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7. Hand and Wrist MCQs

Practice Set 241 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 4801

Topic: Nerve & Tendon
A 22-year-old rugby player avulses his flexor digitorum profundus (FDP) tendon of the ring finger. On surgical exploration, the tendon is found retracted to the level of the A2 pulley but is held there by an intact vinculum longum. According to the Leddy and Packer classification, what type of injury is this?
. Type I
. Type II
. Type III
. Type IV
. Type V

Correct Answer & Explanation

. Type II

Explanation

Leddy and Packer classification of FDP avulsion (Jersey finger): Type I: Retracted to the palm (blood supply severed, needs repair within 7-10 days). Type II: Retracted to the A3 pulley/PIP joint level (held by an intact vinculum longum). Type III: Bony fragment avulsed, caught at the A4 pulley. Type IV: Bony avulsion with simultaneous FDP tendon avulsion from the fracture fragment.

Question 4802

Topic: 7. Hand and Wrist
A child is born with a hypoplastic thumb. Radiographs show the absence of the proximal third of the first metacarpal and severe carpometacarpal joint instability. According to the Blauth classification of thumb hypoplasia, what is the most appropriate definitive surgical treatment?
. Thumb carpometacarpal joint arthrodesis
. Opponensplasty alone
. First web space deepening and tendon transfer
. Pollicization of the index finger
. Free vascularized toe transfer

Correct Answer & Explanation

. Pollicization of the index finger

Explanation

The child has a Blauth Type IIIb thumb hypoplasia (absence of the proximal metacarpal and a deficient CMC joint). Types IIIb, IV, and V are best treated with thumb ablation and index finger pollicization. Types I, II, and IIIa (stable CMC) are treated with reconstruction (opponensplasty, web space widening).

Question 4803

Topic: Nerve & Tendon

A 50-year-old mechanic presents with pain, cold intolerance, and a pulsatile mass in the hypothenar eminence. An Allen test is abnormal. Angiography reveals an occlusion of the superficial palmar arch. Which structure is most likely acting as the source of repetitive trauma to the affected vessel?

. Hook of the hamate
. Pisiform
. Trapezial ridge
. Scaphoid tubercle
. Styloid process of the ulna

Correct Answer & Explanation

. Hook of the hamate

Explanation

Hypothenar hammer syndrome is caused by repetitive trauma to the ulnar artery as it passes over the hook of the hamate in Guyon's canal. This leads to thrombosis or aneurysm formation of the superficial palmar arch.

Question 4804

Topic: 7. Hand and Wrist

The major blood supply to the proximal pole of the scaphoid enters the bone at which anatomical location?

. Through the distal tuberosity via branches of the radial artery
. Through the dorsal ridge via the dorsal carpal branch of the radial artery
. Through the volar scaphoid via the superficial palmar arch
. Through the interosseous ligament from the lunate
. Directly into the proximal pole via the anterior interosseous artery

Correct Answer & Explanation

. Through the dorsal ridge via the dorsal carpal branch of the radial artery

Explanation

The scaphoid receives its primary blood supply from the dorsal carpal branch of the radial artery, which enters along the dorsal ridge in the distal half of the bone and provides retrograde flow to the proximal pole. This retrograde blood supply makes proximal pole fractures highly susceptible to avascular necrosis.

Question 4805

Topic: 7. Hand and Wrist

During active ulnar deviation of the normal wrist, what coupled motion occurs at the proximal carpal row?

. Flexion and radial translation
. Flexion and ulnar translation
. Extension and radial translation
. Extension and ulnar translation
. Pure ulnar translation without rotation

Correct Answer & Explanation

. Extension and radial translation

Explanation

During ulnar deviation of the wrist, the scaphoid extends, driving the entire proximal carpal row into extension. Simultaneously, the proximal row translates radially to accommodate the articulation between the capitate and triquetrum.

Question 4806

Topic: 7. Hand and Wrist

A 32-year-old diabetic patient presents with profound swelling, erythema, and tenderness localized to the volar aspect of the distal phalanx of the thumb. The swelling does not extend proximal to the distal flexion crease. What is the most appropriate initial surgical approach for drainage?

