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7. Hand and Wrist MCQs

Practice Set 217 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 4321

Topic: Hand Trauma & Infection
A 35-year-old diabetic patient presents to the emergency department with a swollen, throbbing index finger 3 days after sustaining a puncture wound. The physician suspects acute purulent flexor tenosynovitis. Which of the following is NOT one of Kanavel's cardinal signs for this condition?
. Fusiform swelling of the entire digit
. Digit held in a posture of slight extension
. Tenderness along the course of the flexor tendon sheath
. Severe pain on passive extension of the digit
. All of the above are cardinal signs

Correct Answer & Explanation

. Digit held in a posture of slight extension

Explanation

Kanavel's four cardinal signs of acute flexor tenosynovitis are: 1) Fusiform (sausage-like) swelling of the digit. 2) The digit is held in a posture of slight FLEXION (not extension) to minimize tension on the inflamed sheath. 3) Tenderness along the entire course of the flexor tendon sheath. 4) Disproportionate, severe pain with passive extension of the digit.

Question 4322

Topic: 7. Hand and Wrist
A 45-year-old male with a 10-year history of an untreated scaphoid waist fracture presents with progressive wrist pain and stiffness. Radiographs demonstrate advanced carpal collapse. In Scaphoid Nonunion Advanced Collapse (SNAC) wrist, the earliest arthritic changes typically manifest at which of the following articulations?
. Radioscaphoid (involving the proximal pole)
. Radioscaphoid (involving the distal pole)
. Scaphocapitate
. Capitolunate
. Lunotriquetral

Correct Answer & Explanation

. Radioscaphoid (involving the distal pole)

Explanation

In a SNAC wrist, the scaphoid is ununited. The proximal pole remains attached to the lunate via the intact scapholunate ligament and maintains a concentric articulation with the scaphoid fossa of the radius. The distal pole flexes and rotates, creating an incongruent articulation with the radial styloid. Therefore, Stage I of SNAC wrist arthritis begins at the articulation between the radial styloid and the distal pole of the scaphoid. Stage II involves the scaphocapitate joint, and Stage III involves the capitolunate joint.

Question 4323

Topic: 7. Hand and Wrist
A 55-year-old manual laborer presents with advanced Scapholunate Advanced Collapse (SLAC) of the wrist. Radiographs reveal diffuse radiocarpal and midcarpal arthritis. Which of the following carpal articulations is classically SPARED in a SLAC wrist, allowing for motion-preserving salvage procedures such as a four-corner fusion?
. Radioscaphoid joint
. Capitolunate joint
. Radiolunate joint
. Scaphotrapezial joint
. Lunotriquetral joint

Correct Answer & Explanation

. Radiolunate joint

Explanation

In SLAC wrist, the radiolunate joint is classically spared. This is due to the spherical congruence of the radiolunate articulation, which does not experience the same sheer forces and translation that lead to articular wear at the radioscaphoid and capitolunate joints. This anatomic feature allows for proximal row carpectomy or scaphoid excision with four-corner fusion to be viable options.

Question 4324

Topic: Nerve & Tendon

A 24-year-old male sustains a C5-C6 brachial plexus avulsion injury (Erb's palsy). Six months post-injury, he has no elbow flexion but normal hand function. An Oberlin transfer is planned. Which of the following describes the classic Oberlin I transfer?

. Transfer of a fascicle of the median nerve to the brachialis motor branch
. Transfer of a fascicle of the ulnar nerve to the biceps motor branch
. Transfer of the spinal accessory nerve to the suprascapular nerve
. Transfer of the intercostal nerves to the musculocutaneous nerve
. Transfer of the thoracodorsal nerve to the biceps motor branch

Correct Answer & Explanation

. Transfer of a fascicle of the median nerve to the brachialis motor branch

Explanation

The classic Oberlin transfer (Oberlin I) involves taking a redundant fascicle from the ulnar nerve (typically one supplying the FCU) and transferring it to the motor branch of the biceps (part of the musculocutaneous nerve) to restore elbow flexion in upper trunk brachial plexus injuries.

