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7. Hand and Wrist MCQs

Practice Set 224 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 4461

Topic: Nerve & Tendon

A 35-year-old male presents with a rigidly stiff elbow 5 months after suffering a traumatic brain injury and prolonged ICU stay.

Radiographs confirm extensive bridging heterotopic ossification (HO) anteriorly. He is neurologically intact. Regarding the surgical excision of this HO, which of the following statements reflects the most currently accepted treatment principle?

. Surgery must be delayed until at least 12-18 months post-injury to prevent recurrence.
. Early excision (at 4-6 months) can be performed safely once the ossification appears radiographically mature with clear trabeculations.
. A preoperative bone scan and normalization of alkaline phosphatase are strict prerequisites for excision.
. Post-operative immobilization in a cast for 6 weeks is mandatory to prevent hematoma and recurrence.
. The ulnar nerve is typically protected by the anterior HO mass and rarely requires neurolysis.

Correct Answer & Explanation

. Surgery must be delayed until at least 12-18 months post-injury to prevent recurrence.

Explanation

Current evidence suggests that waiting 12-18 months or for normal alkaline phosphatase levels is unnecessary and prolongs disability. Early excision (around 4-6 months) is safe and effective as long as the HO demonstrates radiographic maturity (sharp margins and trabecular pattern). Early mobilization, not prolonged immobilization, is crucial postoperatively. Ulnar neurolysis is frequently required due to the global capsular release often needed.

Question 4462

Topic: Nerve & Tendon

A 42-year-old bodybuilder undergoes a single-incision anterior repair for a distal biceps tendon rupture. Postoperatively, he complains of numbness along the radial aspect of his forearm. Which nerve was most likely injured during the surgical approach?

. Superficial radial nerve
. Lateral antebrachial cutaneous nerve
. Posterior interosseous nerve
. Median nerve
. Ulnar nerve

Correct Answer & Explanation

. Superficial radial nerve

Explanation

The lateral antebrachial cutaneous nerve (LABCN) exits between the biceps and brachialis and is the most commonly injured nerve during a single-incision anterior distal biceps repair due to lateral retraction.

Question 4463

Topic: Nerve & Tendon

While evaluating a patient with a suspected nerve palsy, the examiner asks the patient to firmly grasp a piece of paper between the thumb and the index finger. As the examiner pulls the paper away, the patient's thumb interphalangeal (IP) joint hyperflexes. This compensatory maneuver is known as Froment's sign. Which muscle is compensating for the underlying deficit?

. Adductor pollicis
. Flexor pollicis longus
. Abductor pollicis brevis
. First dorsal interosseous
. Opponens pollicis

Correct Answer & Explanation

. Adductor pollicis

Explanation

Froment's sign evaluates ulnar nerve function. The adductor pollicis is paralyzed (ulnar nerve), so the patient compensates by firing the flexor pollicis longus (innervated by the anterior interosseous nerve branch of the median nerve) to hold the paper, causing marked thumb IP joint flexion.

Question 4464

Topic: Nerve & Tendon

A 40-year-old new mother presents with radial-sided wrist pain. During physical examination, the physician grasps the patient's thumb and sharply ulnar deviates the wrist, eliciting severe pain over the first dorsal compartment. Which specific eponym correctly identifies this provocative maneuver?

. Finkelstein's test
. Eichhoff's test
. Wartenberg's sign
. Phalen's maneuver
. Tinel's sign

Correct Answer & Explanation

. Finkelstein's test

Explanation

Grasping the thumb and ulnar deviating the wrist is the true Finkelstein's test. Eichhoff's test involves the patient clenching their thumb inside their fist, followed by the examiner passively ulnar deviating the wrist. Although Eichhoff's is often mistakenly called Finkelstein's in practice, the original description of Finkelstein's specifically mentions the examiner grasping the thumb.

Question 4465

Topic: Nerve & Tendon

A 50-year-old female presents with weakness in her hand. The examiner observes that the patient's small finger remains in an abducted posture and she is unable to actively adduct it. This finding (Wartenberg's sign) is caused by the unopposed action of which muscle, and what is its innervation?