. A mid-lateral incision avoiding the neurovascular bundles
. A transverse volar incision directly over the pad
. A dorsal longitudinal incision
. A volar zigzag (Bruner) incision extending to the proximal phalanx
. A fish-mouth incision at the fingertip

Correct Answer & Explanation

. A mid-lateral incision avoiding the neurovascular bundles

Explanation

The patient has a felon, which is a closed-space infection of the pulp of the distal phalanx. The standard recommended surgical drainage is via a mid-lateral (or unilateral longitudinal) incision to avoid scarring the sensitive tactile volar pad and to adequately disrupt the vertical septa. Fish-mouth incisions are generally discouraged due to painful scarring and tip deformities.

Question 4807

Topic: 7. Hand and Wrist

A patient demonstrates normal function of all intrinsic muscles of the hand despite an isolated complete transection of the ulnar nerve at the elbow. Which of the following anatomic variants best explains this clinical finding?

. Riche-Cannieu anastomosis
. Marinacci communication
. Martin-Gruber anastomosis
. Berrettini anastomosis
. Linburg-Comstock anomaly

Correct Answer & Explanation

. Martin-Gruber anastomosis

Explanation

A Martin-Gruber anastomosis is a communication between the median and ulnar nerves in the forearm. Motor fibers travel with the median nerve down the arm and cross over to the ulnar nerve in the forearm to innervate the intrinsic muscles of the hand, preserving hand intrinsic function even if the ulnar nerve is transected proximal to the anastomosis. Riche-Cannieu is a median-ulnar connection in the palm.

Question 4808

Topic: 7. Hand and Wrist

A 28-year-old sustains a low median nerve transection at the wrist. To restore opposition, an opponensplasty using the extensor indicis proprius (EIP) (Burkhalter transfer) is planned. To optimize the biomechanics of true opposition, the line of pull for the transferred tendon should be directed toward which anatomical landmark?

. The pisiform
. The radial styloid
. The hook of the hamate
. The distal radioulnar joint
. The Lister's tubercle

Correct Answer & Explanation

. The pisiform

Explanation

True opposition of the thumb requires palmar abduction, flexion, and pronation. To recreate this combined motion during an opponensplasty (like the EIP or FDS transfers), the tendon should be routed from the thumb metacarpophalangeal joint toward the pisiform to provide the optimal line of pull for pronation and palmar abduction.

Question 4809

Topic: Wrist & Carpus

The Palmer classification is used for Triangular Fibrocartilage Complex (TFCC) lesions. A traumatic avulsion of the TFCC from its distal attachment at the lunate or triquetrum is classified as:

. Class 1A
. Class 1B
. Class 1C
. Class 1D
. Class 2C

Correct Answer & Explanation

. Class 1B

Explanation

Palmer classification of traumatic (Class 1) TFCC tears: 1A = central perforation; 1B = ulnar avulsion (with or without an ulnar styloid fracture); 1C = distal avulsion (from the carpus - lunate/triquetrum via ulnotriquetral/ulnolunate ligaments); 1D = radial avulsion (from the sigmoid notch). Class 2 represents degenerative tears.

Question 4810

Topic: Nerve & Tendon

During a surgical release for de Quervain's tenosynovitis, the surgeon must be cautious of anatomical variants. The first dorsal extensor compartment typically contains the Extensor Pollicis Brevis (EPB) and the Abductor Pollicis Longus (APL). What is the most common anatomical variation found within this compartment?

. Absence of the EPB tendon
. Multiple slips of the APL tendon
. Multiple slips of the EPB tendon
. An anomalous extensor indicis proprius tendon
. The presence of a septation separating the EPB and APL in 95% of patients

Correct Answer & Explanation

. Multiple slips of the APL tendon

Explanation

Anatomical variations in the first dorsal compartment are a frequent cause of surgical failure in de Quervain's release. The most common variation is the presence of multiple slips of the APL tendon (present in up to 80% of individuals). A separate subcompartment (septation) for the EPB is present in approximately 40-60% of patients, not 95%.

Question 4811

Topic: Hand Trauma & Infection

In a complete rupture of the ulnar collateral ligament (UCL) of the thumb metacarpophalangeal joint (Stener lesion), healing is prevented due to the interposition of which structure between the torn ends of the ligament?

