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7. Hand and Wrist MCQs

Practice Set 229 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 4561

Topic: Nerve & Tendon

A patient with severe cubital tunnel syndrome undergoes surgical decompression. The surgeon traces the ulnar nerve proximally to distally. What is the most common site of ulnar nerve compression in this condition?

. Arcade of Struthers
. Medial intermuscular septum
. Osborne's ligament (FCU aponeurosis)
. Deep flexor pronator aponeurosis
. Guyon's canal

Correct Answer & Explanation

. Arcade of Struthers

Explanation

The most common site of ulnar nerve compression at the elbow is between the two heads of the flexor carpi ulnaris (FCU), which are connected by the cubital tunnel retinaculum, also known as Osborne's ligament.

Question 4562

Topic: 7. Hand and Wrist

A 30-year-old mechanic complains of chronic dorsal wrist pain. Radiographs demonstrate a scapholunate gap of 4 mm and a radiolunate angle of 20 degrees extended. What is the most likely secondary deformity?

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

Correct Answer & Explanation

. Volar intercalated segment instability (VISI)

Explanation

Scapholunate ligament disruption leads to dorsal intercalated segment instability (DISI). The lunate extends because the intact lunotriquetral ligament pulls it dorsally while the unsupported scaphoid flexes.

Question 4563

Topic: 7. Hand and Wrist

Following a single-incision anterior approach for a distal biceps tendon repair, a patient demonstrates an inability to extend the fingers and thumb, but wrist extension is preserved with radial deviation. Which nerve was most likely injured?

. Median nerve
. Ulnar nerve
. Posterior interosseous nerve (PIN)
. Anterior interosseous nerve (AIN)
. Superficial sensory radial nerve

Correct Answer & Explanation

. Median nerve

Explanation

The PIN is at risk during the single-incision anterior approach to the distal biceps due to overly aggressive lateral retraction. Injury causes loss of finger and thumb extension, while radial wrist extension is preserved via the ECRL.

Question 4564

Topic: Hand Trauma & Infection

A skier falls while holding a ski pole, sustaining a hyperabduction injury to the thumb. An MRI reveals an ulnar collateral ligament (UCL) tear with the torn end displaced superficial to the adductor pollicis aponeurosis. What is the most appropriate management?

. Thumb spica cast for 6 weeks
. Buddy taping for 3 weeks
. Corticosteroid injection into the first MCP joint
. Surgical repair of the UCL
. First carpometacarpal arthrodesis

Correct Answer & Explanation

. Thumb spica cast for 6 weeks

Explanation

This describes a Stener lesion, where the adductor aponeurosis interposes between the torn UCL and its anatomic insertion. This interposition prevents spontaneous healing, making surgical repair the definitive indication.

Question 4565

Topic: 7. Hand and Wrist

Which of the following anatomic boundaries defines Zone II in the classification of flexor tendon injuries of the hand?

. From the musculotendinous junction to the carpal tunnel
. From the distal palmar crease to the insertion of the FDS
. From the insertion of the FDS to the insertion of the FDP
. Within the boundaries of the carpal tunnel
. Distal to the FDP insertion

Correct Answer & Explanation

. From the musculotendinous junction to the carpal tunnel

Explanation

Zone II, historically known as "no man's land", extends from the A1 pulley (distal palmar crease) to the insertion of the flexor digitorum superficialis (FDS). Both FDS and FDP tendons lie tightly within the fibro-osseous sheath in this zone.

Question 4566

Topic: 7. Hand and Wrist
A 35-year-old manual laborer presents with dorsal wrist pain and decreased grip strength. Radiographs show sclerosis and collapse of the lunate, with negative ulnar variance. Which of the following is the most appropriate joint-leveling procedure?
. Ulnar shortening osteotomy
. Radial shortening osteotomy
. Proximal row carpectomy
. Total wrist arthrodesis
. Scaphoid excision and four-corner fusion

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

In early-stage Kienböck's disease (avascular necrosis of the lunate) associated with negative ulnar variance, a radial shortening osteotomy unloads the lunate. This shifts mechanical forces appropriately to the radioulnar and ulnocarpal joints.

Question 4567

Topic: 7. Hand and Wrist

A 25-year-old male falls on an outstretched hand. Lateral wrist radiographs show the capitate displaced dorsally, while the lunate remains articulated with the distal radius. What is the diagnosis?

. Lunate dislocation
. Perilunate dislocation
. Scapholunate dissociation
. Midcarpal dislocation
. Barton's fracture

Correct Answer & Explanation

. Lunate dislocation

Explanation

In a perilunate dislocation, the lunate remains within the lunate fossa of the radius, but the capitate is dislocated dorsally. In a true lunate dislocation, the lunate is displaced volarly (spilled teacup sign) while the capitate aligns with the radius.

Question 4568

Topic: 7. Hand and Wrist

When evaluating a lateral radiograph of a normal adult wrist, what is the average normal volar tilt of the distal radius articular surface?