. Abductor digiti minimi; Ulnar nerve
. Extensor digiti minimi; Radial nerve
. Third palmar interosseous; Ulnar nerve
. Extensor digitorum communis; Posterior interosseous nerve
. Lumbrical to the fifth digit; Median nerve

Correct Answer & Explanation

. Abductor digiti minimi; Ulnar nerve

Explanation

Wartenberg's sign is seen in ulnar neuropathy. The ulnar-innervated palmar interossei (responsible for adduction) are paralyzed. The small finger is pulled into abduction by the unopposed action of the extensor digiti minimi (EDM), which is innervated by the radial nerve via the posterior interosseous nerve (PIN).

Question 4466

Topic: 7. Hand and Wrist
A patient complains of numbness in the ring and small fingers and weakness of finger abduction. Tapping over the volar-ulnar aspect of the wrist produces tingling in the small finger. If the lesion is localized to Zone I of Guyon's canal, which neurological deficits would be expected?
. Isolated sensory deficit to the volar small and ulnar half of the ring finger
. Isolated motor deficit to the hypothenar muscles and interossei
. Combined motor and sensory deficits to the ulnar digits and intrinsic muscles
. Motor deficit to the adductor pollicis with intact hypothenar muscles
. Sensory deficit to the dorsal ulnar aspect of the hand only

Correct Answer & Explanation

. Combined motor and sensory deficits to the ulnar digits and intrinsic muscles

Explanation

Guyon's canal is divided into three zones. Zone I is proximal to the bifurcation of the ulnar nerve into superficial (sensory) and deep (motor) branches. A lesion here produces both motor (intrinsic weakness) and sensory (volar small/ring finger) deficits. Zone II lesions cause isolated motor deficits, and Zone III lesions cause isolated sensory deficits.

Question 4467

Topic: 7. Hand and Wrist

A 22-year-old male sustains a scaphoid fracture. The risk of avascular necrosis (AVN) is heavily dependent on the fracture location due to the unique vascular anatomy of the scaphoid. Which of the following accurately describes the primary vascular supply to the proximal pole of the scaphoid?

. Volar carpal branches entering the distal pole and traveling retrogradely
. Dorsal carpal branch of the radial artery entering the distal pole and traveling retrogradely
. Dorsal carpal branch of the radial artery entering the dorsal ridge and traveling proximally
. Direct branches from the ulnar artery entering the proximal pole directly
. Interosseous branches from the scapholunate ligament

Correct Answer & Explanation

. Volar carpal branches entering the distal pole and traveling retrogradely

Explanation

The primary blood supply to the scaphoid (providing 70-80% of its circulation, including the entire proximal pole) comes from the dorsal carpal branch of the radial artery. These vessels enter the scaphoid at the non-articular dorsal ridge near the waist and travel in a retrograde fashion to supply the proximal pole. Proximal pole fractures therefore have the highest risk of AVN.

Question 4468

Topic: 7. Hand and Wrist
A 30-year-old carpenter sustains a laceration to the volar aspect of his index finger at the level of the proximal interphalangeal (PIP) joint, resulting in an inability to flex the DIP joint while the PIP joint can still be flexed against resistance. In which flexor tendon zone did this injury occur?
. Zone I
. Zone II
. Zone III
. Zone IV
. Zone V

Correct Answer & Explanation

. Zone I

Explanation

The patient has an isolated laceration of the Flexor Digitorum Profundus (FDP) tendon. Because the Flexor Digitorum Superficialis (FDS) remains intact (PIP flexion against resistance is preserved), the injury must be located distal to the insertion of the FDS on the middle phalanx. This characterizes a Zone I flexor tendon injury.

Question 4469

Topic: Nerve & Tendon

A patient presents with persistent abduction posturing of the small finger. This finding (Wartenberg's sign) is caused by unopposed action of which muscle, and what is the underlying nerve injury?

. Extensor digiti minimi; Radial nerve palsy
. Abductor digiti minimi; Ulnar nerve palsy
. Extensor digiti minimi; Ulnar nerve palsy
. Abductor digiti minimi; Median nerve palsy
. Flexor digiti minimi; Ulnar nerve palsy

Correct Answer & Explanation

. Extensor digiti minimi; Radial nerve palsy

Explanation

Wartenberg's sign is the abducted posture of the small finger due to the unopposed action of the extensor digiti minimi, which is innervated by the radial nerve. It manifests when the ulnar nerve-innervated palmar interossei (specifically the 3rd palmar interosseous) are weak or paralyzed.

