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7. Hand and Wrist MCQs

Practice Set 228 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 4541

Topic: 7. Hand and Wrist
A 32-year-old male presents with dorsal wrist pain. Imaging confirms Kienbock's disease with lunate sclerosis, fragmentation, and carpal height collapse. The radioscaphoid angle is 65 degrees, but the articular surfaces of the scaphoid and capitate are preserved. He has negative ulnar variance. Which of the following is the most appropriate surgical treatment?
. Radial shortening osteotomy
. Scaphoid-trapezium-trapezoid (STT) fusion
. Proximal row carpectomy (PRC)
. Lunate excision and capitate shortening
. Total wrist arthrodesis

Correct Answer & Explanation

. Proximal row carpectomy (PRC)

Explanation

This patient has Lichtman Stage IIIB Kienbock's disease, defined by lunate fragmentation, carpal collapse, and fixed scaphoid rotation (radioscaphoid angle > 60 degrees), without secondary arthritis. Joint leveling procedures (radial shortening) are generally contraindicated once fixed carpal collapse has occurred. Proximal row carpectomy (PRC) or STT/SC fusion are appropriate salvage procedures. PRC provides reliable pain relief and motion for Stage IIIB when the proximal capitate is preserved.

Question 4542

Topic: 7. Hand and Wrist

During an open carpal tunnel release, the surgeon identifies a nerve branch originating from the median nerve immediately distal to the transverse carpal ligament, which recurrently hooks back over the ligament to innervate the thenar musculature. This anatomical variant is classified according to Poisel. Which variant is this?

. Extraligamentous
. Subligamentous
. Transligamentous
. Pre-ligamentous
. Ulnar approach variant

Correct Answer & Explanation

. Extraligamentous

Explanation

According to Poisel's classification of the recurrent motor branch of the median nerve: Extraligamentous (most common, ~50%) branches distal to the transverse carpal ligament (TCL) and turns back to the thenar muscles. Subligamentous (~30%) branches within the carpal tunnel and runs under the TCL before turning up. Transligamentous (~20%) branches within the tunnel and pierces directly through the TCL.

Question 4543

Topic: Wrist & Carpus

A 28-year-old gymnast presents with ulnar-sided wrist pain, clicking, and a feeling of instability. Physical examination demonstrates severe pain with ulnar deviation and axial loading (TFCC compression test). MRI arthrogram shows a tear of the triangular fibrocartilage complex (TFCC) at its ulnar attachment, specifically involving the fovea at the base of the ulnar styloid. According to the Palmer classification, what type of tear is this, and what is its healing potential?

. Palmer 1A, poor healing potential
. Palmer 1B, good healing potential
. Palmer 1C, poor healing potential
. Palmer 1D, excellent healing potential
. Palmer 2A, good healing potential

Correct Answer & Explanation

. Palmer 1A, poor healing potential

Explanation

Palmer 1B tears are traumatic avulsions of the TFCC from its ulnar insertion (fovea or base of ulnar styloid). Because the peripheral 10-20% of the TFCC is highly vascularized (supplied by ulnar artery branches), 1B tears have excellent healing potential and are amenable to surgical repair. Palmer 1A (central articular disc) tears are avascular and typically treated with debridement.

Question 4544

Topic: Nerve & Tendon

In surgical decompression of the ulnar nerve for cubital tunnel syndrome, which structure forms the roof of the cubital tunnel and represents a common site of primary compression?

. Struthers' ligament
. Osborne's ligament (fascia)
. The aponeurosis of the flexor carpi radialis
. The intermuscular septum
. The anconeus epitrochlearis

Correct Answer & Explanation

. Struthers' ligament

Explanation

The cubital tunnel is bordered anteriorly by the medial epicondyle, laterally by the olecranon, and its floor is the MCL. The roof is formed by Osborne's ligament (the arcuate ligament or fascia), which connects the two heads of the flexor carpi ulnaris (FCU). This is a primary site of compression for the ulnar nerve at the elbow.

Question 4545

Topic: 7. Hand and Wrist
A 45-year-old manual laborer presents with chronic wrist pain. Radiographs reveal a scaphoid nonunion advanced collapse (SNAC) wrist with degenerative changes isolated to the radioscaphoid joint. The capitolunate and radiolunate joints are well-preserved. According to the SNAC classification, what is the stage and most appropriate surgical treatment?
. Stage I; Radial styloidectomy and scaphoid open reduction internal fixation with bone grafting
. Stage II; Proximal row carpectomy or scaphoid excision and 4-corner fusion
. Stage III; Proximal row carpectomy
. Stage III; Total wrist arthrodesis
. Stage I; Total wrist arthroplasty

Correct Answer & Explanation

. Stage II; Proximal row carpectomy or scaphoid excision and 4-corner fusion

Explanation

SNAC Stage I involves arthritis isolated to the radial styloid-scaphoid articulation. Stage II involves the entire radioscaphoid fossa. Stage III involves periscaphoid and capitolunate arthritis. The radiolunate joint is typically spared. If changes involve the entire radioscaphoid joint but spare the midcarpal (capitolunate) joint, it is Stage II. Appropriate treatments include proximal row carpectomy (PRC) or scaphoid excision + 4-corner fusion. Stage I treatment is often radial styloidectomy + scaphoid bone grafting.