. 0 degrees
. 11 degrees
. 22 degrees
. 5 degrees dorsal
. 15 degrees dorsal

Correct Answer & Explanation

. 0 degrees

Explanation

The normal anatomic volar tilt of the distal radius is approximately 11 to 12 degrees. Restoration of this volar tilt is an important radiographic parameter during the surgical fixation of distal radius fractures.

Question 4569

Topic: 7. Hand and Wrist

A patient presents with weakness in making an "OK" sign with their thumb and index finger, but has absolutely no sensory deficits in the hand. Which of the following muscles is most likely affected?

. Abductor pollicis brevis
. Flexor pollicis longus
. Adductor pollicis
. First dorsal interosseous
. Flexor digitorum superficialis

Correct Answer & Explanation

. Abductor pollicis brevis

Explanation

The anterior interosseous nerve (AIN) supplies the flexor pollicis longus, the flexor digitorum profundus to the index and long fingers, and the pronator quadratus. AIN neuropathy presents as a purely motor deficit, classically demonstrated by an inability to pinch.

Question 4570

Topic: Nerve & Tendon

During surgical decompression for cubital tunnel syndrome, which of the following structures represents a potential site of ulnar nerve compression located approximately 8 cm proximal to the medial epicondyle?

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

Correct Answer & Explanation

. Osborne's ligament

Explanation

The Arcade of Struthers is a fascial band located about 8 cm proximal to the medial epicondyle that can compress the ulnar nerve. The Ligament of Struthers, by contrast, compresses the median nerve.

Question 4571

Topic: Nerve & Tendon

A 21-year-old baseball pitcher presents with posteromedial elbow pain that occurs specifically during the deceleration phase of throwing. Physical examination reveals a 10-degree loss of terminal elbow extension and a positive valgus overpressure test. What is the most likely diagnosis?

. Ulnar collateral ligament (UCL) complete rupture
. Valgus extension overload syndrome
. Little leaguer's elbow
. Flexor-pronator mass strain
. Cubital tunnel syndrome

Correct Answer & Explanation

. Ulnar collateral ligament (UCL) complete rupture

Explanation

Valgus extension overload (VEO) syndrome occurs in overhead throwing athletes due to repetitive valgus stress and extreme extension during the deceleration and follow-through phases. This causes impingement of the posteromedial olecranon tip against the olecranon fossa, leading to osteophyte formation, loose bodies, posteromedial pain, and a mechanical loss of terminal extension.

Question 4572

Topic: Nerve & Tendon

During a medial ulnar collateral ligament (UCL) reconstruction on a 21-year-old baseball pitcher using the modified Jobe technique, a muscle-splitting approach through the flexor-pronator mass is planned. To prevent painful postoperative neuroma formation, the surgeon must carefully identify and protect the medial antebrachial cutaneous nerve (MACN). What is the typical anatomic course of the MACN in this operative field?

. It courses posterior to the medial epicondyle within the cubital tunnel alongside the ulnar nerve.
. It crosses the operative field from anterior to posterior, typically 2 to 3 cm distal to the medial epicondyle.
. It crosses the operative field running parallel to the ulnar nerve directly over the medial epicondyle.
. It courses deep to the flexor pronator mass and is only at risk during the subperiosteal elevation of the origin.
. It lies entirely within the brachialis muscle belly and is rarely encountered during UCL reconstruction.

Correct Answer & Explanation

. It courses posterior to the medial epicondyle within the cubital tunnel alongside the ulnar nerve.

Explanation

The medial antebrachial cutaneous nerve (MACN) runs anterior to the medial epicondyle and sends branches that cross the standard UCL incision from anterior to posterior. These branches are typically found in the subcutaneous tissue approximately 2 to 3 cm distal to the medial epicondyle. Careful superficial dissection is mandatory to avoid cutting these branches, which leads to highly symptomatic neuromas in throwing athletes.

Question 4573

Topic: Nerve & Tendon

A 45-year-old female undergoes an open carpal tunnel release. During the procedure, the incision is inadvertently placed too far ulnar to the axis of the ring finger. Which of the following structures is most at immediate risk?

. Recurrent motor branch of the median nerve
. Superficial palmar arch
. Palmar cutaneous branch of the median nerve
. Ulnar nerve and artery
. Flexor pollicis longus tendon

Correct Answer & Explanation

. Recurrent motor branch of the median nerve

Explanation

During an open carpal tunnel release, placing the incision too far ulnar (ulnar to the ring finger axis) places the contents of Guyon's canal (the ulnar nerve and artery) at risk. The incision is typically made in line with the radial border of the ring finger to safely avoid the palmar cutaneous branch of the median nerve radially and the ulnar neurovascular bundle ulnarly.