Question 4470

Topic: Nerve & Tendon

A patient with a documented ulnar nerve neuropathy exhibits a persistent abduction posture of the small finger at rest (Wartenberg's sign). Which intact muscle is responsible for this unopposed abduction?

. Extensor digiti minimi
. Abductor digiti minimi
. Third palmar interosseous
. Fourth dorsal interosseous
. Flexor digiti minimi

Correct Answer & Explanation

. Extensor digiti minimi

Explanation

Wartenberg's sign is an abduction deformity of the small finger due to ulnar nerve palsy. It results from weakness of the third palmar interosseous muscle and unopposed abduction by the radial nerve-innervated extensor digiti minimi.

Question 4471

Topic: 7. Hand and Wrist

A 55-year-old woman complains of pain at the base of her thumb that worsens with pinching activities. Axial loading, pushing, and rotating the first metacarpal on the trapezium elicits sharp pain and crepitus. Which test was performed, and what is the underlying diagnosis?

. Finkelstein test for De Quervain tenosynovitis
. Grind test for carpometacarpal (CMC) osteoarthritis
. Watson test for scapholunate dissociation
. Pivot shift test for thumb instability
. Froment's sign for ulnar neuropathy

Correct Answer & Explanation

. Finkelstein test for De Quervain tenosynovitis

Explanation

The Grind test evaluates the thumb carpometacarpal joint for osteoarthritis. Axial loading and rotation of the metacarpal base against the trapezium elicits pain and crepitus in a positive test.

Question 4472

Topic: 7. Hand and Wrist

A 34-year-old postpartum woman complains of radial-sided wrist pain. The examiner instructs the patient to clench her thumb inside her fist and ulnarly deviates the wrist, reproducing sharp pain. Which two tendons are being provoked in the first dorsal compartment?

. Extensor pollicis longus and extensor pollicis brevis
. Abductor pollicis longus and extensor pollicis brevis
. Abductor pollicis longus and extensor pollicis longus
. Extensor carpi radialis longus and brevis
. Extensor indicis proprius and abductor pollicis longus

Correct Answer & Explanation

. Extensor pollicis longus and extensor pollicis brevis

Explanation

The maneuver described is Eichhoff's test, which is commonly used to diagnose De Quervain's tenosynovitis. It places tension on the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) within the first dorsal extensor compartment.

Question 4473

Topic: Nerve & Tendon

A patient presents with persistent numbness in their ring and small fingers. Upon observation, the examiner notes that the patient's small finger rests in an abducted position. This finding (Wartenberg's sign) is due to unopposed action of which muscle?

. Extensor digiti minimi
. Abductor digiti minimi
. Third palmar interosseous
. Fourth dorsal interosseous
. Flexor digiti minimi

Correct Answer & Explanation

. Extensor digiti minimi

Explanation

Wartenberg's sign is the abducted resting posture of the small finger resulting from ulnar nerve palsy. The intact radially innervated extensor digiti minimi pulls the finger into abduction, overcoming the paralyzed ulnarly innervated third palmar interosseous muscle.

Question 4474

Topic: 7. Hand and Wrist

A basketball player jammed his finger. The PIP joint is flexed to 90 degrees over the edge of a table, and the patient is asked to extend the middle phalanx against resistance. The examiner feels weak PIP extension, and the DIP joint becomes rigidly extended. This indicates a rupture of which structure?

. Flexor digitorum profundus
. Terminal extensor tendon
. Central slip of the extensor mechanism
. Sagittal band
. Radial collateral ligament

Correct Answer & Explanation

. Flexor digitorum profundus

Explanation

Elson's test evaluates the integrity of the central slip. When the central slip is ruptured, attempting to extend the PIP joint transfers extensor force through the lateral bands, causing paradoxical rigid extension of the DIP joint.

Question 4475

Topic: Nerve & Tendon

A patient presents with generalized arm pain and weakness. The examiner asks the patient to resist bilateral internal rotation of the shoulders. The examiner then lightly strokes the skin over the patient's cubital tunnel and immediately asks the patient to resist internal rotation again. A sudden, momentary loss of resistance is noted. What does this signify?

