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7. Hand and Wrist MCQs

Practice Set 225 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 4481

Topic: Hand Trauma & Infection

A 35-year-old carpenter presents with a painful, swollen index finger following a minor puncture wound. Which of the following is NOT one of Kanavel's four cardinal signs of acute pyogenic flexor tenosynovitis?

. Fusiform swelling of the entire digit
. Tenderness specifically along the flexor tendon sheath
. Digit held in a rigidly extended posture
. Pain elicited by passive extension of the digit
. Flexed resting posture of the digit

Correct Answer & Explanation

. Fusiform swelling of the entire digit

Explanation

Kanavel's four cardinal signs include fusiform swelling, flexed resting posture (NOT rigidly extended), tenderness along the flexor sheath, and pain on passive extension. A resting extended posture contradicts these criteria.

Question 4482

Topic: Nerve & Tendon
During an open carpal tunnel release, the surgeon must carefully identify and protect the recurrent motor branch of the median nerve. This specific nerve branch innervates all of the following muscles EXCEPT the:
. Opponens pollicis
. Abductor pollicis brevis
. Superficial head of the flexor pollicis brevis
. Adductor pollicis
. None of the above

Correct Answer & Explanation

. Adductor pollicis

Explanation

The recurrent motor branch of the median nerve innervates the thenar musculature (opponens pollicis, abductor pollicis brevis, and superficial head of the flexor pollicis brevis). The adductor pollicis is innervated by the deep branch of the ulnar nerve.

Question 4483

Topic: Wrist & Carpus

A 40-year-old manual laborer presents with wrist pain and a known scaphoid nonunion. Radiographs reveal Scaphoid Nonunion Advanced Collapse (SNAC) Stage II. Which of the following best describes the pattern of arthritic involvement in this stage?

. Arthritis limited to the radial styloid
. Arthritis of the entire radioscaphoid joint
. Arthritis involving both the radioscaphoid and capitolunate joints
. Isolated radiolunate arthritis
. Pancarpal arthritis including the radioulnar joint

Correct Answer & Explanation

. Arthritis limited to the radial styloid

Explanation

SNAC Stage II is characterized by osteoarthritis involving the entire radioscaphoid joint. The radiolunate joint is typically spared in all SNAC stages due to its congruent spherical articulation, distinguishing it from the elliptical radioscaphoid joint.

Question 4484

Topic: Wrist & Carpus

A 55-year-old female undergoes volar locked plating for a distal radius fracture. At her 6-month follow-up, she presents with an inability to actively flex the interphalangeal joint of her thumb. This complication is most highly associated with plate placement distal to which anatomic landmark?

. Lister's tubercle
. The watershed line
. The sigmoid notch
. The volar radioulnar ligament
. The pronator quadratus insertion

Correct Answer & Explanation

. Lister's tubercle

Explanation

Placement of a volar plate distal to the watershed line of the distal radius places the hardware in direct contact with the flexor tendons. This prominent hardware causes irritation and can lead to rupture of the flexor pollicis longus (FPL) tendon.

Question 4485

Topic: 7. Hand and Wrist
A 24-year-old professional rugby player sustains an injury to his right ring finger when he grabs an opponent's jersey. He presents with an inability to actively flex the distal interphalangeal (DIP) joint. Radiographs show a large bony avulsion fragment from the volar base of the distal phalanx resting at the level of the proximal interphalangeal (PIP) joint. According to the Leddy and Packer classification, what type of flexor digitorum profundus (FDP) avulsion injury is this?
. Type I
. Type II
. Type III
. Type IV
. Type V

Correct Answer & Explanation

. Type III

Explanation

The Leddy and Packer classification categorizes FDP tendon avulsions ('Jersey finger') based on the level of tendon retraction and the presence of a bony fragment. Type I involves retraction of the tendon into the palm; blood supply is severely compromised, requiring repair within 7-10 days. Type II involves retraction to the level of the PIP joint, held by the intact vinculum longum. Type III involves a large bony avulsion fragment that catches at the A4 pulley (level of the middle phalanx/PIP joint), preventing further proximal retraction. Type IV (added by Smith) is a bony avulsion from the distal phalanx with the tendon avulsed off the bony fragment itself.

