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7. Hand and Wrist MCQs

Practice Set 218 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 4341

Topic: Nerve & Tendon

In a patient presenting with cubital tunnel syndrome, which of the following represents the most common anatomic site of ulnar nerve compression?

. Arcade of Struthers
. Osborne's ligament (cubital tunnel retinaculum)
. Medial intermuscular septum
. Fascia of the flexor carpi ulnaris (FCU)
. Guyon's canal

Correct Answer & Explanation

. Arcade of Struthers

Explanation

Osborne's ligament, a fascial band bridging the two heads of the flexor carpi ulnaris, is the most common site of ulnar nerve compression in cubital tunnel syndrome.

Question 4342

Topic: 7. Hand and Wrist
A patient suffers a deep laceration on the volar aspect of their hand, resulting in transection of both the flexor digitorum superficialis and profundus tendons in the region between the A1 pulley and the FDS insertion. According to the Verdan classification, which flexor tendon zone is injured?
. Zone I
. Zone II
. Zone III
. Zone IV
. Zone V

Correct Answer & Explanation

. Zone II

Explanation

Zone II (historically called 'no man's land') extends from the proximal edge of the A1 pulley to the insertion of the FDS tendon on the middle phalanx. Both FDS and FDP travel together in the flexor sheath here.

Question 4343

Topic: 7. Hand and Wrist

During open carpal tunnel release, care must be taken to identify and protect the contents of the carpal tunnel. Which of the following structures is NOT contained within the carpal tunnel?

. Flexor pollicis longus tendon
. Flexor digitorum superficialis tendons
. Median nerve
. Flexor digitorum profundus tendons
. Flexor carpi radialis tendon

Correct Answer & Explanation

. Flexor pollicis longus tendon

Explanation

The carpal tunnel contains 9 tendons (4 FDS, 4 FDP, 1 FPL) and the median nerve. The flexor carpi radialis (FCR) tendon runs in its own separate fibro-osseous tunnel outside the main carpal tunnel.

Question 4344

Topic: 7. Hand and Wrist
A 35-year-old manual laborer presents with dorsal wrist pain. Radiographs show sclerosis and flattening of the lunate, along with significant negative ulnar variance. He is diagnosed with early-stage Kienböck's disease (Lichtman Stage II). What is the most appropriate surgical joint-leveling procedure?
. Proximal row carpectomy
. Radial shortening osteotomy
. Ulnar shortening osteotomy
. Total wrist arthrodesis
. Four-corner fusion

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

In early Kienböck's disease associated with negative ulnar variance, joint-leveling procedures such as a radial shortening osteotomy (or ulnar lengthening) are indicated to mechanically offload the lunate.

Question 4345

Topic: Nerve & Tendon

A 25-year-old basketball player presents unable to actively extend the distal interphalangeal (DIP) joint of his right ring finger after a jamming injury. Radiographs reveal no fractures. What is the most appropriate initial management?

. Surgical repair of the terminal extensor tendon
. DIP joint splinting in full extension for 6 to 8 weeks
. PIP and DIP joint splinting in extension for 4 weeks
. Buddy taping to the adjacent middle finger for 3 weeks
. Immediate active range of motion to prevent stiffness

Correct Answer & Explanation

. Surgical repair of the terminal extensor tendon

Explanation

A soft tissue mallet finger is an avulsion or rupture of the terminal extensor tendon. It is treated non-operatively with continuous DIP joint extension splinting for 6 to 8 weeks.

Question 4346

Topic: 7. Hand and Wrist

In a patient with an untreated, complete scapholunate ligament tear, altered carpal kinematics lead to a specific deformity. Which radiographic deformity classically develops?

. Volar intercalated segment instability (VISI)
. Dorsal intercalated segment instability (DISI)
. Ulnar translocation of the carpus
. Proximal row carpal collapse
. Scaphoid nonunion advanced collapse (SNAC)

Correct Answer & Explanation

. Volar intercalated segment instability (VISI)

Explanation

Loss of the scapholunate ligament tether causes the scaphoid to flex volarly and the lunate to extend dorsally (following the intact lunotriquetral ligament), creating a Dorsal Intercalated Segment Instability (DISI) deformity.

