following an untreated scaphoid fracture 5 years ago. Radiographs demonstrate a scaphoid non-union advanced collapse (SNAC) pattern. Degenerative changes are noted at the radial styloid and the entire radioscaphoid joint, but the capitolunate and radiolunate joints are preserved. What is the correct SNAC stage for this patient?
. Stage I
. Stage II
. Stage III
. Stage IV
. Stage V

Correct Answer & Explanation

. Stage II

Explanation

The SNAC (Scaphoid Nonunion Advanced Collapse) classification outlines the progression of arthritis. Stage I: Arthritis localized to the radial styloid. Stage II: Arthritis extending to involve the entire radioscaphoid joint. Stage III: Arthritis progresses to involve the capitolunate joint. Stage IV: Pancarpal arthritis (though the radiolunate joint is often remarkably spared until very late). Because the entire radioscaphoid joint is involved but the capitolunate is spared, this is Stage II.

Question 4295

Topic: Nerve & Tendon
A 24-year-old cyclist presents with isolated weakness in finger abduction and adduction. Sensation over the entire palmar and dorsal aspects of the small finger and the ulnar half of the ring finger is perfectly preserved. Examination of the wrist flexors is normal. Which zone of Guyon's canal is the most likely site of ulnar nerve compression?
. Zone 1
. Zone 2
. Zone 3
. Cubital tunnel
. Arcade of Struthers

Correct Answer & Explanation

. Zone 2

Explanation

Guyon's canal is divided into three zones. Zone 1 is proximal to the bifurcation of the ulnar nerve; compression here causes both motor (intrinsic muscle) and sensory (volar ulnar digits) deficits. Zone 2 surrounds the deep motor branch after it bifurcates; compression here results in isolated motor weakness of the ulnar-innervated intrinsic muscles with NORMAL sensation. Zone 3 surrounds the superficial sensory branch; compression here causes isolated sensory loss. Therefore, this pure motor deficit suggests Zone 2 compression.

Question 4296

Topic: 7. Hand and Wrist

A 55-year-old female undergoes volar locking plate fixation for a comminuted distal radius fracture. Six months postoperatively, she presents to the clinic with an inability to actively flex the interphalangeal joint of her thumb. What is the most likely pathophysiological cause of her presentation?

. Extensor pollicis longus (EPL) rupture secondary to dorsal screw prominence
. Anterior interosseous nerve (AIN) palsy
. Flexor digitorum profundus (FDP) rupture
. Median nerve entrapment in the carpal tunnel
. Flexor pollicis longus (FPL) rupture secondary to plate placement distal to the watershed line

Correct Answer & Explanation

. Extensor pollicis longus (EPL) rupture secondary to dorsal screw prominence

Explanation

The most common tendon complication following volar plating of the distal radius is rupture of the flexor pollicis longus (FPL) tendon. This typically occurs due to attritional wear when the plate is placed too distally, crossing the 'watershed line' of the distal radius, leading to chronic friction against the tendon.

Question 4297

Topic: Wrist & Carpus

A patient undergoes volar plating for a distal radius fracture. Postoperatively, the patient develops an attrition rupture of the flexor pollicis longus (FPL) tendon. This complication is most commonly associated with plate placement distal to which anatomical landmark?

. Pronator quadratus insertion
. Lister's tubercle
. Watershed line
. Sigmoid notch
. Radial styloid

Correct Answer & Explanation

. Pronator quadratus insertion

Explanation

Placing a volar locking plate distal to the watershed line of the distal radius causes prominence of the hardware against the volar flexor tendons. This leads to friction, tenosynovitis, and potential attrition rupture of the flexor pollicis longus (FPL) tendon.

Question 4298

Topic: 7. Hand and Wrist

A young adult sustains an isolated transverse fracture of the scaphoid waist. What is the primary anatomical reason this fracture pattern carries a high risk for avascular necrosis of the proximal pole?

. The retrograde blood supply via the dorsal carpal branch of the radial artery
. The high incidence of associated occult perilunate dislocations
. The presence of strong volar radiocarpal ligaments tethering the pole
. The complete coverage of the scaphoid by articular cartilage preventing vascular ingrowth
. The dominant blood supply entering the proximal pole directly and being avulsed

Correct Answer & Explanation

. The retrograde blood supply via the dorsal carpal branch of the radial artery

Explanation

The scaphoid receives its primary blood supply from the dorsal carpal branch of the radial artery, which enters the distal pole and flows in a retrograde fashion to the proximal pole. A waist fracture interrupts this intraosseous supply, frequently causing AVN of the proximal pole.

Question 4299

Topic: 7. Hand and Wrist

A 22-year-old male undergoes open reduction and internal fixation of a Galeazzi fracture-dislocation. Intraoperatively, following anatomic fixation of the radius, the distal radioulnar joint (DRUJ) remains irreducible in neutral and pronation, and blocks supination. What is the most likely interposed structure preventing DRUJ reduction?

. Extensor carpi ulnaris (ECU) tendon
. Extensor digiti minimi (EDM) tendon
. Flexor carpi ulnaris (FCU) tendon
. Median nerve
. Pronator quadratus muscle

Correct Answer & Explanation

. Extensor carpi ulnaris (ECU) tendon

Explanation

In Galeazzi fracture-dislocations, if the DRUJ is irreducible following anatomic radius fixation, soft tissue interposition must be suspected. The most common interposed structure is the extensor carpi ulnaris (ECU) tendon, requiring open exploration and extraction from the joint.

Question 4300

Topic: 7. Hand and Wrist

In a patient with a volar Barton's fracture, the volar lunate facet fragment escapes fixation and displaces volarly. Which of the following carpal ligaments is at greatest risk of disruption, leading to volar subluxation of the lunate?

. Scapholunate interosseous ligament
. Short radiolunate ligament
. Dorsal radiocarpal ligament
. Volar radiocarpal ligament (radioscaphocapitate)
. Lunotriquetral ligament

Correct Answer & Explanation

. Scapholunate interosseous ligament

Explanation

The short radiolunate ligament originates on the volar lunate facet of the distal radius and inserts on the volar aspect of the lunate. It acts as a primary stabilizer of the lunate. Loss of this volar marginal fragment (the 'critical corner') leads to volar lunate subluxation and severe carpal instability.

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