Question 4486

Topic: 7. Hand and Wrist
A 35-year-old construction worker presents with chronic radial-sided wrist pain. Radiographs demonstrate scaphoid nonunion advanced collapse (SNAC). There is significant arthritis at the radioscaphoid joint and the scaphocapitate joint, but the capitolunate joint and the radiolunate facet are radiographically spared. What stage of SNAC wrist does this represent, and what is a standard surgical option?
. Stage I; Radial styloidectomy alone
. Stage II; Proximal row carpectomy (PRC)
. Stage II; Total wrist arthrodesis
. Stage III; Scaphoid excision and four-corner fusion
. Stage III; Scaphoid open reduction and internal fixation with bone grafting

Correct Answer & Explanation

. Stage II; Proximal row carpectomy (PRC)

Explanation

SNAC wrist stages map the progression of arthritis following scaphoid nonunion. Stage I involves arthritis isolated to the radial styloid and the distal scaphoid. Stage II involves the entire radioscaphoid fossa and the scaphocapitate joint. Stage III involves periscaphoid arthritis extending to the capitolunate joint. The radiolunate joint is characteristically spared in all stages because the lunate maintains a concentric spherical relationship with the lunate fossa. For a Stage II SNAC wrist (radioscaphoid and scaphocapitate arthritis), a Proximal Row Carpectomy (PRC) is a viable option as long as the capitolunate joint is preserved. Scaphoid excision with four-corner fusion is also an option for Stage II and is the treatment of choice for Stage III (where PRC is contraindicated due to capitate head arthritis).

Question 4487

Topic: 7. Hand and Wrist
A 42-year-old heavy laborer presents with progressive wrist pain. Radiographs reveal a scaphoid nonunion advanced collapse (SNAC) pattern with severe arthritic changes at the radioscaphoid and capitolunate joints, but the radiolunate joint is perfectly preserved (SNAC Stage III). He desires pain relief but needs to return to heavy manual labor. Which of the following is the most appropriate surgical option?
. Proximal row carpectomy (PRC)
. Four-corner arthrodesis with scaphoid excision
. Total wrist arthrodesis
. Vascularized bone grafting of the scaphoid
. Radial styloidectomy

Correct Answer & Explanation

. Four-corner arthrodesis with scaphoid excision

Explanation

SNAC Stage III involves arthritis of both the radioscaphoid and capitolunate joints. Proximal row carpectomy (PRC) relies on an intact, cartilage-covered capitate head to articulate with the lunate fossa; therefore, capitate arthritis is an absolute contraindication to PRC. Four-corner arthrodesis with scaphoid excision removes the arthritic joints while preserving the pristine radiolunate articulation, providing durable pain relief and strength for a heavy laborer.

Question 4488

Topic: Nerve & Tendon
A 28-year-old carpenter suffers a deep laceration to the volar aspect of his index finger. Surgical exploration reveals complete transection of both the flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) tendons within the fibro-osseous sheath, between the proximal edge of the A1 pulley and the FDS insertion. This injury is located in which flexor tendon zone?
. Zone I
. Zone II
. Zone III
. Zone IV
. Zone V

Correct Answer & Explanation

. Zone II

Explanation

Flexor tendon Zone II, historically called 'no man's land' due to the poor surgical outcomes of the past, extends from the proximal edge of the A1 pulley to the insertion of the FDS tendon on the middle phalanx. Both the FDS and FDP travel tightly together within the fibro-osseous sheath in this zone.

Question 4489

Topic: 7. Hand and Wrist

In the progression of Scaphoid Nonunion Advanced Collapse (SNAC), which of the following carpal articulations is characteristically spared from osteoarthritic changes until the terminal stages of the disease process?

. Radioscaphoid joint
. Capitolunate joint
. Scaphocapitate joint
. Radiolunate joint
. Trapeziometacarpal joint

Correct Answer & Explanation

. Radioscaphoid joint

Explanation

In both SLAC (Scapholunate Advanced Collapse) and SNAC wrists, the radiolunate joint is uniquely spared from early osteoarthritic changes. This is due to the concentric, spherical articulation of the lunate within the lunate fossa of the distal radius, which continues to distribute compressive loads evenly despite the loss of carpal stability. SNAC progression typically begins at the radial styloid-scaphoid articulation, moves to the entire radioscaphoid joint, and then involves the capitolunate joint.

Question 4490

Topic: 7. Hand and Wrist

In the digital flexor tendon pulley system of the hand, which two annular pulleys are biomechanically the most critical to preserve during surgery in order to prevent bowstringing of the flexor tendons?

