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7. Hand and Wrist MCQs

Practice Set 216 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 4301

Topic: 7. Hand and Wrist

A 32-year-old male sustains a perilunate dislocation. The 'Space of Poirier' represents an area of capsular weakness allowing the lunate to dislocate volarly. This space is located between which of the following capsuloligamentous structures?

. Radioscaphocapitate (RSC) and long radiolunate (LRL) ligaments
. Scapholunate and lunotriquetral interosseous ligaments
. Dorsal radiocarpal and dorsal intercarpal ligaments
. Extensor pollicis longus and extensor digitorum communis tendons
. Volar radioulnar and ulnocarpal ligaments

Correct Answer & Explanation

. Radioscaphocapitate (RSC) and long radiolunate (LRL) ligaments

Explanation

The Space of Poirier is a naturally occurring V-shaped area of weakness in the volar wrist capsule, located between the radioscaphocapitate (RSC) ligament and the long radiolunate (LRL) ligament. It opens up during wrist hyperextension, allowing volar dislocation of the lunate in stage IV perilunate injuries.

Question 4302

Topic: 7. Hand and Wrist

A 35-year-old female with severe carpal tunnel syndrome exhibits thenar atrophy.

Which of the following intrinsic muscles of the hand is innervated by the recurrent motor branch of the median nerve?

. Adductor pollicis
. Deep head of flexor pollicis brevis
. Opponens pollicis
. Palmaris brevis
. First dorsal interosseous

Correct Answer & Explanation

. Adductor pollicis

Explanation

The recurrent motor branch of the median nerve innervates the 'OAF' muscles: Opponens pollicis, Abductor pollicis brevis, and the superficial head of the Flexor pollicis brevis. The deep head of FPB, adductor pollicis, palmaris brevis, and interossei are innervated by the ulnar nerve.

Question 4303

Topic: Nerve & Tendon

A 45-year-old male is undergoing an anterior submuscular transposition of the ulnar nerve for recalcitrant cubital tunnel syndrome. During the procedure, the nerve is placed deep to which of the following muscular structures?

. Flexor carpi radialis
. Pronator teres isolated tendon
. Flexor digitorum superficialis
. Flexor-pronator mass
. Brachioradialis

Correct Answer & Explanation

. Flexor carpi radialis

Explanation

In a submuscular transposition, the ulnar nerve is moved anteriorly and placed deep to the flexor-pronator mass (which includes the pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, and flexor carpi ulnaris origins). It is typically laid against the brachialis and flexor digitorum profundus.

Question 4304

Topic: 7. Hand and Wrist

During repair of a Zone II flexor tendon injury, understanding the blood supply is critical. The vinculum breve to the flexor digitorum superficialis (FDS) tendon inserts at which anatomic location?

. Base of the proximal phalanx
. Base of the middle phalanx
. Base of the distal phalanx
. Distal aspect of the proximal phalanx near the PIP joint volar plate
. Neck of the middle phalanx

Correct Answer & Explanation

. Base of the proximal phalanx

Explanation

The vincula are critical for tendon nutrition. The vinculum breve of the FDS inserts on the distal aspect of the proximal phalanx, blending with the volar plate of the PIP joint. The vinculum longum of the FDS is located more proximally.

Question 4305

Topic: Nerve & Tendon

A 45-year-old male presents with a chronic mallet deformity of the ring finger and a secondary swan neck deformity. What is the primary pathoanatomic mechanism causing the PIP joint hyperextension (swan neck) in this setting?

. Rupture of the FDS insertion
. Proximal retraction of the lateral bands
. Attenuation of the PIP joint volar plate
. Rupture of the central slip
. Contracture of the oblique retinacular ligament

Correct Answer & Explanation

. Rupture of the FDS insertion

Explanation

In a chronic mallet finger, the terminal extensor tendon is ruptured, leading to a loss of extension at the DIP joint. The extensor mechanism subsequently retracts proximally, which pulls the lateral bands dorsally and proximally. This translates into an exaggerated extension force across the PIP joint, resulting in a secondary swan neck deformity.