Question 4325

Topic: Wrist & Carpus
According to the Mayfield classification of perilunate instability, what is the anatomic sequence of ligamentous disruption around the lunate as the severity of injury progresses from Stage I to Stage IV?
. Scapholunate -> Lunotriquetral -> Capitolunate -> Dorsal radiocarpal
. Scapholunate -> Capitolunate -> Lunotriquetral -> Dorsal radiocarpal
. Lunotriquetral -> Capitolunate -> Scapholunate -> Dorsal radiocarpal
. Capitolunate -> Scapholunate -> Lunotriquetral -> Volar radiocarpal
. Dorsal radiocarpal -> Scapholunate -> Capitolunate -> Lunotriquetral

Correct Answer & Explanation

. Scapholunate -> Capitolunate -> Lunotriquetral -> Dorsal radiocarpal

Explanation

The Mayfield progression of perilunate instability occurs in a specific sequence around the lunate: Stage I (Scapholunate ligament disruption), Stage II (Capitolunate joint disruption/dislocation), Stage III (Lunotriquetral ligament disruption), and Stage IV (Lunate dislocation, failing the dorsal radiocarpal ligament and extruding the lunate volarly).

Question 4326

Topic: 7. Hand and Wrist

A patient presents with intrinsic muscle weakness in the hand but normal sensation over the volar small finger and dorsal ulnar aspect of the hand. Electromyography confirms compression of the ulnar nerve in Guyon's canal. This presentation is most consistent with compression at which zone?

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

Correct Answer & Explanation

. Zone 1

Explanation

Guyon's canal is divided into 3 zones. Zone 1 is proximal to the nerve bifurcation (motor and sensory deficits). Zone 2 encompasses the deep motor branch after the bifurcation, typically at the hook of the hamate (motor deficits only). Zone 3 encompasses the superficial sensory branch (sensory deficits only).

Question 4327

Topic: Nerve & Tendon

A 40-year-old male develops a boutonniere deformity of the index finger following a crush injury. What is the underlying pathoanatomy responsible for this specific deformity?

. Rupture of the terminal extensor tendon with dorsal subluxation of the lateral bands
. Rupture of the central slip with volar subluxation of the lateral bands
. Rupture of the flexor digitorum superficialis tendon
. Attenuation of the volar plate at the PIP joint
. Contracture of the oblique retinacular ligament

Correct Answer & Explanation

. Rupture of the terminal extensor tendon with dorsal subluxation of the lateral bands

Explanation

A boutonniere deformity is characterized by PIP joint flexion and DIP joint hyperextension. It is caused by rupture or attenuation of the central slip of the extensor mechanism, which allows the lateral bands to subluxate volarly to the axis of rotation of the PIP joint. They then act as flexors of the PIP while continuing to extend the DIP joint.

Question 4328

Topic: 7. Hand and Wrist
A 65-year-old female presents with severe pain at the base of the thumb. Radiographs demonstrate Eaton-Littler Stage IV carpometacarpal (CMC) arthritis. Which radiographic finding distinguishes Stage IV from Stage III?
. Joint space narrowing at the trapeziometacarpal joint
. Sclerosis and osteophyte formation
. Subluxation of the first metacarpal base by more than 1/3
. Involvement of the scaphotrapezial (STT) joint
. Complete obliteration of the trapeziometacarpal joint space

Correct Answer & Explanation

. Involvement of the scaphotrapezial (STT) joint

Explanation

The Eaton-Littler classification of thumb CMC arthritis: Stage I (subtle widening), Stage II (slight narrowing, osteophytes <2mm), Stage III (significant narrowing, osteophytes >2mm, subluxation), and Stage IV (pantrapezial arthritis, which includes involvement of the scaphotrapezotrapezoidal [STT] joint).

Question 4329

Topic: Nerve & Tendon

A 5-year-old girl is treated nonoperatively for a seemingly minimally displaced pediatric lateral condyle fracture. One year later, she is noted to have a nonunion. What is the most common long-term deformity and associated neurologic complication if left untreated?

. Cubitus varus and tardy radial nerve palsy
. Cubitus valgus and tardy ulnar nerve palsy
. Cubitus varus and tardy median nerve palsy
. Cubitus valgus and tardy radial nerve palsy
. Elbow stiffness and tardy median nerve palsy

Correct Answer & Explanation

. Cubitus varus and tardy radial nerve palsy

Explanation

Nonunion of a lateral condyle fracture in a child typically leads to a progressive cubitus valgus deformity as the medial condyle continues to grow while the lateral side does not. This valgus deformity stretches the ulnar nerve over time, leading to a tardy ulnar nerve palsy.

Question 4330

Topic: Nerve & Tendon

During surgical decompression of the ulnar nerve for cubital tunnel syndrome, the surgeon must divide the roof of the cubital tunnel. What structure forms the roof of this tunnel?