. A1 and A3
. A2 and A4
. A3 and A5
. A1 and A5
. C1 and C2

Correct Answer & Explanation

. A1 and A3

Explanation

The A2 and A4 pulleys are the major annular pulleys of the digits. The A2 pulley originates from the periosteum of the proximal phalanx, and the A4 pulley originates from the middle phalanx. Biomechanically, they are the most critical structures in maintaining the mechanical advantage of the flexor tendons; isolated loss of either, or certainly both, leads to severe bowstringing and loss of active flexion arc.

Question 4491

Topic: Nerve & Tendon

During the surgical decompression of the ulnar nerve for cubital tunnel syndrome, multiple potential sites of anatomic compression must be addressed. Which of the following represents the most proximal potential site of ulnar nerve entrapment in the arm?

. Osborne's ligament
. Arcade of Struthers
. Medial intermuscular septum
. Aponeurosis of the flexor carpi ulnaris (FCU)
. Ligament of Struthers

Correct Answer & Explanation

. Osborne's ligament

Explanation

The Arcade of Struthers is a thin fascial band extending from the medial head of the triceps to the medial intermuscular septum, located approximately 8 cm proximal to the medial epicondyle. It represents the most proximal potential site of ulnar nerve compression. Note: The Ligament of Struthers is a distinct structure associated with the supracondylar process that can compress the median nerve, not the ulnar nerve.

Question 4492

Topic: 7. Hand and Wrist

A patient presents with an inability to form an 'OK' sign, instead demonstrating a flat, pulp-to-pulp pinch. Sensation in the hand is completely normal. Which of the following muscles is innervated by the affected nerve?

. Flexor digitorum superficialis
. Pronator teres
. Flexor carpi radialis
. Pronator quadratus
. Abductor pollicis brevis

Correct Answer & Explanation

. Flexor digitorum superficialis

Explanation

The clinical sign described (inability to flex the IP joint of the thumb and DIP joint of the index finger) is classic for Anterior Interosseous Nerve (AIN) syndrome. The AIN is a pure motor branch of the median nerve and innervates the flexor pollicis longus (FPL), the radial half of the flexor digitorum profundus (FDP to index and middle fingers), and the pronator quadratus.

Question 4493

Topic: 7. Hand and Wrist

During surgical approach to the flexor tendon sheath in the hand, care is taken to preserve specific annular pulleys to prevent bowstringing of the flexor tendons. Which combination of pulleys is biomechanically considered the most critical to preserve?

. A1 and A3
. A2 and A4
. A1, A3, and A5
. A2 and A5
. A3 and A4

Correct Answer & Explanation

. A1 and A3

Explanation

The flexor tendon sheath contains five annular (A) and three cruciate (C) pulleys. The A2 pulley (over the proximal phalanx) and A4 pulley (over the middle phalanx) are thick, robust, and biomechanically critical for preventing bowstringing of the flexor tendons. Their preservation or reconstruction is essential for maintaining efficient finger flexion mechanics.

Question 4494

Topic: 7. Hand and Wrist

A patient develops an inability to actively flex the interphalangeal joint of the thumb 6 months after a volar locked plating procedure for a distal radius fracture. This complication is most commonly associated with which surgical error?

. Overpenetration of the dorsal cortex by distal locking screws
. Placement of the plate distal to the watershed line
. Retraction injury to the median nerve during the approach
. Unrecognized injury to the recurrent motor branch of the median nerve
. Failure to adequately repair the pronator quadratus

Correct Answer & Explanation

. Overpenetration of the dorsal cortex by distal locking screws

Explanation

Rupture of the flexor pollicis longus (FPL) tendon is a recognized and dreaded complication of volar plating of distal radius fractures. It most commonly occurs due to attrition of the tendon rubbing against the prominent distal edge of a plate placed distal to the 'watershed line' (the bony prominence on the volar aspect of the distal radius). Overpenetration of dorsal screws risks extensor tendon rupture (often EPL).

Question 4495

Topic: Wrist & Carpus

A 45-year-old female presents with the inability to actively extend her thumb interphalangeal joint 3 months after undergoing open reduction and internal fixation of a distal radius fracture with a volar locking plate. Radiographs reveal a healed fracture with a prominent screw protruding through the dorsal cortex. What is the most likely diagnosis?