Question 4306

Topic: Hand Trauma & Infection

In a complete tear of the ulnar collateral ligament (UCL) of the thumb (Skier's thumb), a Stener lesion may occur. This lesion is characterized by the proximal stump of the torn UCL displacing superficial to which of the following structures?

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

Correct Answer & Explanation

. Adductor pollicis aponeurosis

Explanation

A Stener lesion occurs when the distal attachment of the thumb UCL avulses and gets flipped proximally and superficial to the adductor aponeurosis. The aponeurosis interposes between the torn ligament ends, preventing spontaneous healing and thus necessitating surgical repair.

Question 4307

Topic: 7. Hand and Wrist
A 30-year-old manual laborer presents with progressive dorsal wrist pain. Radiographs show sclerosis and collapse of the lunate, consistent with Kienbock's disease. Based on the Lichtman classification, what specific radiographic finding differentiates Stage IIIA from Stage IIIB?
. Sclerosis of the lunate without collapse
. Lunate collapse with normal scaphoid alignment
. Lunate collapse with fixed scaphoid flexion (rotatory subluxation)
. Radiocarpal arthritis
. Midcarpal arthritis

Correct Answer & Explanation

. Lunate collapse with fixed scaphoid flexion (rotatory subluxation)

Explanation

Lichtman Stage III Kienbock's disease is characterized by lunate collapse. Stage IIIA has lunate collapse but maintains normal carpal alignment (normal scaphoid). Stage IIIB is defined by lunate collapse with fixed scaphoid flexion (rotatory subluxation of the scaphoid), which decreases carpal height.

Question 4308

Topic: 7. Hand and Wrist

A 24-year-old man falls onto an outstretched hand and presents with anatomic snuffbox tenderness. Radiographs reveal a non-displaced fracture through the proximal third of the scaphoid. The high risk of avascular necrosis in this fracture pattern is directly related to its blood supply. Which of the following arteries provides the primary blood supply to the proximal pole of the scaphoid?

. Volar carpal branch of the radial artery
. Dorsal carpal branch of the radial artery
. Deep palmar branch of the ulnar artery
. Anterior interosseous artery
. Superficial palmar arch

Correct Answer & Explanation

. Volar carpal branch of the radial artery

Explanation

The dorsal carpal branch of the radial artery provides 70-80% of the blood supply to the scaphoid. It enters the bone at the dorsal ridge (distal to the waist) and flows in a retrograde fashion to supply the proximal pole. Because of this retrograde intraosseous blood supply, fractures at the waist or proximal third sever the blood flow to the proximal pole, leading to a high rate of avascular necrosis and nonunion. The volar carpal branch supplies only the distal 20-30% of the bone.

Question 4309

Topic: 7. Hand and Wrist
A 55-year-old male with a history of a chronic untreated scapholunate ligament tear presents with increasing wrist pain. Radiographs reveal degenerative narrowing specifically at the articulation between the radial styloid and the scaphoid, with preservation of the rest of the radioscaphoid and midcarpal joints. What is the correct stage of Scapholunate Advanced Collapse (SLAC) in this patient?
. Stage I
. Stage II
. Stage III
. Stage IV
. Stage V

Correct Answer & Explanation

. Stage I

Explanation

The SLAC wrist sequence follows a predictable pattern of degenerative changes based on altered biomechanics. Stage I: Osteoarthritis localized to the radial styloid and the distal scaphoid. Stage II: Involvement of the entire radioscaphoid joint. Stage III: Progression to involve the capitolunate joint. Note that the radiolunate joint is classically spared in SLAC wrist due to the concentric articulation of the lunate in the lunate fossa, which is maintained despite the scaphoid rotation.