. Medial collateral ligament
. Joint capsule
. Osborne's ligament / FCU aponeurosis
. Arcade of Struthers
. Medial intermuscular septum

Correct Answer & Explanation

. Medial collateral ligament

Explanation

The roof of the cubital tunnel is formed by Osborne's ligament (the aponeurosis between the humeral and ulnar heads of the flexor carpi ulnaris). The floor is formed by the posterior band of the medial collateral ligament (MCL) and the elbow joint capsule.

Question 4331

Topic: 7. Hand and Wrist

A 58-year-old male with Dupuytren's disease undergoes a fasciectomy for a severe PIP joint contracture. During dissection, the neurovascular bundle is noted to be displaced volarly and centrally. Which pathologic structure is primarily responsible for PIP joint contracture and this neurovascular displacement?

. Pretendinous cord
. Natatory cord
. Spiral cord
. Lateral cord
. Retrovascular cord

Correct Answer & Explanation

. Pretendinous cord

Explanation

The spiral cord is responsible for PIP joint contracture in Dupuytren's disease and is clinically vital because it displaces the neurovascular bundle centrally, volarly, and proximally, placing it at high risk during surgical excision. It is composed of the pretendinous band, spiral band, lateral digital sheet, and Grayson's ligament.

Question 4332

Topic: 7. Hand and Wrist

When performing a primary flexor tendon repair in Zone II of the hand, biomechanical studies suggest that the strength of the repair is most directly proportional to which of the following factors?

. The caliber (thickness) of the epitendinous suture
. The number of core suture strands crossing the repair site
. The use of a dorsal blocking splint postoperatively
. The location of the knot (inside vs. outside the repair site)
. The distance between the core suture bite and the tendon end

Correct Answer & Explanation

. The caliber (thickness) of the epitendinous suture

Explanation

In flexor tendon repairs, biomechanical studies demonstrate that the tensile strength of the repair is directly proportional to the number of core suture strands crossing the repair site. A 4-strand or 6-strand repair is significantly stronger than a 2-strand repair and allows for early active motion protocols.

Question 4333

Topic: Wrist & Carpus

A 45-year-old female sustains a volar Barton's fracture of the distal radius. This fracture pattern involves a volar marginal articular fragment that subluxates with the carpus. Which critical radiocarpal ligament complex remains attached to this volar fragment, mediating the volar subluxation of the carpus?

. Dorsal radiocarpal ligament
. Scapholunate interosseous ligament
. Volar radiolunate ligaments (short and long)
. Triangular fibrocartilage complex (TFCC)
. Ulnocarpal ligaments

Correct Answer & Explanation

. Dorsal radiocarpal ligament

Explanation

A volar Barton's fracture is a shear fracture of the volar rim of the distal radius (typically involving the volar lunate facet). The volar radiolunate ligaments (short and long) remain attached to this fragment, and because the carpus remains tethered to this fragment via these ligaments, the entire carpus subluxates volarly with the fractured rim.

Question 4334

Topic: 7. Hand and Wrist
A 25-year-old male is diagnosed with Kienböck's disease (avascular necrosis of the lunate). According to the Lichtman classification, what finding distinguishes Stage IIIA from Stage IIIB?
. Stage IIIA has sclerosis of the lunate; IIIB has lunate fragmentation
. Stage IIIA has normal carpal alignment; IIIB demonstrates fixed scaphoid rotary subluxation and carpal collapse
. Stage IIIA shows MRI changes only; IIIB shows radiographic sclerosis
. Stage IIIA is treated with proximal row carpectomy; IIIB is treated with core decompression
. Stage IIIA involves the proximal pole of the lunate; IIIB involves the entire lunate

Correct Answer & Explanation

. Stage IIIA has normal carpal alignment; IIIB demonstrates fixed scaphoid rotary subluxation and carpal collapse

Explanation

In the Lichtman classification for Kienböck's disease, Stage III is characterized by lunate collapse. It is subdivided based on carpal mechanics: Stage IIIA has lunate collapse but normal carpal height and alignment. Stage IIIB has lunate collapse accompanied by fixed scaphoid rotary subluxation (a sign of carpal instability/collapse and decreased carpal height).