Question 4347

Topic: 7. Hand and Wrist

A 22-year-old rugby player felt a sudden 'pop' in his ring finger while trying to tackle an opponent by grabbing their jersey. He is now unable to actively flex his distal interphalangeal (DIP) joint. What is the most likely diagnosis?

. Flexor digitorum superficialis (FDS) rupture
. Central slip extensor rupture
. Flexor digitorum profundus (FDP) avulsion
. Terminal extensor tendon avulsion
. Volar plate avulsion injury

Correct Answer & Explanation

. Flexor digitorum superficialis (FDS) rupture

Explanation

A 'jersey finger' is an avulsion of the flexor digitorum profundus (FDP) tendon from its insertion at the base of the distal phalanx. It most commonly occurs in the ring finger during forced extension of actively flexing digits.

Question 4348

Topic: 7. Hand and Wrist

A 55-year-old female sustains a volar Barton's fracture of the distal radius. Which of the following carpal bones is most likely to subluxate volarly along with the fracture fragment?

. Scaphoid
. Lunate
. Triquetrum
. Capitate
. Trapezium

Correct Answer & Explanation

. Scaphoid

Explanation

In a volar Barton's fracture, the volar marginal fragment of the distal radius shears off. The strong short and long radiolunate ligaments remain attached to this fragment, causing the lunate (and the rest of the carpus) to subluxate volarly with the fractured radius margin. Therefore, the lunate strictly follows the volar fragment.

Question 4349

Topic: 7. Hand and Wrist

A 22-year-old male falls on an outstretched hand and sustains a fracture of the proximal pole of the scaphoid.

He undergoes percutaneous fixation. What is the primary arterial supply to the proximal pole of the scaphoid that places it at high risk for avascular necrosis?

. Volar carpal branch of the radial artery
. Superficial palmar arch
. Retrograde flow from the dorsal carpal branch of the radial artery
. Anterior interosseous artery
. Ulnar artery branches

Correct Answer & Explanation

. Volar carpal branch of the radial artery

Explanation

The scaphoid receives its primary blood supply from the dorsal carpal branch of the radial artery. These vessels enter the scaphoid at the dorsal ridge (near the waist) and supply the proximal pole in a retrograde fashion. Therefore, fractures at the waist or proximal pole disrupt this delicate retrograde supply, leading to a high rate of avascular necrosis and nonunion.

Question 4350

Topic: 7. Hand and Wrist

A 55-year-old female was treated non-operatively with a cast for a non-displaced Colles fracture. Six weeks post-injury, she returns to the clinic reporting a sudden, painless inability to extend the interphalangeal joint of her thumb. What is the most likely etiology of her new deficit?

. Complex regional pain syndrome type I
. Iatrogenic median nerve compression in the carpal tunnel
. Attritional rupture of the extensor pollicis longus tendon
. Avulsion of the thumb ulnar collateral ligament
. Malunion of the distal radius causing mechanical block

Correct Answer & Explanation

. Complex regional pain syndrome type I

Explanation

Extensor pollicis longus (EPL) tendon rupture is a well-known complication of non-displaced distal radius fractures. It occurs due to attritional wear against the fracture callus at Lister's tubercle or vascular compromise within the intact third extensor compartment.

Question 4351

Topic: 7. Hand and Wrist

A 24-year-old male falls onto an outstretched hand, sustaining a proximal pole scaphoid fracture. The high risk of avascular necrosis (AVN) in this fracture pattern is directly related to the retrograde blood supply of the scaphoid. The primary arterial supply to the proximal pole enters at which of the following anatomical locations?

. Volar tubercle
. Deep palmar arch vessels entering the waist
. Dorsal carpal branch entering the dorsal ridge
. Direct branches into the proximal pole articular cartilage
. Anterior interosseous artery

Correct Answer & Explanation

. Volar tubercle

Explanation

The primary blood supply to the scaphoid is derived from the dorsal carpal branch of the radial artery, which enters at the dorsal ridge near the waist and flows in a retrograde fashion to supply the proximal pole.