Question 4574

Topic: 7. Hand and Wrist
A flexor tendon laceration occurs in the region extending from the distal palmar crease to the middle of the middle phalanx. This injury falls into which anatomical flexor tendon zone?
. Zone I
. Zone II
. Zone III
. Zone IV
. Zone V

Correct Answer & Explanation

. Zone II

Explanation

Zone II, historically termed 'no man's land' due to poor surgical outcomes in the past, extends from the A1 pulley (distal palmar crease) to the insertion of the flexor digitorum superficialis (FDS) at the mid-middle phalanx. Both FDS and FDP tendons run tightly within the flexor sheath in this zone.

Question 4575

Topic: 7. Hand and Wrist

Which of the following physical examination maneuvers is considered the most sensitive for the clinical diagnosis of Carpal Tunnel Syndrome?

. Tinel's sign at the wrist
. Phalen's test
. Durkan's carpal compression test
. Semmes-Weinstein monofilament testing
. Weber two-point discrimination

Correct Answer & Explanation

. Tinel's sign at the wrist

Explanation

Durkan's carpal compression test, which involves applying direct pressure over the carpal tunnel for 30 seconds to elicit paresthesias, has been shown to be the most sensitive and specific physical examination provocative test for diagnosing Carpal Tunnel Syndrome, outperforming both Tinel's and Phalen's tests.

Question 4576

Topic: 7. Hand and Wrist
A 28-year-old carpenter sustains a laceration over the volar aspect of the proximal phalanx of his index finger, resulting in an inability to flex the distal and proximal interphalangeal joints. This injury is located in which of the following flexor tendon zones?
. 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', extends from the proximal edge of the A1 pulley to the insertion of the flexor digitorum superficialis (FDS) on the middle phalanx. Injuries here involve both the FDS and FDP tendons within the narrow fibro-osseous sheath, making surgical repair challenging.

Question 4577

Topic: 7. Hand and Wrist

A 25-year-old male presents with chronic wrist pain following an untreated injury 2 years ago. Radiographs reveal a scaphoid nonunion with advanced carpal collapse. Which of the following articulations is classically spared from arthritic changes in a Scaphoid Nonunion Advanced Collapse (SNAC) wrist?

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

Correct Answer & Explanation

. Radioscaphoid joint

Explanation

In both Scapholunate Advanced Collapse (SLAC) and Scaphoid Nonunion Advanced Collapse (SNAC) patterns of wrist arthritis, the radiolunate joint is characteristically spared. This is due to the concentric, spherical articulation of the lunate fossa and the lunate, which avoids abnormal shear forces even when carpal kinematics are altered.

Question 4578

Topic: 7. Hand and Wrist

A 24-year-old male falls on an outstretched hand and sustains a non-displaced fracture of the scaphoid waist. Which of the following best describes the blood supply to the proximal pole of the scaphoid?

. Volar carpal branch of the radial artery entering proximally
. Dorsal carpal branch of the radial artery entering distally and flowing retrogradely
. Anterior interosseous artery entering the waist
. Ulnar artery branches entering the distal pole
. Superficial palmar arch branches entering proximally

Correct Answer & Explanation

. Volar carpal branch of the radial artery entering proximally

Explanation

The scaphoid receives its primary blood supply from the dorsal carpal branch of the radial artery, which enters the distal pole and flows in a retrograde fashion. This retrograde blood supply puts proximal pole fractures at high risk for avascular necrosis.

Question 4579

Topic: Nerve & Tendon

A 29-year-old rugby player injures his ring finger. Examination reveals inability to actively flex the distal interphalangeal (DIP) joint. Radiographs are negative. MRI shows the flexor digitorum profundus (FDP) tendon is retracted into the palm. What is the optimal timeframe for surgical repair?

. Within 24 hours
. Within 7-10 days
. Within 3-4 weeks
. Within 6-8 weeks
. Delayed reconstruction with tendon graft at 3 months

Correct Answer & Explanation

. Within 24 hours

Explanation

This is a Zone 1 FDP avulsion (Jersey finger) retracted into the palm (Leddy-Packer Type 1). The vincula are torn, compromising blood supply, so repair must be performed within 7-10 days to prevent tendon necrosis and irreversible contracture.

Question 4580

Topic: Nerve & Tendon

During a volar (Henry) approach to the proximal radius, the supinator muscle must be reflected to safely expose the radial shaft while protecting the posterior interosseous nerve (PIN). The PIN enters the supinator through a fibrous arch. What is the name of this anatomical structure?

. Arcade of Struthers
. Arcade of Frohse
. Lacertus fibrosus
. Ligament of Struthers
. Osborne's fascia

Correct Answer & Explanation

. Arcade of Struthers

Explanation

The Arcade of Frohse is the proximal fibrous edge of the superficial head of the supinator muscle and is the most common site of PIN compression. The Arcade of Struthers is located in the arm (ulnar nerve compression), the Lacertus fibrosus (bicipital aponeurosis) covers the median nerve/brachial artery, the Ligament of Struthers connects a supracondylar process to the medial epicondyle (median nerve compression), and Osborne's fascia bridges the two heads of the FCU at the cubital tunnel.

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