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7. Hand and Wrist MCQs

Practice Set 239 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 4761

Topic: 7. Hand and Wrist
Historically, primary repair of flexor tendon lacerations in a specific anatomic zone of the hand was avoided due to high rates of adhesions and stiffness, earning it the moniker 'No Man's Land'. Which zone does this describe?
. Zone I
. Zone II
. Zone III
. Zone IV
. Zone V

Correct Answer & Explanation

. Zone II

Explanation

Bunnell famously termed Zone II 'No Man's Land'. It extends from the A1 pulley (distal palmar crease) to the FDS insertion (middle of the middle phalanx). Because both the FDS and FDP tendons run tightly together within the fibro-osseous sheath here, early attempts at primary repair often resulted in dense adhesions. Today, primary repair with early active protocols is the standard of care.

Question 4762

Topic: 7. Hand and Wrist

A 24-year-old gymnast presents with ulnar-sided wrist pain and distal radioulnar joint (DRUJ) instability following a forced wrist extension and pronation injury. Wrist arthroscopy reveals an avulsion of the triangular fibrocartilage complex (TFCC) from its ulnar insertion at the fovea. Under the Palmer classification, this is a:

. Palmer 1A
. Palmer 1B
. Palmer 1C
. Palmer 1D
. Palmer 2A

Correct Answer & Explanation

. Palmer 1B

Explanation

The Palmer classification divides TFCC tears into traumatic (Type 1) and degenerative (Type 2). 1A is a central articular disk tear; 1B is an ulnar avulsion (with or without ulnar styloid fracture) leading to DRUJ instability; 1C is a distal avulsion (volar ulnocarpal ligaments); and 1D is a radial avulsion.

Question 4763

Topic: 7. Hand and Wrist

A 50-year-old woman presents with volar forearm aching and numbness in the radial 3.5 digits. Which of the following physical examination findings most reliably differentiates Pronator Syndrome from Carpal Tunnel Syndrome?

. A positive Phalen's maneuver
. Numbness in the index and middle fingertips
. Weakness of the abductor pollicis brevis (APB)
. Numbness over the skin of the thenar eminence
. Nocturnal awakening with hand pain

Correct Answer & Explanation

. Numbness over the skin of the thenar eminence

Explanation

The palmar cutaneous branch of the median nerve arises approximately 5 cm proximal to the carpal tunnel and passes superficial to the flexor retinaculum to supply sensation to the thenar eminence. In Carpal Tunnel Syndrome, this branch is spared, so thenar sensation is normal. In Pronator Syndrome (proximal median nerve compression), thenar sensation is decreased.

Question 4764

Topic: 7. Hand and Wrist
A 28-year-old manual laborer presents with dorsal wrist pain and decreased grip strength. Radiographs show sclerosis of the lunate with a coronal fracture line, but carpal height is preserved and there is no evidence of radiocarpal arthritis. Ulnar variance is negative 2 mm. What is the most appropriate surgical treatment?
. Proximal row carpectomy
. Radial shortening osteotomy
. Lunate excision and silastic replacement
. Four-corner fusion
. Vascularized bone graft without offloading

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

This patient has Lichtman stage IIIA Kienböck's disease with ulnar negative variance. Radial shortening osteotomy unloads the lunate and is the procedure of choice to halt progression and prevent carpal collapse.

Question 4765

Topic: 7. Hand and Wrist

In a patient presenting with advanced Dupuytren's contracture of the ring finger, which of the following fascial structures is responsible for displacing the neurovascular bundle centrally and superficially?

. Pretendinous band
. Natatory ligament
. Spiral cord
. Central cord
. Lateral cord

Correct Answer & Explanation

. Spiral cord

Explanation

The spiral cord is formed by the pretendinous band, spiral band, lateral digital sheet, and Grayson's ligament. Its contraction displaces the neurovascular bundle medially and palmarly, putting it at high risk of transection during surgical excision.

Question 4766

Topic: Wrist & Carpus

A 55-year-old female with long-standing rheumatoid arthritis suddenly loses the ability to actively flex the interphalangeal joint of her thumb. This attritional tendon rupture (Mannerfelt syndrome) most commonly occurs secondary to friction over which bony structure?

. Lister's tubercle
. Volar aspect of the scaphoid
. Dorsal aspect of the distal radius
. Pisiform
. Hook of the hamate

Correct Answer & Explanation

. Volar aspect of the scaphoid

Explanation

Mannerfelt syndrome refers to the attritional rupture of the flexor pollicis longus (FPL) tendon. It classically occurs due to friction over a prominent volar scaphoid osteophyte penetrating the capsule in rheumatoid arthritis.

Question 4767

Topic: Hand Trauma & Infection

A 25-year-old skier falls while holding a pole, forcibly hyperabducting his thumb. MRI confirms a complete tear of the ulnar collateral ligament (UCL) of the thumb MCP joint with a Stener lesion. Which structure is interposed between the torn UCL and its anatomic insertion?

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

Correct Answer & Explanation

. Adductor pollicis aponeurosis

Explanation

A Stener lesion occurs when the distally torn UCL of the thumb flips and rests superficial to the adductor pollicis aponeurosis. This interposition prevents anatomic healing and necessitates surgical repair.

