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7. Hand and Wrist MCQs

Practice Set 219 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 4361

Topic: Nerve & Tendon

A 55-year-old male undergoes a single-incision anterior repair for an acute distal biceps tendon rupture. Postoperatively, he exhibits an expected neurologic deficit. Which nerve is at greatest risk of stretch injury during the superficial dissection and lateral retractor placement of this approach?

. Posterior interosseous nerve
. Lateral antebrachial cutaneous nerve
. Median nerve
. Ulnar nerve
. Anterior interosseous nerve

Correct Answer & Explanation

. Posterior interosseous nerve

Explanation

The lateral antebrachial cutaneous nerve (LABCN) is at high risk of stretch neurapraxia during the superficial dissection and retraction in a single-incision anterior approach. The posterior interosseous nerve is at higher risk during a two-incision approach or with excessive deep radial retraction.

Question 4362

Topic: Nerve & Tendon

A patient undergoes an ulnar nerve transposition for severe cubital tunnel syndrome. During the approach, the nerve must be carefully mobilized from its native groove. Which fascial structure forms the direct roof of the cubital tunnel and must be released?

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

Correct Answer & Explanation

. Osborne's ligament

Explanation

The roof of the cubital tunnel is formed by Osborne's ligament (the cubital tunnel retinaculum), which spans between the medial epicondyle and the olecranon. Struthers' ligament is located proximally in the arm and is associated with median nerve compression.

Question 4363

Topic: 7. Hand and Wrist

A 40-year-old manual laborer undergoes an open subpectoral biceps tenodesis. Postoperatively, he exhibits profound weakness in wrist and finger extension, though elbow extension is intact. Which nerve was most likely injured due to errant retractor placement?

. Median nerve
. Ulnar nerve
. Radial nerve
. Posterior interosseous nerve
. Musculocutaneous nerve

Correct Answer & Explanation

. Median nerve

Explanation

The radial nerve runs directly posterior to the humerus and can be compressed or injured with aggressive deep retractor placement along the lateral aspect of the humerus during a subpectoral biceps tenodesis.

Question 4364

Topic: 7. Hand and Wrist
A 42-year-old construction worker with a 5-year history of a scaphoid waist nonunion presents with severe wrist pain. Radiographs demonstrate joint space narrowing at the radioscaphoid articulation, as well as degenerative changes at the capitolunate joint. The radiolunate joint is preserved. Which of the following is the most appropriate surgical treatment?
. Radial styloidectomy and scaphoid fixation
. Proximal row carpectomy (PRC)
. Scaphoid excision and four-corner arthrodesis
. Total wrist arthroplasty
. Vascularized bone grafting

Correct Answer & Explanation

. Scaphoid excision and four-corner arthrodesis

Explanation

The patient has Stage III SNAC (Scaphoid Nonunion Advanced Collapse), characterized by the addition of capitolunate arthritis to radioscaphoid arthritis. Proximal row carpectomy (PRC) relies on a preserved capitate head to articulate with the lunate fossa of the radius; therefore, capitolunate arthritis is a strict contraindication to PRC. Scaphoid excision and four-corner fusion is the treatment of choice for Stage III SNAC.

Question 4365

Topic: Wrist & Carpus

A surgeon plans to perform a 1,2 intercompartmental supraretinacular artery (1,2 ICSRA) vascularized bone graft for a scaphoid proximal pole nonunion. The pedicle for this graft is derived from which of the following source vessels?

. Anterior interosseous artery
. Radial artery
. Ulnar artery
. Posterior interosseous artery
. Deep palmar arch

Correct Answer & Explanation

. Anterior interosseous artery

Explanation

The 1,2 ICSRA is a consistently present branch of the radial artery. It courses distally on the dorsal aspect of the distal radius between the first and second extensor compartments and is utilized for pedicled vascularized bone grafts to the scaphoid (Zaidemberg's graft).

Question 4366

Topic: 7. Hand and Wrist

Which of the following best describes the dominant arterial supply to the proximal pole of the scaphoid?

