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7. Hand and Wrist MCQs

Practice Set 232 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 4621

Topic: 7. Hand and Wrist
A 55-year-old male presents with chronic wrist pain and a known history of a scapholunate ligament tear. Radiographs demonstrate advanced osteoarthritis specifically involving the radioscaphoid joint and the capitolunate joint, with complete sparing of the radiolunate joint. What stage of Scapholunate Advanced Collapse (SLAC) does this represent?
. Stage I
. Stage II
. Stage III
. Stage IV
. Stage V

Correct Answer & Explanation

. Stage III

Explanation

SLAC wrist arthritis progresses predictably: Stage I involves only the radial styloid-scaphoid articulation; Stage II involves the entire radioscaphoid joint; Stage III involves proximal migration of the capitate with capitolunate arthritis. The radiolunate joint is characteristically spared due to the conformal nature of the fossa and intact radiolunate ligaments.

Question 4622

Topic: Hand Trauma & Infection

In the context of a thumb ulnar collateral ligament (UCL) rupture (Skier's thumb), a Stener lesion is anatomically defined as the interposition of which structure between the torn ends of the UCL?

. Abductor pollicis brevis aponeurosis
. Adductor pollicis aponeurosis
. Extensor pollicis longus tendon
. Extensor pollicis brevis tendon
. Flexor pollicis longus tendon

Correct Answer & Explanation

. Adductor pollicis aponeurosis

Explanation

A Stener lesion occurs when the torn ulnar collateral ligament (UCL) of the thumb metacarpophalangeal joint flips proximally and comes to rest superficial to the adductor pollicis aponeurosis. This interposition prevents primary ligamentous healing and is a strong indication for surgical repair.

Question 4623

Topic: 7. Hand and Wrist
A patient sustains a laceration to the volar aspect of the hand, severing the flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS) of the middle finger. The injury is located between the A1 pulley and the insertion of the FDS on the middle phalanx. This injury corresponds to which flexor tendon zone?
. Zone I
. Zone II
. Zone III
. Zone IV
. Zone V

Correct Answer & Explanation

. Zone II

Explanation

Zone II (historically called 'no man's land') extends from the proximal aspect of the A1 pulley (at the distal palmar crease) to the insertion of the flexor digitorum superficialis (FDS) on the middle phalanx. Both FDS and FDP tendons lie within the tight fibro-osseous sheath in this zone.

Question 4624

Topic: 7. Hand and Wrist
A 32-year-old laborer presents with progressive dorsal wrist pain. Radiographs reveal sclerosis and fragmentation of the lunate with negative ulnar variance. According to the Lichtman classification, lunate collapse with fixed scaphoid rotation (signet ring sign) but no radiocarpal or midcarpal arthritis is classified as:
. Stage II
. Stage IIIA
. Stage IIIB
. Stage IV
. Stage V

Correct Answer & Explanation

. Stage IIIA

Explanation

Kienböck's disease Lichtman classification: Stage I has normal plain films but MRI changes; Stage II has lunate sclerosis without collapse; Stage IIIA has lunate collapse without fixed scaphoid rotation; Stage IIIB has lunate collapse with fixed scaphoid rotation; Stage IV has associated carpal arthritis.

Question 4625

Topic: Nerve & Tendon

A 6-year-old boy falls from monkey bars and sustains a widely displaced posterolateral extension-type supracondylar humerus fracture. Which nerve is most commonly injured in this specific fracture displacement pattern?

. Median nerve
. Anterior interosseous nerve (AIN)
. Radial nerve
. Ulnar nerve
. Musculocutaneous nerve

Correct Answer & Explanation

. Anterior interosseous nerve (AIN)

Explanation

In extension-type supracondylar humerus fractures, the direction of distal fragment displacement determines the structures at risk. Posterolateral displacement stretches the median nerve and specifically the anterior interosseous nerve (AIN) over the proximal metaphyseal spike. Posteromedial displacement places the radial nerve at risk.