Question 4768

Topic: 7. Hand and Wrist

A 30-year-old male presents with dorsal wrist pain and a clunking sensation. Radiographs demonstrate a scapholunate gap of 4 mm and a radiolunate angle indicating 25 degrees of dorsal tilt. Which ligament complex must be injured to allow this specific deformity?

. Volar radiocarpal ligaments only
. Scapholunate interosseous ligament and dorsal intercarpal ligament
. Lunotriquetral ligament and volar radioulnar ligament
. Triquetrohamate ligament
. Ulnocarpal ligament complex

Correct Answer & Explanation

. Scapholunate interosseous ligament and dorsal intercarpal ligament

Explanation

A DISI (Dorsal Intercalated Segment Instability) deformity requires rupture of the scapholunate interosseous ligament as well as secondary stabilizers, particularly the dorsal intercarpal ligament. This uncouples the scaphoid and lunate, allowing the lunate to fall into extension.

Question 4769

Topic: Hand Trauma & Infection

A 40-year-old diabetic patient presents with a swollen, painful index finger. Which of the following is NOT one of Kanavel's cardinal signs of pyogenic flexor tenosynovitis?

. Fusiform swelling of the digit
. Pain on active extension
. Tenderness along the flexor tendon sheath
. Digit held in a flexed posture
. Pain on passive extension

Correct Answer & Explanation

. Pain on passive extension

Explanation

Kanavel's four cardinal signs of flexor tenosynovitis include fusiform swelling, the digit resting in flexion, tenderness along the tendon sheath, and severe pain on passive (not active) extension. Pain on passive extension is usually the earliest and most reliable sign.

Question 4770

Topic: Nerve & Tendon

A patient with an untreated zone I extensor tendon laceration develops a secondary deformity characterized by PIP joint hyperextension and DIP joint flexion. What is the primary pathoanatomical cause of the PIP hyperextension?

. Rupture of the FDP tendon
. Dorsal subluxation of the lateral bands
. Volar subluxation of the lateral bands
. Proximal retraction of the extensor mechanism and increased tension on the central slip
. Rupture of the volar plate at the DIP joint

Correct Answer & Explanation

. Proximal retraction of the extensor mechanism and increased tension on the central slip

Explanation

An untreated mallet finger can lead to a swan neck deformity. The disrupted terminal extensor tendon allows the entire extensor mechanism to retract proximally, concentrating unchecked extension forces on the central slip, which hyperextends the PIP joint.

Question 4771

Topic: 7. Hand and Wrist

A 45-year-old carpenter complains of aching pain in his proximal forearm and numbness in his thumb, index, and middle fingers. Which physical examination finding most reliably differentiates pronator syndrome from carpal tunnel syndrome?

. Positive Tinel's sign at the wrist
. Weakness of the flexor pollicis longus
. Decreased sensation over the thenar eminence
. Atrophy of the abductor pollicis brevis
. Night pain and awakening

Correct Answer & Explanation

. Decreased sensation over the thenar eminence

Explanation

The palmar cutaneous branch of the median nerve innervates the skin over the thenar eminence and branches off proximal to the carpal tunnel. Therefore, sensation here is preserved in carpal tunnel syndrome but may be decreased in higher compression like pronator syndrome.

Question 4772

Topic: Wrist & Carpus

Which Palmer classification of triangular fibrocartilage complex (TFCC) tears has the best potential for healing with direct surgical repair due to its regional vascularity?

. Palmer 1A (Central perforation)
. Palmer 1B (Ulnar avulsion)
. Palmer 1C (Distal avulsion)
. Palmer 1D (Radial avulsion)
. Palmer 2C (Degenerative perforation)

Correct Answer & Explanation

. Palmer 1B (Ulnar avulsion)

Explanation

Palmer 1B tears involve an avulsion of the TFCC from the distal ulna. The ulnar periphery of the TFCC is well-vascularized (the 'red zone'), providing excellent healing potential following direct capsular or osseous repair.

Question 4773

Topic: Nerve & Tendon

A patient sustains a high ulnar nerve transection at the elbow. During recovery, the claw deformity of the ring and small fingers becomes paradoxically more pronounced. What phenomenon is responsible for this worsening deformity?

. Quadriga effect
. Lumbrical plus finger
. Boutonniere deformity
. Martin-Gruber anastomosis
. Ulnar paradox

Correct Answer & Explanation

. Ulnar paradox

Explanation

The 'ulnar paradox' occurs because a high ulnar nerve injury paralyzes both the intrinsic hand muscles and the FDP to the ring/small fingers, resulting in a mild claw. As the nerve regenerates distally, FDP function returns first, strongly flexing the DIP joints against paralyzed intrinsics, worsening the claw.

Question 4774

Topic: 7. Hand and Wrist

De Quervain's tenosynovitis involves the first dorsal compartment of the wrist. Multiple slips of which tendon are most commonly found within a separate subsheath in this compartment, frequently contributing to nonoperative treatment failure?