Question 4546

Topic: Nerve & Tendon

In evaluating a patient with a severe closed traction injury to the brachial plexus, which of the following electrodiagnostic or clinical findings is MOST indicative of a preganglionic nerve root avulsion rather than a postganglionic lesion?

. Absent sensory nerve action potentials (SNAPs)
. Preserved sensory nerve action potentials (SNAPs) in an anesthetic dermatome
. Denervation potentials in the deltoid and biceps muscles
. Presence of a Tinel's sign in the supraclavicular fossa
. Recovery of motor function following neurolysis

Correct Answer & Explanation

. Absent sensory nerve action potentials (SNAPs)

Explanation

In a preganglionic root avulsion, the dorsal root ganglion (DRG) remains intact and attached to the peripheral nerve. Therefore, the peripheral sensory axons do not undergo Wallerian degeneration, and SNAPs remain normal or preserved, even though the patient has no sensation in that dermatome (because the connection to the spinal cord is severed). In postganglionic injuries, the lesion is distal to the DRG, leading to Wallerian degeneration and absent SNAPs.

Question 4547

Topic: 7. Hand and Wrist

Which of the following anatomic variations of the recurrent motor branch of the median nerve is most common, according to the Lanz classification?

. Extraligamentous with recurrent course
. Subligamentous with recurrent course
. Transligamentous
. Ulnar origin of the motor branch
. Accessory motor branch at the distal carpal tunnel

Correct Answer & Explanation

. Extraligamentous with recurrent course

Explanation

According to the Lanz classification of the recurrent motor branch of the median nerve, the extraligamentous type (branching distal to the transverse carpal ligament and curving back to innervate the thenar muscles) is the most common, occurring in approximately 46-90% of individuals depending on the study. Transligamentous and subligamentous variations are less common but critical to recognize to avoid iatrogenic injury during carpal tunnel release.

Question 4548

Topic: Wrist & Carpus

A 28-year-old gymnast presents with ulnar-sided wrist pain. MRI arthrogram reveals a tear of the triangular fibrocartilage complex (TFCC) at its ulnar attachment to the fovea, with distal radioulnar joint (DRUJ) instability. According to the Palmer classification, what type of tear is this, and what is its healing potential?

. Palmer 1A; poor healing potential due to avascularity
. Palmer 1B; good healing potential due to rich vascular supply
. Palmer 1C; good healing potential due to rich vascular supply
. Palmer 1D; poor healing potential due to avascularity
. Palmer 2C; poor healing potential due to avascularity

Correct Answer & Explanation

. Palmer 1A; poor healing potential due to avascularity

Explanation

Palmer Class 1 refers to traumatic TFCC tears. Palmer 1B is a peripheral tear involving the ulnar attachment (fovea or base of ulnar styloid). Because the peripheral 10-25% of the TFCC is well-vascularized by branches of the ulnar artery, these tears have good healing potential and are typically treated with surgical repair. Palmer 1A (central articular disc tears) are avascular and generally require debridement rather than repair.

Question 4549

Topic: 7. Hand and Wrist
A 32-year-old male presents with dorsal wrist pain. Radiographs demonstrate sclerosis of the lunate with coronal fracture lines, but the carpal height is maintained. The distal radius has negative ulnar variance. Which of the following is the most appropriate surgical treatment?
. Radial shortening osteotomy
. Proximal row carpectomy
. Scaphocapitate fusion
. Total wrist arthrodesis
. Lunate excision and silastic replacement

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

The patient has Kienbock's disease (avascular necrosis of the lunate). The presence of coronal fracture lines with maintained carpal height corresponds to Lichtman Stage IIIa. In the presence of ulnar minus variance, a joint-leveling procedure such as a radial shortening osteotomy is the gold standard, as it unloads the lunate and can halt progression. Proximal row carpectomy or intercarpal fusions are reserved for Stage IIIb (carpal collapse) or Stage IV (radiocarpal arthritis).

Question 4550

Topic: 7. Hand and Wrist

A 35-year-old carpenter amputates his left index fingertip. The injury is a volar oblique amputation with exposed distal phalanx bone. Which of the following local flaps is most appropriate to provide durable coverage and preserve length for this specific injury pattern?