. Volar branches of the radial artery entering the distal pole
. Branches of the anterior interosseous artery entering the volar waist
. Dorsal carpal branch of the radial artery entering via the dorsal ridge
. Deep palmar arch branches entering via the scaphotrapezial joint
. Nutrient vessels arising directly from the ulnar artery

Correct Answer & Explanation

. Volar branches of the radial artery entering the distal pole

Explanation

The primary blood supply to the scaphoid is retrograde. The dorsal carpal branch of the radial artery provides 70-80% of the blood supply, entering through the dorsal ridge and supplying the proximal pole and waist in a retrograde fashion. This poor vascularity puts the proximal pole at high risk for avascular necrosis following fracture.

Question 4367

Topic: Wrist & Carpus

When distinguishing between Scapholunate Advanced Collapse (SLAC) and Scaphoid Nonunion Advanced Collapse (SNAC), which of the following radiographic findings is uniquely characteristic of SNAC?

. Arthrosis of the radiolunate joint
. Sparing of the radiolunate joint
. Normal scapholunate interval
. Proximal migration of the capitate
. Arthrosis of the radioscaphoid joint

Correct Answer & Explanation

. Arthrosis of the radiolunate joint

Explanation

Both SLAC and SNAC predictably spare the radiolunate joint (until end-stage pancarpal arthritis) and both feature progressive radioscaphoid and midcarpal arthritis. However, in SNAC, the scapholunate ligament remains intact, tethering the proximal scaphoid fragment to the lunate; thus, the scapholunate interval remains normal. In SLAC, this ligament is torn, causing a widened SL interval (Terry Thomas sign).

Question 4368

Topic: 7. Hand and Wrist

A patient with a chronic scaphoid waist nonunion develops a significant humpback deformity but has no radiographic evidence of wrist osteoarthritis or proximal pole AVN. The surgeon plans to correct the deformity. Which approach and grafting technique is most appropriate to restore carpal kinematics?

. Dorsal approach with a vascularized 1,2 ICSRA graft
. Volar approach with an inlay corticocancellous graft
. Volar approach with an opening wedge structural bone graft
. Dorsal approach with a closing wedge osteotomy
. Volar approach with headless compression screw fixation without grafting

Correct Answer & Explanation

. Dorsal approach with a vascularized 1,2 ICSRA graft

Explanation

A humpback deformity in a scaphoid nonunion requires restoration of the volar scaphoid length to correct the intrascaphoid angle and secondary DISI deformity. A volar approach with a structural opening wedge bone graft (often harvested from the iliac crest) placed volarly corrects the deformity and restores normal carpal alignment.

Question 4369

Topic: 7. Hand and Wrist

To accurately assess a scaphoid fracture for union or the degree of humpback deformity, computed tomography (CT) scans should be reformatted. What is the optimal plane of reconstruction to evaluate the true longitudinal axis of the scaphoid?

. Sagittal plane parallel to the third metacarpal
. Axial plane parallel to the distal radius articular surface
. Parasagittal plane 45 degrees to the standard sagittal plane of the wrist
. True coronal plane perpendicular to the lunate
. Transverse plane along the scaphotrapezial joint

Correct Answer & Explanation

. Sagittal plane parallel to the third metacarpal

Explanation

The scaphoid lies at an oblique angle (approximately 45 degrees volar to the coronal plane and 45 degrees radial to the sagittal plane). To accurately evaluate the scaphoid morphology and trabecular bridging, CT imaging must be reformatted along its true longitudinal axis, which corresponds to a parasagittal plane approximately 45 degrees to the standard sagittal plane of the wrist.

Question 4370

Topic: 7. Hand and Wrist

During a proximal row carpectomy (PRC) for Stage II SNAC wrist, the surgeon must be careful to preserve which of the following ligaments to prevent ulnar translation of the remaining carpus?

. Radiolunate ligament
. Radioscaphocapitate ligament
. Dorsal intercarpal ligament
. Scaphotrapezial ligament
. Ulnocarpal complex

Correct Answer & Explanation

. Radiolunate ligament

Explanation

During a PRC, the proximal carpal row (scaphoid, lunate, triquetrum) is excised, and the capitate articulates with the lunate fossa. The radioscaphocapitate (RSC) ligament acts as a primary volar sling and stabilizer; its preservation is critical to prevent ulnar translation of the carpus off the distal radius.

Question 4371

Topic: 7. Hand and Wrist

Following scaphoid excision and four-corner arthrodesis for advanced SNAC wrist, the patient complains of persistent pain 9 months postoperatively. Radiographs indicate a pseudarthrosis. Which of the following articulations is the most common site for nonunion in a four-corner fusion?