Question 4335

Topic: 7. Hand and Wrist
A 35-year-old mechanic presents with chronic wrist pain and limited extension following an untreated fall on an outstretched hand 5 years ago. Radiographs demonstrate scapholunate dissociation with radioscaphoid and capitolunate arthritis, but sparing of the radiolunate articulation. Which of the following is the most appropriate definitive management?
. Proximal row carpectomy
. Four-corner arthrodesis with scaphoid excision
. Scapholunate ligament reconstruction
. Total wrist arthroplasty
. Radial styloidectomy

Correct Answer & Explanation

. Four-corner arthrodesis with scaphoid excision

Explanation

This patient has Scapholunate Advanced Collapse (SLAC) stage III, which involves the capitolunate joint. Proximal row carpectomy is contraindicated due to capitate arthritis, making four-corner fusion the treatment of choice.

Question 4336

Topic: Wrist & Carpus

A 32-year-old male sustains a Galeazzi fracture-dislocation. Following rigid internal fixation of the radius, the distal radioulnar joint (DRUJ) is evaluated and found to be unstable in all positions of forearm rotation. What is the most appropriate next step in management?

. Open exploration and repair of the TFCC or percutaneous pinning of the DRUJ in a reduced position
. Cast immobilization in full supination for 6 weeks
. Immediate resection of the distal ulna (Darrach procedure)
. Dynamic splinting of the wrist and forearm
. Ulnar shortening osteotomy

Correct Answer & Explanation

. Open exploration and repair of the TFCC or percutaneous pinning of the DRUJ in a reduced position

Explanation

If the DRUJ remains grossly unstable in all planes after rigid radial fixation in a Galeazzi fracture, the joint must be stabilized via percutaneous transfixation pins or open TFCC repair.

Question 4337

Topic: Wrist & Carpus

A 60-year-old female presents with a comminuted distal radius fracture and undergoes volar locked plating. During screw placement in the most distal row, the surgeon must be careful to avoid dorsal cortex penetration to prevent tendon rupture in which dorsal extensor compartment?

. First dorsal compartment
. Second dorsal compartment
. Third dorsal compartment
. Fourth dorsal compartment
. Sixth dorsal compartment

Correct Answer & Explanation

. First dorsal compartment

Explanation

Dorsal screw prominence past the distal radius cortex frequently irritates or ruptures the extensor pollicis longus (EPL) tendon, which resides in the third dorsal compartment.

Question 4338

Topic: 7. Hand and Wrist

A 24-year-old rock climber presents with a popping sensation and pain in his right ring finger while bearing weight on a crimp hold. Clinical examination reveals pain and swelling over the volar aspect of the proximal phalanx, exacerbated by resisted PIP joint flexion. Which flexor tendon pulley is most likely injured?

. A1 pulley
. A2 pulley
. A3 pulley
. A4 pulley
. A5 pulley

Correct Answer & Explanation

. A1 pulley

Explanation

The A2 pulley, located at the level of the proximal phalanx, is the most critical biomechanical pulley and the most frequently ruptured in rock climbers.

Question 4339

Topic: 7. Hand and Wrist

A 22-year-old male sustains a proximal pole scaphoid fracture. Which of the following describes the primary blood supply to the scaphoid and explains the high risk of avascular necrosis in proximal pole fractures?

. Palmar carpal branch of the ulnar artery, supplying anterograde flow
. Dorsal carpal branch of the radial artery, supplying retrograde flow
. Deep palmar arch, supplying retrograde flow
. Superficial palmar arch, supplying anterograde flow
. Anterior interosseous artery, supplying dual flow

Correct Answer & Explanation

. Palmar carpal branch of the ulnar artery, supplying anterograde flow

Explanation

The primary blood supply to the scaphoid is from the dorsal carpal branch of the radial artery, which enters distally and provides retrograde blood flow to the proximal pole, making it highly susceptible to avascular necrosis.

Question 4340

Topic: Wrist & Carpus

Six weeks after being treated non-operatively for a non-displaced distal radius fracture, a 68-year-old woman presents with a sudden inability to actively extend her thumb interphalangeal (IP) joint. Which tendon transfer is the most appropriate definitive management?

. Extensor indicis proprius (EIP) to Extensor pollicis longus (EPL)
. Extensor carpi radialis brevis (ECRB) to EPL
. Flexor digitorum superficialis (FDS) to EPL
. Palmaris longus (PL) to EPL
. Brachioradialis (BR) to EPL

Correct Answer & Explanation

. Extensor indicis proprius (EIP) to Extensor pollicis longus (EPL)

Explanation

Spontaneous rupture of the EPL tendon is a known complication of non-displaced distal radius fractures. The EIP to EPL tendon transfer is the gold standard treatment to restore thumb IP extension.

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