Question 4352

Topic: 7. Hand and Wrist

A 22-year-old male presents with radial-sided wrist pain after a fall onto an outstretched hand. X-rays reveal a displaced fracture of the proximal pole of the scaphoid. What is the predominant blood supply to the scaphoid that makes this specific fracture pattern highly prone to nonunion and avascular necrosis?

. Volar carpal branch of the radial artery entering distally
. Dorsal carpal branch of the radial artery entering distally
. Volar carpal branch of the ulnar artery entering proximally
. Dorsal carpal branch of the ulnar artery entering proximally
. Intraosseous branches from the capitate

Correct Answer & Explanation

. Volar carpal branch of the radial artery entering distally

Explanation

The scaphoid receives its primary blood supply (up to 80%) from the dorsal carpal branch of the radial artery, which enters the bone at the dorsal ridge (distal to the waist) and flows in a retrograde fashion to the proximal pole. Fractures at the waist or proximal pole disrupt this retrograde supply, leading to a high rate of avascular necrosis and nonunion for proximal pole fragments.

Question 4353

Topic: 7. Hand and Wrist

Six weeks after an initially uncomplicated volar plating of a distal radius fracture, a 55-year-old female presents with a sudden inability to actively extend her thumb interphalangeal joint. What is the most likely cause of this complication?

. Attritional rupture of the Extensor Pollicis Longus (EPL) tendon
. Iatrogenic laceration of the Extensor Pollicis Brevis (EPB) tendon
. Posterior interosseous nerve (PIN) entrapment
. Flexor Pollicis Longus (FPL) tendon rupture
. De Quervain's tenosynovitis

Correct Answer & Explanation

. Attritional rupture of the Extensor Pollicis Longus (EPL) tendon

Explanation

Attritional rupture of the Extensor Pollicis Longus (EPL) tendon is a well-known complication following distal radius fractures, both operatively and non-operatively treated. In the setting of volar plating, prominent dorsal screws that penetrate the dorsal cortex can act as a frictional saw, irritating and eventually rupturing the EPL tendon as it courses around Lister's tubercle in the third dorsal compartment.

Question 4354

Topic: 7. Hand and Wrist

A 25-year-old male falls onto an outstretched hand. A lateral radiograph of the wrist demonstrates a dorsally dislocated capitate, while the lunate is displaced volarly into the carpal tunnel, resembling a 'spilled teacup'. Which specific nerve deficit is most commonly associated with this acute injury pattern?

. Inability to forcefully extend the thumb IP joint
. Numbness over the dorsal first web space
. Weakness in finger abduction and adduction
. Numbness over the volar aspect of the thumb, index, and middle fingers
. Inability to flex the distal phalanx of the thumb

Correct Answer & Explanation

. Inability to forcefully extend the thumb IP joint

Explanation

The injury described is a lunate dislocation (volar displacement of the lunate). The displaced lunate protrudes into the carpal tunnel, frequently compressing the median nerve. This results in acute carpal tunnel syndrome, characterized by numbness and tingling in the median nerve distribution (volar aspect of thumb, index, middle, and radial half of the ring finger).

Question 4355

Topic: 7. Hand and Wrist
A professional American football player forcibly hyperextends his first metatarsophalangeal (MTP) joint during a tackle. MRI confirms a complete rupture of the plantar plate (Grade III turf toe injury). Which of the following describes the most common anatomical site of failure in a complete plantar plate rupture requiring surgical repair?
. Distal insertion of the plantar plate at the base of the proximal phalanx
. Proximal attachment of the plantar plate at the metatarsal neck
. Intersesamoid ligament rupture without plate avulsion
. Medial collateral ligament of the MTP joint isolated tear
. Conjoined tendon of the adductor hallucis avulsion

Correct Answer & Explanation

. Distal insertion of the plantar plate at the base of the proximal phalanx

Explanation

Turf toe represents a sprain or rupture of the first MTP joint plantar plate. The most common site of failure in a Grade III (complete tear) turf toe injury is at the distal insertion of the plantar plate onto the base of the proximal phalanx. Proximal tearing or sesamoid diastasis can occur but distal avulsion is classically targeted in surgical repair.