. Lunotriquetral
. Triquetrohamate
. Capitolunate
. Capitohamate
. Radioscaphoid

Correct Answer & Explanation

. Lunotriquetral

Explanation

Nonunion is a well-recognized complication of four-corner arthrodesis (fusion of the lunate, capitate, hamate, and triquetrum). The capitolunate joint is the most common site of pseudarthrosis, likely due to its central location, high relative motion prior to fusion, and the significant shear forces transmitted across it during wrist loading.

Question 4372

Topic: Wrist & Carpus

A 25-year-old male sustains a proximal pole scaphoid fracture. After 6 months of conservative management, he has an established nonunion. MRI with gadolinium demonstrates no enhancement of the proximal pole fragment. What is the most appropriate surgical intervention to optimize the chance of union?

. Percutaneous retrograde headless compression screw
. Volar approach with non-vascularized iliac crest bone graft
. Proximal row carpectomy
. Vascularized bone graft (e.g., free MFC or pedicled)
. Scaphoid excision and 4-corner fusion

Correct Answer & Explanation

. Percutaneous retrograde headless compression screw

Explanation

Lack of gadolinium enhancement on MRI indicates avascular necrosis (AVN) of the proximal pole. In a young patient without advanced arthrosis (SNAC), attempting joint preservation is paramount. A vascularized bone graft (pedicled from the radius or a free medial femoral condyle graft) provides the highest union rates for scaphoid nonunions complicated by severe ischemia or AVN.

Question 4373

Topic: 7. Hand and Wrist
A 65-year-old low-demand patient with Stage III SNAC wrist presents with significant pain but wishes to avoid procedures that alter carpal mechanics or require prolonged immobilization. A total wrist denervation is planned. Which two nerves provide the most significant sensory contribution to the wrist joint and are primary targets for this procedure?
. Posterior interosseous nerve (PIN) and anterior interosseous nerve (AIN)
. Deep branch of the ulnar nerve and recurrent motor branch of the median nerve
. Superficial radial nerve and medial antebrachial cutaneous nerve
. Palmar cutaneous branch of the median nerve and dorsal sensory branch of the ulnar nerve
. Median nerve proper and ulnar nerve proper

Correct Answer & Explanation

. Posterior interosseous nerve (PIN) and anterior interosseous nerve (AIN)

Explanation

Total or partial wrist denervation is a palliative procedure for chronic wrist pain. The anterior interosseous nerve (AIN) and the posterior interosseous nerve (PIN) carry the primary nociceptive sensory fibers from the deep wrist joint capsule. Resecting these terminal branches significantly reduces pain while preserving motor function and wrist motion.

Question 4374

Topic: 7. Hand and Wrist

A 50-year-old heavy manual laborer with Stage IV SNAC wrist (pancarpal arthritis) opts for total wrist arthrodesis to maximize grip strength and eliminate pain. To optimize postoperative hand function, what is the ideal position for total wrist arthrodesis?

. 0 degrees (neutral) extension and 10 degrees radial deviation
. 10-15 degrees extension and 5-10 degrees ulnar deviation
. 30 degrees extension and 15 degrees radial deviation
. 5 degrees flexion and neutral deviation
. 25 degrees extension and 20 degrees ulnar deviation

Correct Answer & Explanation

. 0 degrees (neutral) extension and 10 degrees radial deviation

Explanation

Total wrist arthrodesis provides a stable, painless wrist for heavy laborers. The optimal position for functional grip strength and activities of daily living is 10 to 15 degrees of extension and 5 to 10 degrees of ulnar deviation. This positioning optimally tensions the finger flexors, maximizing mechanical advantage for grip.

Question 4375

Topic: 7. Hand and Wrist

A 33-year-old athlete with a scaphoid waist nonunion demonstrates early degenerative changes strictly isolated to the articulation between the scaphoid and the radial styloid. There is no midcarpal arthritis. What is the most appropriate surgical management?

. Total wrist arthrodesis
. Proximal row carpectomy
. Scaphoid excision and 4-corner arthrodesis
. Scaphoid nonunion takedown, bone grafting, internal fixation, and radial styloidectomy
. Distal scaphoid pole excision

Correct Answer & Explanation

. Total wrist arthrodesis

Explanation

The patient has Stage I SNAC, defined by arthritis isolated to the radioscaphoid joint (specifically the radial styloid). The standard of care for Stage I SNAC in an active patient is to attempt salvage of the scaphoid via nonunion takedown, bone grafting, and rigid fixation, coupled with a radial styloidectomy to excise the focal area of arthrosis and relieve impingement/pain.