Question 4626

Topic: 7. Hand and Wrist

A 45-year-old female presents with vague volar forearm pain and paresthesias in the thumb, index, and middle fingers. Symptoms worsen with resisted forearm pronation. Examination reveals diminished sensation over the thenar eminence but no weakness of the flexor pollicis longus. What is the most likely diagnosis?

. Anterior Interosseous Nerve (AIN) syndrome
. Pronator syndrome
. Carpal tunnel syndrome
. C6 cervical radiculopathy
. Cubital tunnel syndrome

Correct Answer & Explanation

. Pronator syndrome

Explanation

Pronator syndrome is a proximal compression neuropathy of the median nerve. Numbness over the thenar eminence helps distinguish it from carpal tunnel syndrome, as the palmar cutaneous branch of the median nerve branches proximal to the carpal tunnel. Exacerbation with resisted pronation is characteristic. AIN syndrome is a pure motor neuropathy.

Question 4627

Topic: Nerve & Tendon

During an in situ ulnar nerve decompression for cubital tunnel syndrome, a tight fascial band is encountered just distal to the medial epicondyle, bridging the humeral and ulnar heads of the flexor carpi ulnaris (FCU). What is the specific anatomical name of this structure?

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

Correct Answer & Explanation

. Osborne's ligament

Explanation

Osborne's ligament (or the cubital tunnel retinaculum) forms the roof of the cubital tunnel, bridging the humeral and ulnar heads of the flexor carpi ulnaris (FCU) just distal to the medial epicondyle. The Arcade of Struthers is a fascial band located approximately 8 cm proximal to the medial epicondyle.

Question 4628

Topic: 7. Hand and Wrist

In Dupuytren's contracture, the neurovascular bundle is often displaced centrally and superficially by the spiral cord. The spiral cord is formed by the pathological alteration of several normal fascial structures. Which of the following normally occurring structures is a component of the spiral cord complex?

. Cleland's ligament
. Natatory ligament
. Superficial transverse palmar ligament
. Grayson's ligament
. Central band

Correct Answer & Explanation

. Grayson's ligament

Explanation

The spiral cord in Dupuytren's disease displaces the neurovascular bundle medially/centrally and superficially, making it highly vulnerable during surgical fasciectomy. It is formed by the diseased amalgamation of four normal structures: the pretendinous band, the spiral band, the lateral digital sheet, and Grayson's ligament. Cleland's ligament is dorsal to the bundle and is typically spared.

Question 4629

Topic: 7. Hand and Wrist

A patient presents with a chronic Boutonniere deformity consisting of proximal interphalangeal (PIP) joint flexion and distal interphalangeal (DIP) joint hyperextension. This deformity primarily results from the rupture or attenuation of which extensor mechanism structure, followed by volar subluxation of another?

. Terminal slip rupture; volar subluxation of the central slip
. Central slip rupture; volar subluxation of the lateral bands
. Sagittal band rupture; volar subluxation of the extensor digitorum communis
. Transverse retinacular ligament rupture; volar subluxation of the lateral bands
. Triangular ligament rupture; volar subluxation of the terminal slip

Correct Answer & Explanation

. Central slip rupture; volar subluxation of the lateral bands

Explanation

A Boutonniere deformity initiates with the disruption or attenuation of the central slip of the extensor mechanism at its insertion on the middle phalanx. This allows the lateral bands to subluxate volarly past the axis of rotation of the PIP joint, causing them to act as PIP flexors while maintaining their strong continuous extensor pull on the distal phalanx.

Question 4630

Topic: Wrist & Carpus

A 60-year-old female undergoes volar locked plating for a distal radius fracture. Six months later, she presents with an inability to actively flex the interphalangeal joint of her thumb. Which radiographic finding is most predictive of this specific complication?

. Plate placement proximal to the watershed line
. Plate placement distal to the watershed line
. Dorsal screw penetration past the far cortex
. Intra-articular screw penetration into the radiocarpal joint
. Loss of radial inclination by more than 10 degrees

Correct Answer & Explanation

. Plate placement distal to the watershed line

Explanation

Flexor pollicis longus (FPL) tendon rupture is a known complication of volar plating of the distal radius. Plates placed distal to the watershed line (Soong grade 2) have the highest risk of attritional FPL rupture due to tendon impingement.