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

Correct Answer & Explanation

. Adductor pollicis aponeurosis

Explanation

A Stener lesion occurs when the distal attachment of the thumb UCL avulses and gets trapped superficial to the adductor aponeurosis. The adductor aponeurosis acts as a mechanical barrier between the torn ligament and its insertion site, preventing spontaneous healing and necessitating surgical repair.

Question 4812

Topic: Nerve & Tendon

A 35-year-old cyclist presents with weakness in pinching and crossing his fingers. Physical examination reveals pronounced atrophy of the first dorsal interosseous muscle and weak thumb adduction. Two-point discrimination is 4 mm over both the volar and dorsal aspects of the small finger. Sensation over the hypothenar eminence is intact. A mass compressing the ulnar nerve is suspected. In which zone of Guyon's canal is the lesion most likely located?

. Zone 1
. Zone 2
. Zone 3
. Zone 4
. Zone 5

Correct Answer & Explanation

. Zone 3

Explanation

Guyon's canal is divided into three zones. Zone 1 extends from the proximal edge of the palmar carpal ligament to the bifurcation of the ulnar nerve; compression here causes mixed motor and sensory deficits. Zone 2 contains the deep motor branch and extends from the bifurcation to the deep motor arch; compression here causes isolated motor deficits (interossei, adductor pollicis, and deep heads of the FPB and lumbricals) with spared sensation, as seen in this patient. Zone 3 contains the superficial sensory branch; compression here causes isolated sensory loss to the volar ring and small fingers.

Question 4813

Topic: 7. Hand and Wrist
A 62-year-old male presents with chronic, severe wrist pain. Radiographs demonstrate advanced radiocarpal arthritis with complete obliteration of the radioscaphoid and capitolunate joint spaces. The radiolunate joint is entirely preserved. Which of the following anatomical structures is responsible for the preservation of the radiolunate joint in this condition?
. Scapholunate interosseous ligament
. Radioscaphocapitate ligament
. Lunotriquetral interosseous ligament
. Dorsal radiocarpal ligament
. Volar radioulnar ligament

Correct Answer & Explanation

. Radioscaphocapitate ligament

Explanation

The patient has Stage III Scapholunate Advanced Collapse (SLAC) wrist, which involves capitolunate arthritis. A hallmark of SLAC wrist is the universal preservation of the radiolunate joint. This is due to the concentric, spherical congruency of the radiolunate articulation and the absence of strong anomalous forces, which are maintained by the intact long radiolunate ligament and the stabilizing sling effect of the radioscaphocapitate (RSC) ligament.

Question 4814

Topic: 7. Hand and Wrist

At what age should a child with a simple, complete syndactyly of the thumb and index finger undergo surgical release?

. By 6 months of age
. Between 12 and 18 months of age
. Between 2 and 3 years of age
. At 4 years of age
. At skeletal maturity

Correct Answer & Explanation

. By 6 months of age

Explanation

Syndactyly of the border digits (thumb-index and ring-small) should be released early, typically by 6 months of age. This prevents progressive flexion and angular deformities caused by the differing longitudinal growth rates of the adjacent, tethered fingers. In contrast, syndactyly of central digits (e.g., middle-ring) is usually released later, between 12 and 18 months of age.

Question 4815

Topic: Wrist & Carpus

A 45-year-old carpenter complains of progressive wrist pain over the ulnar aspect. Radiographs show positive ulnar variance with subchondral cystic changes in the lunate and ulnar head. MRI demonstrates a central tear of the triangular fibrocartilage complex (TFCC). Following a failed 6-month trial of conservative management, what is the most appropriate surgical intervention?

. Arthroscopic TFCC repair to the fovea
. Arthroscopic wafer procedure
. Ulnar shortening osteotomy
. Darrach procedure
. Bowers hemiresection interposition arthroplasty

Correct Answer & Explanation

. Ulnar shortening osteotomy

Explanation

The patient has ulnar impaction syndrome with positive ulnar variance. An ulnar shortening osteotomy is the most appropriate surgical treatment for a patient with positive ulnar variance and an intact DRUJ, as it directly addresses the mechanical overload while tightening the ulnocarpal ligaments. An arthroscopic wafer procedure is generally reserved for patients with neutral or slightly positive variance (less than 2-3 mm) or when avoiding osteotomy hardware is desired, but shortening osteotomy remains the gold standard for distinct positive variance.