. V-Y advancement flap (Atasoy)
. Cross-finger flap
. Thenar flap
. Moberg advancement flap
. First dorsal metacarpal artery flap

Correct Answer & Explanation

. V-Y advancement flap (Atasoy)

Explanation

A volar oblique amputation of the fingertip results in more loss of the volar pad than the dorsal nail matrix. A cross-finger flap is ideal for volar oblique injuries because it provides glabrous, durable skin coverage from the dorsum of an adjacent finger. A V-Y advancement flap (Atasoy) is best for dorsal oblique or transverse amputations. A Moberg flap is strictly for the thumb.

Question 4551

Topic: Nerve & Tendon

When evaluating a patient for cubital tunnel syndrome, the examiner asks the patient to hold a piece of paper tightly between the thumb and index finger while the examiner pulls it away. The patient compensates by flexing the interphalangeal (IP) joint of the thumb. What is this sign called and what muscle weakness does it indicate?

. Wartenberg's sign; Abductor digiti minimi
. Froment's sign; Adductor pollicis
. Egawa's sign; Dorsal interossei
. Jeanne's sign; Flexor pollicis brevis
. Tinel's sign; First dorsal interosseous

Correct Answer & Explanation

. Wartenberg's sign; Abductor digiti minimi

Explanation

Froment's sign occurs when a patient pinches a piece of paper between the thumb and index finger. If the adductor pollicis (innervated by the ulnar nerve) is weak, the patient compensates by firing the flexor pollicis longus (innervated by the anterior interosseous nerve/median nerve), leading to hyperflexion of the thumb IP joint.

Question 4552

Topic: 7. Hand and Wrist
A 29-year-old chef sustains a laceration to the volar aspect of his right long finger at the level of the proximal phalanx, resulting in an inability to flex both the PIP and DIP joints. The injury is classified as being in which flexor tendon zone, and what is the primary reason this zone was historically called 'no man's land'?
. Zone I; High risk of vascular compromise
. Zone II; High risk of adhesions between FDS and FDP within the fibro-osseous sheath
. Zone III; Lumbrical muscle interference with healing
. Zone IV; Carpal tunnel scarring
. Zone V; High risk of concomitant nerve injury

Correct Answer & Explanation

. Zone II; High risk of adhesions between FDS and FDP within the fibro-osseous sheath

Explanation

The laceration is at the level of the proximal phalanx, corresponding to Zone II (from the A1 pulley to the FDS insertion). This area was historically termed 'no man's land' by Bunnell because both the flexor digitorum superficialis (FDS) and profundus (FDP) run closely together within the narrow fibro-osseous tendon sheath. Primary repair in this zone historically had poor outcomes due to dense adhesions between the tendons and the sheath.

Question 4553

Topic: Hand Trauma & Infection

Which of the following is NOT one of the four classic Kanavel signs indicating pyogenic flexor tenosynovitis?

. Fusiform swelling of the digit
. Severe pain with passive extension of the digit
. Erythema extending proximal to the metacarpophalangeal joint
. Flexed resting posture of the digit
. Tenderness along the course of the flexor tendon sheath

Correct Answer & Explanation

. Fusiform swelling of the digit

Explanation

Kanavel's four cardinal signs of pyogenic flexor tenosynovitis are: 1) Fusiform (sausage-like) swelling of the digit, 2) Flexed resting posture of the digit, 3) Tenderness to palpation along the course of the flexor tendon sheath, and 4) Severe pain elicited by passive extension of the digit (most sensitive sign). Erythema extending proximal to the MCP joint is not a classic Kanavel sign and may indicate a deeper space infection or diffuse cellulitis.

Question 4554

Topic: Wrist & Carpus

A 30-year-old male sustains a distal third radial shaft fracture. Radiographs reveal widening of the distal radioulnar joint (DRUJ) on the PA view and dorsal displacement of the ulna on the lateral view. Following open reduction and internal fixation of the radius with a compression plate, the DRUJ remains grossly unstable in all positions of forearm rotation and irreducible. What is the most appropriate next step in management?

. Application of a long arm cast in full supination for 6 weeks
. Closed reduction of the DRUJ and transfixion pinning of the radius to the ulna
. Open exploration of the DRUJ and repair of the TFCC
. Resection of the distal ulna (Darrach procedure)
. Distal radioulnar joint arthrodesis (Sauve-Kapandji procedure)

Correct Answer & Explanation

. Application of a long arm cast in full supination for 6 weeks

Explanation

The injury is a Galeazzi fracture-dislocation. After anatomic rigid fixation of the radial shaft, the DRUJ must be assessed. If the DRUJ is grossly unstable in all positions of forearm rotation or irreducible, it indicates severe disruption of the stabilizing structures with potential soft tissue interposition (e.g., ECU tendon or capsule). The most appropriate next step is open exploration of the DRUJ to remove interposed tissue and directly repair the TFCC.