Question 4310

Topic: 7. Hand and Wrist
A 30-year-old manual laborer presents with chronic, aching dorsal wrist pain. MRI demonstrates avascular necrosis of the lunate. Plain radiographs show lunate sclerosis but normal architecture without collapse. Radiographic evaluation reveals an ulnar variance of -3 mm. Which of the following is the most appropriate initial surgical intervention if conservative management fails?
. Proximal row carpectomy
. Radial shortening osteotomy
. Ulnar shortening osteotomy
. Lunate excision and silastic replacement
. Four-corner fusion

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

The patient has Lichtman Stage II Kienböck's disease (lunate sclerosis without collapse) with ulnar minus (negative) variance. The goal of joint-leveling procedures is to decrease the compressive forces across the radiolunate joint. In a patient with negative ulnar variance, a radial shortening osteotomy (or alternatively, an ulnar lengthening osteotomy) is the procedure of choice. Proximal row carpectomy or four-corner fusion are salvage procedures reserved for advanced stages (Stage IIIb or IV) with carpal collapse and arthritis.

Question 4311

Topic: 7. Hand and Wrist

A 50-year-old diabetic woman presents with triggering and locking of her long finger that has been refractory to two corticosteroid injections. She undergoes surgical release. During the procedure, the surgeon must identify and release the specific structure responsible for the pathology while preserving the critical mechanical pulleys. What is the correct proximal-to-distal sequence of the flexor tendon pulleys in the digit?

. A1, A2, C1, A3, C2, A4, C3, A5
. A1, C1, A2, C2, A3, C3, A4, C4, A5
. A1, A2, A3, C1, C2, C3, A4, A5
. C1, A1, C2, A2, C3, A3, C4, A4
. A1, C1, C2, A2, A3, C3, A4, A5

Correct Answer & Explanation

. A1, A2, C1, A3, C2, A4, C3, A5

Explanation

The flexor tendon sheath contains five annular (A) pulleys and three cruciate (C) pulleys. The correct proximal-to-distal sequence is A1 (at the MCP joint), A2 (proximal phalanx), C1, A3 (PIP joint), C2, A4 (middle phalanx), C3, and A5 (DIP joint). The A2 and A4 pulleys are mechanically critical to prevent bowstringing and must be preserved. Trigger finger is caused by a stenosing tenosynovitis at the A1 pulley, which is the structure divided during release.

Question 4312

Topic: 7. Hand and Wrist
A 25-year-old male sustains a deep glass laceration over the volar aspect of the proximal phalanx of his index finger. Exploration reveals that both the flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) tendons are completely severed. In which flexor tendon zone did this injury occur?
. Zone I
. Zone II
. Zone III
. Zone IV
. Zone V

Correct Answer & Explanation

. Zone II

Explanation

Flexor tendon Zone II extends from the proximal edge of the A1 pulley to the insertion of the FDS on the middle phalanx. Historically known as 'no man's land', lacerations in this zone frequently involve both the FDS and FDP tendons. Because the tendons are tightly enclosed within the fibro-osseous sheath in this zone, repairs are technically demanding and prone to restrictive adhesions. Zone I is distal to the FDS insertion (only FDP is present).

Question 4313

Topic: 7. Hand and Wrist
A 22-year-old rugby player presents after a match unable to actively flex the DIP joint of his ring finger after grabbing an opponent's jersey. Radiographs reveal a large bony avulsion fragment from the volar base of the distal phalanx that is situated intra-articularly at the DIP joint. According to the Leddy-Packer classification of flexor digitorum profundus (FDP) avulsions, what type of injury is this?
. Type I
. Type II
. Type III
. Type IV
. Type V

Correct Answer & Explanation

. Type III

Explanation

Jersey fingers are classified by Leddy and Packer based on the level of tendon retraction. Type I: Tendon retracts into the palm; requires repair within 7-10 days due to compromised blood supply. Type II: Tendon retracts to the level of the PIP joint, held by the intact vinculum longum. Type III: A large bony fragment is avulsed and catches at the A4 pulley, preventing proximal retraction; the fragment remains intra-articular at the DIP joint. Type IV involves both a bony avulsion and an independent avulsion of the tendon off the bony fragment.