Question 4631

Topic: 7. Hand and Wrist

A 45-year-old manual laborer presents with chronic wrist pain and is diagnosed with Scapholunate Advanced Collapse (SLAC). According to the predictable pattern of SLAC wrist arthropathy, which carpal articulation is characteristically spared even in advanced stages?

. Radioscaphoid joint
. Capitolunate joint
. Radiolunate joint
. Scaphotrapezial joint
. Triquetrohamate joint

Correct Answer & Explanation

. Radiolunate joint

Explanation

In a SLAC wrist, the radiolunate joint is characteristically spared from degenerative changes. This occurs due to the congruent spherical anatomy of the lunate fossa and the stabilizing presence of the intact short radiolunate ligament.

Question 4632

Topic: Nerve & Tendon

A 30-year-old mechanic undergoes a Zone II flexor digitorum profundus (FDP) and superficialis (FDS) repair of the index finger. To optimize tendon gliding and minimize rupture risk, which of the following intraoperative pulley management strategies is most appropriate if the bulky repair catches during active flexion?

. Venting the A2 pulley up to 50% if needed
. Complete excision of the A4 pulley
. Resection of the A1 and A3 pulleys without touching A2 or A4
. Excision of all pulleys and immediate two-stage reconstruction
. Converting to a static immobilization protocol for 6 weeks

Correct Answer & Explanation

. Venting the A2 pulley up to 50% if needed

Explanation

Modern flexor tendon repair protocols demonstrate that venting up to 50% of the A2 pulley or completely venting the A4 pulley is safe if a bulky repair catches during excursion. This allows for smooth gliding and early active motion without causing clinically significant bowstringing.

Question 4633

Topic: 7. Hand and Wrist

A 42-year-old male undergoes a single-incision anterior approach for a distal biceps tendon repair using cortical button fixation. Postoperatively, he notes weakness in extending his thumb and fingers, though wrist extension is preserved with a radial deviation bias. Which nerve was most likely injured during the procedure?

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

Correct Answer & Explanation

. Posterior interosseous nerve

Explanation

The posterior interosseous nerve (PIN) is highly at risk during the single-incision anterior approach to the distal biceps, particularly from excessive lateral retraction or blind drilling of the posterior radial cortex. PIN injury results in weakened digit and thumb extension, while radial wrist extension (ECRL) remains preserved.

Question 4634

Topic: Wrist & Carpus

A 40-year-old manual laborer with a chronic scapholunate ligament tear develops Scapholunate Advanced Collapse (SLAC). Radiographs reveal arthritis limited to the radioscaphoid joint, while the radiolunate joint is spared. Which ligament is primarily responsible for preserving the radiolunate articulation in the typical SLAC wrist progression?

. Radioscaphocapitate ligament
. Long radiolunate ligament
. Short radiolunate ligament
. Dorsal intercarpal ligament
. Volar radioulnar ligament

Correct Answer & Explanation

. Short radiolunate ligament

Explanation

The short radiolunate ligament provides robust stabilization to the lunate, maintaining its relationship with the lunate fossa even as the scaphoid rotates into flexion. This anatomic feature spares the radiolunate joint from degenerative changes until late stages of SLAC.

Question 4635

Topic: 7. Hand and Wrist

A 32-year-old male sustains a Bado Type I Monteggia fracture-dislocation. Following closed reduction of the ulnar fracture and radial head, the patient exhibits an inability to extend his thumb and fingers at the metacarpophalangeal joints, but wrist extension is preserved with radial deviation. Which nerve is most likely injured?

. Median nerve
. Anterior interosseous nerve
. Ulnar nerve
. Posterior interosseous nerve
. Musculocutaneous nerve

Correct Answer & Explanation

. Posterior interosseous nerve

Explanation

The posterior interosseous nerve (PIN) is vulnerable to traction injury during anterior dislocation of the radial head. Preservation of wrist extension with radial deviation occurs because the extensor carpi radialis longus (ECRL) is innervated by the radial nerve proper proximal to the PIN branch.