Question 4356

Topic: 7. Hand and Wrist

A 22-year-old American football lineman sustains an acute hyperextension injury to his first MTP joint. MRI confirms a complete tear of the plantar plate. During surgical repair, where is the most common anatomic location of the plantar plate disruption?

. Mid-substance of the plantar plate
. Avulsion from the metatarsal neck
. Avulsion from the base of the proximal phalanx
. Avulsion of the sesamoids from the flexor hallucis brevis
. Disruption of the intersesamoid ligament

Correct Answer & Explanation

. Mid-substance of the plantar plate

Explanation

In severe 'turf toe' injuries requiring surgery, the plantar plate most commonly fails via avulsion from its distal insertion at the base of the proximal phalanx. Surgical repair involves reattaching the complex to the proximal phalanx base.

Question 4357

Topic: 7. Hand and Wrist

Which anatomical boundaries define Zone II of the flexor tendon system in the hand, traditionally referred to as 'No Man's Land'?

. From the musculotendinous junction to the distal edge of the carpal tunnel
. From the distal edge of the carpal tunnel to the proximal edge of the A1 pulley
. From the proximal edge of the A1 pulley to the insertion of the flexor digitorum superficialis (FDS)
. From the insertion of the FDS to the insertion of the flexor digitorum profundus (FDP)
. Distal to the insertion of the FDP

Correct Answer & Explanation

. From the musculotendinous junction to the distal edge of the carpal tunnel

Explanation

Zone II extends from the proximal edge of the A1 pulley (which coincides roughly with the distal palmar crease) to the insertion of the flexor digitorum superficialis (FDS) on the middle phalanx. It is called 'No Man's Land' due to historically poor results of primary tendon repair within this tight fibro-osseous canal.

Question 4358

Topic: 7. Hand and Wrist

During an open carpal tunnel release, the surgeon must avoid injury to the recurrent motor branch of the median nerve. According to the Lanz classification, which of the following represents the most common anatomic variation of this branch?

. Extraligamentous origin with a recurrent course
. Subligamentous origin with a direct course
. Transligamentous origin piercing the flexor retinaculum
. Origin ulnar to the main median nerve trunk
. High bifurcation of the median nerve

Correct Answer & Explanation

. Extraligamentous origin with a recurrent course

Explanation

The most common anatomic variation of the recurrent motor branch of the median nerve (Lanz Group I) is an extraligamentous origin (branching distal to the transverse carpal ligament) with a recurrent course back to the thenar musculature, occurring in approximately 50-80% of hands.

Question 4359

Topic: 7. Hand and Wrist
A 30-year-old carpenter sustains a laceration to the volar aspect of his index finger precisely at the level of the proximal interphalangeal (PIP) joint, transecting both the FDP and FDS tendons. This injury corresponds to which flexor tendon zone?
. Zone I
. Zone II
. Zone III
. Zone IV
. Zone V

Correct Answer & Explanation

. Zone II

Explanation

Zone II, historically known as 'no man's land', extends from the A1 pulley at the distal palmar crease to the insertion of the flexor digitorum superficialis (FDS) at the middle phalanx. Injuries at the PIP joint involve both the FDP and FDS within this tight fibro-osseous sheath.

Question 4360

Topic: Nerve & Tendon

A surgeon is performing an open elbow contracture release via an extensile lateral column approach (Kocher). During the release of the anterior capsule to improve elbow extension, which nerve is at the greatest risk of iatrogenic injury and must be meticulously protected?

. Radial nerve
. Ulnar nerve
. Median nerve
. Musculocutaneous nerve
. Medial antebrachial cutaneous nerve

Correct Answer & Explanation

. Radial nerve

Explanation

During a lateral approach to the elbow (such as the Kocher or Kaplan intervals) for anterior capsular release, the radial nerve is the most vulnerable neurologic structure. The radial nerve crosses the elbow joint anterior to the radiocapitellar joint and lateral capsule. It can be easily injured if the retractor is placed improperly or if capsulotomy is performed without maintaining a protective layer of the brachialis muscle. The median nerve is situated more medially and is protected by the brachialis, while the ulnar nerve is located posteriorly in the cubital tunnel.

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