Question 4314

Topic: Hand Trauma & Infection

A 35-year-old skier falls while gripping his ski pole and presents with weakness in thumb pinch and pain over the ulnar aspect of the thumb MCP joint. MRI reveals a complete rupture of the ulnar collateral ligament (UCL). The distal end of the torn ligament is displaced, preventing spontaneous healing. Which structure is the torn UCL typically displaced superficial to in this classic lesion?

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

Correct Answer & Explanation

. Adductor pollicis aponeurosis

Explanation

The patient has a Stener lesion, a common complication of a complete thumb UCL rupture (Skier's/Gamekeeper's thumb). In a Stener lesion, the distal end of the completely torn UCL flips back and becomes trapped superficial to the adductor pollicis aponeurosis. Because the aponeurosis interposes between the torn ligament and its insertion on the proximal phalanx, anatomic healing cannot occur without surgical intervention.

Question 4315

Topic: 7. Hand and Wrist

A 40-year-old female presents with aching pain in her anterior forearm and numbness in the radial 3.5 digits. On examination, she has a negative Tinel's sign at the wrist. She demonstrates numbness over the thenar eminence. Furthermore, she has weakness in thumb interphalangeal joint flexion and index finger DIP joint flexion. What is the most likely primary site of nerve compression?

. Transverse carpal ligament
. Two heads of the pronator teres
. Arcade of Frohse
. Ligament of Struthers
. Guyon's canal

Correct Answer & Explanation

. Transverse carpal ligament

Explanation

This patient has Pronator Syndrome, a proximal median neuropathy. The key findings differentiating this from Carpal Tunnel Syndrome (CTS) are the numbness over the thenar eminence (supplied by the palmar cutaneous branch of the median nerve, which branches proximal to the transverse carpal ligament) and motor weakness in the Anterior Interosseous Nerve (AIN) distribution (FPL and FDP to the index finger). The most common site of compression in Pronator Syndrome is between the two heads of the pronator teres muscle. The Ligament of Struthers is a much rarer cause of proximal median nerve compression that would also affect the pronator teres muscle itself.

Question 4316

Topic: Nerve & Tendon

A competitive cyclist presents with numbness in his small finger and the ulnar half of his ring finger on the volar aspect, along with weakness of finger abduction and adduction. Sensation over the dorso-ulnar aspect of the hand is completely intact. Based on these findings, compression of the ulnar nerve is most likely occurring in which zone of Guyon's canal?

. Zone 1
. Zone 2
. Zone 3
. It is compressed at the Cubital Tunnel
. Arcade of Struthers

Correct Answer & Explanation

. Zone 1

Explanation

Guyon's canal is divided into three zones. Zone 1 is proximal to the bifurcation of the ulnar nerve into superficial and deep branches; compression here causes both motor (intrinsic muscle weakness) and volar sensory deficits (numbness in volar small/ring fingers). The dorsal ulnar cutaneous nerve branches 5-8 cm proximal to the wrist, so its territory (dorso-ulnar hand) is spared in Guyon's canal compression, distinguishing it from cubital tunnel syndrome. Zone 2 compression affects only the deep motor branch. Zone 3 compression affects only the superficial sensory branch.

Question 4317

Topic: Nerve & Tendon

A 45-year-old mechanic complains of lateral elbow pain radiating down the dorsal forearm. The pain is exacerbated by repetitive pronation and supination. On examination, maximal point tenderness is localized approximately 4 to 5 cm distal to the lateral epicondyle in the extensor muscle mass. Resisted active extension of the middle finger (with the elbow extended) reproduces the pain. There is no demonstrable motor weakness or finger drop. What is the most likely diagnosis?