. Extensor pollicis longus
. Abductor pollicis longus
. Extensor pollicis brevis
. Extensor carpi radialis longus
. Extensor indicis proprius

Correct Answer & Explanation

. Abductor pollicis longus

Explanation

The first dorsal compartment contains the APL and EPB. The APL commonly has multiple tendon slips (up to 7), and the EPB often lies within a separate anatomical subsheath, which blocks the flow of corticosteroid injections if not recognized.

Question 4775

Topic: 7. Hand and Wrist

A 30-year-old male manual laborer presents with chronic, centralized dorsal wrist pain. Radiographs reveal sclerosis of the lunate without collapse or fragmentation, and a negative ulnar variance of 3 mm. MRI confirms diffuse T1 hypointensity throughout the lunate. Which of the following is the most appropriate primary surgical intervention?

. Proximal row carpectomy
. Radial shortening osteotomy
. Scaphocapitate fusion
. Lunate excision and silastic replacement
. Total wrist arthrodesis

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

This patient has Lichtman Stage II Kienbock's disease with ulnar negative variance. A joint-leveling procedure such as a radial shortening osteotomy unloads the lunate and is the treatment of choice.

Question 4776

Topic: 7. Hand and Wrist
A 25-year-old man falls on an outstretched hand and presents with severe acute wrist pain. Radiographs demonstrate a perilunate dislocation. According to the Mayfield progressive perilunar instability classification, a Stage III injury is defined by disruption of which of the following structures?
. Scapholunate interosseous ligament
. Lunocapitate articulation
. Lunotriquetral ligament
. Volar radiolunate ligament with lunate extrusion
. Triangular fibrocartilage complex

Correct Answer & Explanation

. Lunotriquetral ligament

Explanation

Mayfield Stage III instability involves disruption of the lunotriquetral articulation, allowing the entire carpus to dislocate dorsal to the lunate. Stage I is scapholunate, Stage II involves the space of Poirier, and Stage IV is volar lunate extrusion.

Question 4777

Topic: 7. Hand and Wrist

In a Bennett fracture-dislocation of the thumb base, the distinct volar-ulnar beak fragment of the first metacarpal base remains anatomically reduced relative to the trapezium. Which ligament is primarily responsible for holding this fragment in place?

. Dorsal radial ligament
. Intermetacarpal ligament
. Anterior oblique ligament
. Ulnar collateral ligament
. Volar plate

Correct Answer & Explanation

. Anterior oblique ligament

Explanation

The anterior oblique ligament (often called the volar beak ligament) securely tethers the volar-ulnar fragment of the first metacarpal to the trapezium. The distal shaft fragment is displaced proximally, dorsally, and radially by the APL, EPL, and adductor pollicis.

Question 4778

Topic: Nerve & Tendon

A 22-year-old rugby player is unable to actively flex the distal interphalangeal (DIP) joint of his right ring finger after grabbing an opponent's jersey. MRI demonstrates the flexor digitorum profundus (FDP) tendon retracted completely into the palm. According to the Leddy-Packer classification, what is the expected status of the vincula and the recommended timeframe for surgical repair?

. Vincula intact; repair can be delayed up to 3 months
. Vincula ruptured; repair should be performed within 7-10 days
. Vincula intact; repair should be performed within 7-10 days
. Vincula ruptured; necessitating a planned two-stage tendon graft
. Vincula intact; immediate primary repair within 24 hours is mandatory

Correct Answer & Explanation

. Vincula ruptured; repair should be performed within 7-10 days

Explanation

Retraction of the FDP tendon into the palm defines a Type I Jersey finger, meaning the vincula longus and brevis are ruptured. Due to the compromised blood supply, surgical repair must be performed within 7-10 days to prevent tendon necrosis and myostatic contracture.

Question 4779

Topic: 7. Hand and Wrist
In the surgical management of Dupuytren's disease, dissecting the spiral cord is notorious for causing iatrogenic digital nerve injury. The spiral cord is formed by the pathological contraction of multiple normal fascial bands, EXCEPT:
. Pretendinous band
. Spiral band
. Lateral digital sheet
. Grayson's ligament
. Cleland's ligament

Correct Answer & Explanation

. Cleland's ligament

Explanation

Cleland's ligaments are located dorsal to the neurovascular bundles and are classically spared in Dupuytren's disease. The spiral cord consists of the pretendinous band, spiral band, lateral digital sheet, and Grayson's ligament.

Question 4780

Topic: 7. Hand and Wrist

A 34-year-old tennis player reports persistent ulnar-sided wrist pain and clicking during forearm supination. MRI reveals an avulsion of the triangular fibrocartilage complex (TFCC) from its insertion at the fovea of the ulnar head, without distal radioulnar joint instability. This describes which Palmer classification type?

. Palmer Type 1A
. Palmer Type 1B
. Palmer Type 1C
. Palmer Type 1D
. Palmer Type 2A

Correct Answer & Explanation

. Palmer Type 1B

Explanation

A Palmer Type 1B tear is an acute, traumatic avulsion of the TFCC from its ulnar insertion (fovea or base of the ulnar styloid). Type 1A is central, 1C is volar, and 1D is radial.

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