Question 4636

Topic: 7. Hand and Wrist

A 28-year-old male sustains a high-energy wrist injury. Radiographs show a volar dislocation of the lunate, while the rest of the carpus remains aligned with the radius. The patient exhibits numbness in the thumb, index, and middle fingers. What is the appropriate initial management?

. Urgent closed reduction and percutaneous pinning
. Urgent closed reduction and carpal tunnel release if symptoms persist
. Routine splinting and scheduled MRI
. Immediate carpectomy of the lunate
. Observation and high-dose corticosteroids

Correct Answer & Explanation

. Urgent closed reduction and carpal tunnel release if symptoms persist

Explanation

This is a Stage IV perilunate (lunate) dislocation, which frequently causes acute carpal tunnel syndrome due to the volarly displaced lunate. Urgent closed reduction is required; if median nerve symptoms do not resolve immediately, an emergent carpal tunnel release and open reduction are indicated.

Question 4637

Topic: Wrist & Carpus

A 55-year-old female undergoes volar locking plate fixation for a displaced distal radius fracture. Six months postoperatively, she suddenly loses the ability to actively flex her thumb interphalangeal joint. This complication is most directly related to plate placement in relation to which anatomic landmark?

. Dorsal tubercle of Lister
. Volar watershed line
. Sigmoid notch
. Radial styloid
. Brachioradialis insertion

Correct Answer & Explanation

. Volar watershed line

Explanation

Placement of a volar plate distal to the watershed line of the distal radius places the flexor pollicis longus (FPL) tendon at high risk for attrition and rupture. The watershed line is a critical radiographic and surgical landmark used to prevent prominent hardware.

Question 4638

Topic: 7. Hand and Wrist

Following a Zone II flexor tendon repair of the index finger, a standard rehabilitation protocol emphasizes early active mobilization. Which biomechanical factor in the surgical repair provides the necessary strength to safely permit early active motion without rupture?

. Use of braided non-absorbable epitendinous sutures alone
. Increasing the number of core suture strands crossing the repair site
. Venting of the A2 pulley completely
. Sheath closure with 6-0 prolene
. Immobilization in 45 degrees of wrist extension

Correct Answer & Explanation

. Increasing the number of core suture strands crossing the repair site

Explanation

The ultimate tensile strength of a flexor tendon repair is directly proportional to the number of core suture strands crossing the repair site. A 4-strand or 6-strand core repair provides sufficient strength to withstand the forces of early active motion protocols.

Question 4639

Topic: Nerve & Tendon

During surgical decompression for cubital tunnel syndrome, the ulnar nerve is traced distally into the forearm. Compression at this level is most commonly caused by the aponeurotic band between the two heads of the flexor carpi ulnaris (FCU). What is the name of this structure?

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

Correct Answer & Explanation

. Osborne's ligament

Explanation

Osborne's ligament (or Osborne's fascia) forms the roof of the cubital tunnel, bridging the olecranon and the medial epicondyle, and continues distally between the two heads of the FCU. The Arcade of Struthers is a distinct structure located proximal to the medial epicondyle.

Question 4640

Topic: 7. Hand and Wrist

A 35-year-old male presents with chronic wrist pain. Radiographs reveal a scaphoid nonunion with radioscaphoid arthritis, but the capitolunate and radiolunate joints are completely spared. What is the most appropriate surgical treatment for this Stage II Scaphoid Nonunion Advanced Collapse (SNAC)?

. Total wrist arthrodesis
. Scaphoid excision and four-corner arthrodesis
. Proximal row carpectomy
. Radial styloidectomy alone
. Both scaphoid excision with four-corner fusion and proximal row carpectomy are acceptable

Correct Answer & Explanation

. Both scaphoid excision with four-corner fusion and proximal row carpectomy are acceptable

Explanation

Stage II SNAC wrist involves arthritis between the distal radius and the scaphoid, sparing the midcarpal and radiolunate joints. Both scaphoid excision with four-corner fusion and proximal row carpectomy (PRC) are well-established, motion-preserving salvage procedures for this stage.

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