. Psychogenic weakness
. Cervical myelopathy
. Ulnar nerve entrapment at the elbow
. Medial epicondylitis
. Thoracic outlet syndrome

Correct Answer & Explanation

. Psychogenic weakness

Explanation

The scratch collapse test is a highly sensitive provocative test for peripheral nerve entrapment. Stroking the skin over a site of nerve compression (such as the ulnar nerve at the cubital tunnel) triggers a brief inhibitory spinal reflex, causing transient loss of motor tone.

Question 4476

Topic: 7. Hand and Wrist

A 24-year-old male falls onto an outstretched hand and sustains a displaced fracture of the proximal pole of the scaphoid. He is at high risk for avascular necrosis (AVN). The scaphoid is predominantly supplied by retrograde blood flow from which of the following vessels?

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

Correct Answer & Explanation

. Superficial palmar arch

Explanation

The blood supply to the scaphoid predominantly comes from the dorsal carpal branch of the radial artery, which enters the scaphoid at the dorsal ridge near the waist and supplies the proximal pole via retrograde intraosseous flow. Because of this tenuous retrograde supply, proximal pole fractures have a high rate of AVN and nonunion.

Question 4477

Topic: 7. Hand and Wrist

A 28-year-old carpenter sustains a laceration over the volar aspect of his proximal phalanx (Zone II), completely severing the flexor digitorum profundus (FDP) tendon. To allow for a safe early active motion rehabilitation protocol, what is the optimal core suture configuration for the tendon repair?

. 1-strand repair
. 2-strand repair
. 4- to 6-strand repair
. 8-strand repair
. 10-strand repair

Correct Answer & Explanation

. 1-strand repair

Explanation

To withstand the forces of an early active motion rehabilitation protocol (which helps prevent tendon adhesions in Zone II), an FDP repair requires sufficient tensile strength. Biomechanical studies have shown that 4- to 6-strand core suture repairs provide the optimal balance of strength without adding excessive bulk that would impede gliding. A 2-strand repair is too weak for early active motion.

Question 4478

Topic: Hand Trauma & Infection

A 24-year-old manual laborer presents with acute swelling, severe pain, and a flexed posture of his dominant index finger after a puncture wound. Which of the following is NOT one of Kanavel's cardinal signs of flexor tendon sheath infection?

. Fusiform swelling of the digit
. Severe pain with passive extension of the digit
. Tenderness along the course of the flexor tendon sheath
. Pain with active flexion of the digit
. Flexed resting posture of the digit

Correct Answer & Explanation

. Fusiform swelling of the digit

Explanation

Kanavel's four cardinal signs of purulent flexor tenosynovitis are: fusiform swelling, flexed posture, pain with passive extension, and tenderness along the flexor sheath. Pain with active flexion is not considered one of the specific cardinal signs.

Question 4479

Topic: Wrist & Carpus

A 60-year-old woman undergoes volar plate fixation for a displaced distal radius fracture. Four months postoperatively, she suddenly loses the ability to actively flex her thumb interphalangeal joint. This complication is most directly related to plate placement distal to which anatomic landmark?

. Lister's tubercle
. The watershed line
. The sigmoid notch
. The radial styloid
. The ulnar styloid

Correct Answer & Explanation

. Lister's tubercle

Explanation

Placement of a volar plate distal to the watershed line of the distal radius causes hardware prominence. This can lead to attritional rupture of the flexor pollicis longus (FPL) tendon.

Question 4480

Topic: Nerve & Tendon

A 6-year-old child sustains a displaced extension-type supracondylar humerus fracture. Upon clinical examination, the child is unable to flex the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger (unable to make an 'OK' sign). Which nerve branch is most likely injured?

. Posterior interosseous nerve
. Anterior interosseous nerve
. Recurrent motor branch of the median nerve
. Deep branch of the ulnar nerve
. Superficial radial nerve

Correct Answer & Explanation

. Posterior interosseous nerve

Explanation

The anterior interosseous nerve (AIN), a branch of the median nerve, is the most commonly injured nerve in extension-type supracondylar humerus fractures. It innervates the flexor pollicis longus and the flexor digitorum profundus to the index finger.

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