. Lateral epicondylitis
. Posterior interosseous nerve syndrome
. Radial tunnel syndrome
. Wartenberg's syndrome
. Intersection syndrome

Correct Answer & Explanation

. Lateral epicondylitis

Explanation

Radial tunnel syndrome represents a painful compression of the radial nerve (typically the posterior interosseous nerve branch) in the proximal forearm without classic motor weakness. It is often confused with lateral epicondylitis; however, the point of maximal tenderness in radial tunnel syndrome is 4-5 cm distal to the lateral epicondyle over the supinator/mobile wad, whereas in lateral epicondylitis it is directly over or immediately adjacent to the epicondyle. PIN syndrome typically presents with motor weakness (inability to extend digits/thumb) rather than just pain. Wartenberg's syndrome is compression of the superficial sensory branch of the radial nerve in the distal forearm.

Question 4318

Topic: Wrist & Carpus

A 28-year-old gymnast presents with ulnar-sided wrist pain and clicking after a fall. Examination reveals a positive fovea sign. Arthroscopy confirms a traumatic avulsion of the Triangular Fibrocartilage Complex (TFCC) from its insertion at the fovea of the ulnar head. According to the Palmer classification, what type of TFCC tear is this?

. Class 1A
. Class 1B
. Class 1C
. Class 1D
. Class 2A

Correct Answer & Explanation

. Class 1A

Explanation

The Palmer classification divides TFCC tears into traumatic (Class 1) and degenerative (Class 2). Class 1A is a central perforation (avascular zone, typically debrided). Class 1B is an ulnar avulsion (from the ulnar styloid or fovea, highly vascular, amenable to repair). Class 1C is a distal avulsion involving the ulnocarpal ligaments. Class 1D is a radial avulsion (from the sigmoid notch of the radius). Class 2 tears involve degenerative wear.

Question 4319

Topic: Nerve & Tendon

A 50-year-old male is undergoing in-situ decompression of the ulnar nerve for severe cubital tunnel syndrome. The surgeon meticulously releases the nerve along its entire course around the elbow to prevent postoperative tethering. Which of the following is the most common anatomical site of ulnar nerve compression in this region?

. Arcade of Struthers
. Medial intermuscular septum
. Osborne's ligament
. Deep flexor-pronator aponeurosis
. Anconeus epitrochlearis

Correct Answer & Explanation

. Arcade of Struthers

Explanation

The most common site of ulnar nerve compression at the elbow is at the cubital tunnel retinaculum, also known as Osborne's ligament or fascia. This thick band extends from the medial epicondyle to the olecranon and bridges the two heads of the flexor carpi ulnaris (FCU). Other potential sites of compression include the Arcade of Struthers (proximal), medial intermuscular septum, the deep flexor-pronator aponeurosis, and occasionally an anomalous muscle like the anconeus epitrochlearis, but Osborne's ligament is the most frequently implicated structure.

Question 4320

Topic: 7. Hand and Wrist
A 32-year-old construction worker falls from a scaffolding. Lateral wrist radiographs demonstrate the lunate completely displaced volar to the radius and tipped forward like a 'spilled teacup', while the capitate remains aligned with the longitudinal axis of the radius. According to the Mayfield classification of carpal instability, what stage of injury has occurred?
. Stage I
. Stage II
. Stage III
. Stage IV
. Stage V

Correct Answer & Explanation

. Stage IV

Explanation

Mayfield described a progressive sequence of perilunate instability based on the path of force around the lunate. Stage I: Scapholunate dissociation. Stage II: Perilunate dislocation (capitate dislocates dorsally while lunate remains in the radial fossa). Stage III: Lunotriquetral disruption. Stage IV: Lunate dislocation (the lunate is squeezed out volarly into the carpal tunnel, appearing as a 'spilled teacup' on the lateral radiograph, and the capitate drops back to articulate with the radius).

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