Question 4376

Topic: 7. Hand and Wrist

In the setting of an unstable scaphoid waist nonunion with secondary carpal collapse, lateral radiographs of the wrist are obtained. Which of the following angular measurements definitively confirms the presence of a Dorsal Intercalated Segment Instability (DISI) deformity?

. Scapholunate angle less than 30 degrees
. Scapholunate angle greater than 60 degrees
. Capitolunate angle less than 10 degrees
. Radiolunate angle of 0 degrees
. Volar tilt of the lunate greater than 15 degrees

Correct Answer & Explanation

. Scapholunate angle less than 30 degrees

Explanation

In a normal wrist, the scapholunate angle on a lateral radiograph is between 30 and 60 degrees. In a DISI deformity (which occurs in scaphoid nonunion due to uncoupling of the scaphoid and lunate), the lunate extends (dorsal tilt) while the distal scaphoid flexes. This divergence results in an abnormally increased scapholunate angle, typically greater than 60 degrees.

Question 4377

Topic: 7. Hand and Wrist

A surgeon performs a vascularized bone graft using a pedicle derived from the volar carpal artery to treat a scaphoid waist nonunion. Where is the osteocutaneous or bone flap typically harvested from when utilizing this specific vascular pedicle?

. The dorsal ulnar distal radius
. The volar distal radius proximal to the radiocarpal joint
. The medial femoral condyle
. The olecranon process
. The iliac crest

Correct Answer & Explanation

. The dorsal ulnar distal radius

Explanation

The volar carpal artery vascularized bone graft (often referred to as the Kuhlmann graft) is harvested from the volar aspect of the distal radius. It is particularly useful for scaphoid waist nonunions requiring volar placement of the graft, such as when correcting a humpback deformity from a volar approach, providing both structural support and active blood supply.

Question 4378

Topic: Wrist & Carpus
A 35-year-old male presents with wrist pain 8 years after a scaphoid fracture. Radiographs show radioscaphoid and capitolunate arthritis, but the radiolunate and lunotriquetral joints are spared. The diagnosis is SNAC Stage III. What is the most appropriate motion-preserving procedure?
. Radial styloidectomy
. Proximal row carpectomy (PRC)
. Scaphoid excision and four-corner fusion
. Total wrist arthroplasty
. Scaphoid open reduction and internal fixation with iliac crest bone graft

Correct Answer & Explanation

. Scaphoid excision and four-corner fusion

Explanation

SNAC III involves radioscaphoid and capitolunate arthritis. Proximal row carpectomy is contraindicated due to capitolunate degeneration; therefore, scaphoid excision and four-corner fusion is the preferred motion-preserving treatment.

Question 4379

Topic: Wrist & Carpus

In the progression of Scaphoid Nonunion Advanced Collapse (SNAC), which of the following joints is typically the last to be involved or remains definitively spared compared to SLAC arthritis?

. Radioscaphoid joint
. Capitolunate joint
. Radiolunate joint
. Scaphotrapezial joint
. Scaphocapitate joint

Correct Answer & Explanation

. Radioscaphoid joint

Explanation

In both SLAC and SNAC wrists, the radiolunate joint is characteristically spared due to the congruent spherical articulation and absence of abnormal shear forces. Arthritis progresses through the radioscaphoid and midcarpal joints before ever affecting the radiolunate joint in end-stage disease.

Question 4380

Topic: 7. Hand and Wrist

A 29-year-old athlete with a scaphoid waist nonunion has localized arthritis restricted to the radial styloid and the distal scaphoid. There is no humpback deformity. What is the most appropriate surgical management?

. Scaphoid excision and four-corner fusion
. Proximal row carpectomy
. Radial styloidectomy and scaphoid fixation with bone graft
. Total wrist arthrodesis
. Scaphoid proximal pole excision

Correct Answer & Explanation

. Scaphoid excision and four-corner fusion

Explanation

This represents a SNAC Stage I wrist. The optimal treatment is a radial styloidectomy to address the localized arthritis combined with scaphoid ORIF and bone grafting to heal the nonunion.

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