. Flexor pollicis longus rupture
. Extensor pollicis longus rupture
. Extensor indicis proprius rupture
. Flexor digitorum profundus rupture
. Extensor digitorum communis rupture

Correct Answer & Explanation

. Flexor pollicis longus rupture

Explanation

Extensor pollicis longus (EPL) rupture is a known complication of distal radius fractures treated with volar plating. It typically occurs due to mechanical attrition and friction over prominent dorsal screws that protrude past the dorsal cortex.

Question 4496

Topic: 7. Hand and Wrist

A 60-year-old male presents with worsening clumsiness in his hands, frequent falls, and a wide-based gait. During physical examination, flicking the volar surface of the distal phalanx of the middle finger results in rapid reflex flexion of the thumb and index finger. What is this clinical sign called?

. Tinel sign
. Hoffmann sign
. Phalen sign
. Lhermitte sign
. Wartenberg sign

Correct Answer & Explanation

. Tinel sign

Explanation

The Hoffmann sign is a classic upper motor neuron reflex elicited by flicking the nail of the middle finger, causing flexion of the thumb and index finger. It is a key clinical finding indicating spinal cord compression in cervical spondylotic myelopathy.

Question 4497

Topic: 7. Hand and Wrist

A 40-year-old manual laborer presents with chronic wrist pain. Radiographs demonstrate a chronic, ununited scaphoid waist fracture with secondary degenerative changes. According to the Scaphoid Nonunion Advanced Collapse (SNAC) progression pattern, which joint is typically the first to demonstrate arthritic changes?

. Radioscaphoid joint
. Lunocapitate joint
. Radiolunate joint
. Scaphotrapezial joint
. Distal radioulnar joint

Correct Answer & Explanation

. Radioscaphoid joint

Explanation

In the SNAC wrist progression, degenerative arthritic changes occur in a highly predictable sequence. Arthritis first develops at the articulation between the distal scaphoid fragment and the radial styloid (radioscaphoid joint).

Question 4498

Topic: Hand Trauma & Infection

A 32-year-old carpenter presents with a swollen, painful index finger 3 days after a puncture wound. Suspecting pyogenic flexor tenosynovitis, the examining physician assesses for Kanavel's cardinal signs. Which of the following is one of these classic signs?

. Extension of the digit is painless
. The finger is held in a rigidly extended resting posture
. Fusiform swelling of the entire digit
. Tenderness strictly localized to the distal interphalangeal joint
. Erythema tracking proximally into the forearm

Correct Answer & Explanation

. Extension of the digit is painless

Explanation

Kanavel's four cardinal signs of flexor tenosynovitis include fusiform (sausage-like) swelling of the digit, a flexed resting posture, severe pain with passive extension, and tenderness along the entire flexor tendon sheath.

Question 4499

Topic: 7. Hand and Wrist

A 40-year-old male presents with the inability to actively flex the interphalangeal joint of his right thumb and distal interphalangeal joint of his index finger. Passive wrist extension results in spontaneous, symmetric flexion of the thumb and all digits. What is the most likely diagnosis?

. Ulnar nerve palsy
. Anterior interosseous nerve (AIN) syndrome
. Posterior interosseous nerve (PIN) syndrome
. Flexor pollicis longus (FPL) tendon rupture
. Radial nerve palsy

Correct Answer & Explanation

. Ulnar nerve palsy

Explanation

The presence of spontaneous flexion of the thumb and index finger during passive wrist extension confirms an intact tenodesis effect, ruling out a tendon rupture. The specific weakness of the flexor pollicis longus and flexor digitorum profundus to the index finger indicates Anterior Interosseous Nerve (AIN) syndrome.

Question 4500

Topic: Nerve & Tendon

Which structure forms the roof of the cubital tunnel and is implicated as the primary site of ulnar nerve compression in most cases of cubital tunnel syndrome?

. Arcade of Struthers
. Osborne's ligament
. Medial intermuscular septum
. Aponeurosis of the flexor carpi radialis
. Lacertus fibrosus

Correct Answer & Explanation

. Arcade of Struthers

Explanation

Osborne's ligament (the cubital tunnel retinaculum) bridges the two heads of the flexor carpi ulnaris. It forms the roof of the cubital tunnel and is the most common site of ulnar nerve compression at the elbow.

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