Question 4555

Topic: 7. Hand and Wrist

A 30-year-old carpenter undergoes a 4-strand Zone 2 flexor tendon repair. Postoperatively, the therapist initiates an early active motion protocol rather than a passive motion protocol. What is the primary biomechanical benefit of this approach?

. Higher long-term tendon rupture rate
. Decreased work of flexion and tendon adhesions
. Increased repair strength via delayed healing phases
. Prevention of intrinsic hand muscle contracture
. Elimination of the need for an intact A2 pulley

Correct Answer & Explanation

. Higher long-term tendon rupture rate

Explanation

Early active motion protocols after multi-strand flexor tendon repairs significantly decrease adhesion formation and improve tendon excursion, thereby decreasing the work of flexion. A minimum of a 4-strand core repair is required to withstand the forces of active motion.

Question 4556

Topic: 7. Hand and Wrist
A 45-year-old male presents with chronic wrist pain. Radiographs reveal a scaphoid nonunion advanced collapse (SNAC) wrist with degenerative changes extending into the capitolunate joint (Stage III). Which of the following carpal articulations is characteristically spared in this disease progression?
. Radioscaphoid joint
. Capitolunate joint
. Radiolunate joint
. Scaphocapitate joint
. Lunotriquetral joint

Correct Answer & Explanation

. Radiolunate joint

Explanation

In both SLAC and SNAC wrist patterns, the radiolunate articulation is characteristically spared because the spherical lunate remains congruent with the lunate fossa, lacking the shear forces seen in the radioscaphoid joint. This allows for salvage procedures like a proximal row carpectomy or four-corner fusion.

Question 4557

Topic: Wrist & Carpus
A 32-year-old male manual laborer is diagnosed with Stage II Kienböck's disease. Radiographs reveal sclerosis of the lunate without collapse, and an ulnar minus variance of 3 mm. What is the most appropriate surgical intervention to halt disease progression?
. Proximal row carpectomy
. Total wrist fusion
. Radial shortening osteotomy
. Lunate excision and silastic implant
. Arthroscopic debridement

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

In early-stage Kienböck's disease (Stages I, II, or IIIa) in a patient with negative ulnar variance, a joint-leveling procedure such as a radial shortening osteotomy is indicated to offload the radiolunate joint and promote revascularization.

Question 4558

Topic: 7. Hand and Wrist
Dupuytren's contracture is characterized by the formation of nodules and cords in the palmar fascia. At the molecular and cellular level, this disease is primarily driven by the proliferation of which cell type and an abnormal shift in collagen production?
. Myofibroblasts; Shift from Type I to Type III collagen
. Chondrocytes; Shift from Type II to Type I collagen
. Fibroblasts; Shift from Type III to Type I collagen
. Osteoblasts; Shift from Type I to Type III collagen
. Macrophages; Shift from Type IV to Type II collagen

Correct Answer & Explanation

. Myofibroblasts; Shift from Type I to Type III collagen

Explanation

The pathophysiology of Dupuytren's contracture involves the proliferation of myofibroblasts and a pathological increase in Type III collagen relative to Type I collagen, leading to tissue contraction.

Question 4559

Topic: 7. Hand and Wrist
A 60-year-old female undergoes a ligament reconstruction and tendon interposition (LRTI) procedure for Eaton Stage III trapeziometacarpal osteoarthritis. Which tendon is most commonly harvested as the autograft for this reconstruction to suspend the first metacarpal?
. Flexor carpi radialis (FCR)
. Extensor carpi radialis longus (ECRL)
. Abductor pollicis longus (APL)
. Extensor pollicis brevis (EPB)
. Palmaris longus

Correct Answer & Explanation

. Flexor carpi radialis (FCR)

Explanation

The Flexor Carpi Radialis (FCR) tendon is the workhorse autograft used in the LRTI procedure. It is passed through a drill hole in the base of the first metacarpal to prevent proximal migration after trapeziectomy.

Question 4560

Topic: 7. Hand and Wrist
A 55-year-old male presents with a Stage II Scapholunate Advanced Collapse (SLAC) wrist, demonstrating arthritis at the radioscaphoid joint but sparing the midcarpal joint. Which of the following surgical options is considered INCORRECT as a definitive standalone treatment for his pathology?
. Proximal row carpectomy (PRC)
. Scaphoid excision and four-corner fusion
. Total wrist arthrodesis
. Radial styloidectomy alone
. Partial wrist denervation combined with PRC

Correct Answer & Explanation

. Radial styloidectomy alone

Explanation

Radial styloidectomy alone is insufficient for Stage II SLAC wrist, as it only addresses the impingement at the styloid and ignores the advanced arthritic changes in the scaphoid fossa. PRC or 4-corner fusion are the treatments of choice.

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