Question 4816

Topic: 7. Hand and Wrist

During surgical exploration for a severed flexor tendon in the thumb, preservation of which of the following pulley systems is most critical to prevent bowstringing of the Flexor Pollicis Longus (FPL)?

. A1 pulley
. Oblique pulley
. A2 pulley
. Annular pulley of the metacarpal neck
. Cruciate pulley

Correct Answer & Explanation

. Oblique pulley

Explanation

The flexor pulley system of the thumb consists of two annular pulleys (A1, A2) and one oblique pulley. The oblique pulley, located over the mid-portion of the proximal phalanx, is the most critical pulley in the thumb to prevent bowstringing of the FPL tendon. It is analogous in importance to the A2 and A4 pulleys in the fingers.

Question 4817

Topic: 7. Hand and Wrist

A 55-year-old female presents with the sudden inability to flex the interphalangeal (IP) joint of her right thumb. She has a 10-year history of rheumatoid arthritis. Radiographs of the wrist show advanced carpal collapse. Which of the following is the most likely cause of this tendon rupture?

. Atrition over a dorsal osteophyte on the lunate
. Atrition over a volar osteophyte on the scaphoid
. Atrition over a prominent ulnar styloid
. Chronic tenosynovitis at the A1 pulley
. Spontaneous avulsion from the distal phalanx base

Correct Answer & Explanation

. Atrition over a volar osteophyte on the scaphoid

Explanation

This patient has Mannerfelt-Norman syndrome, which is the spontaneous rupture of the Flexor Pollicis Longus (FPL) tendon. In patients with rheumatoid arthritis, this rupture most commonly occurs secondary to attrition rubbing against a sharp volar osteophyte projecting from the scaphoid (or less commonly, the trapezium) as it enters the carpal tunnel.

Question 4818

Topic: 7. Hand and Wrist
A newborn is evaluated for a congenital hand anomaly and is found to have a completely duplicated thumb on the right hand. Radiographs show a single first metacarpal with two complete proximal phalanges and two distal phalanges. According to the Wassel classification, what type of radial polydactyly is this?
. Type II
. Type III
. Type IV
. Type V
. Type VI

Correct Answer & Explanation

. Type IV

Explanation

The Wassel classification describes radial polydactyly. Type IV involves duplication of both the proximal and distal phalanges with a single (often broad or bifid at the distal end) metacarpal. It is the most common type of radial polydactyly, accounting for roughly 40-50% of cases. Type II is a duplicated distal phalanx. Type VI is a duplicated metacarpal with duplicated phalanges.

Question 4819

Topic: 7. Hand and Wrist

In the surgical treatment of established compartment syndrome of the hand, standard dorsal incisions are used to release the interosseous compartments. To fully release all dorsal and volar interosseous muscles, as well as the adductor compartment, where should the dorsal longitudinal incisions be placed?

. Over the 1st and 3rd metacarpals
. Over the 2nd and 4th metacarpals
. Over the 3rd and 5th metacarpals
. In the 1st, 2nd, and 3rd web spaces
. Over the 2nd and 5th metacarpals

Correct Answer & Explanation

. Over the 2nd and 4th metacarpals

Explanation

The hand contains 10 compartments (4 dorsal interossei, 3 volar interossei, thenar, hypothenar, adductor). The interosseous compartments are typically released via two dorsal longitudinal incisions placed over the 2nd and 4th metacarpals. The incision over the 2nd metacarpal allows access to the 1st and 2nd dorsal interossei, the 1st volar interosseous, and the adductor pollicis. The incision over the 4th metacarpal allows access to the 3rd and 4th dorsal interossei and the 2nd and 3rd volar interossei.

Question 4820

Topic: 7. Hand and Wrist

A 24-year-old male presents with right wrist pain after a fall on an outstretched hand. Radiographs reveal a scaphoid waist fracture. Which of the following describes the primary blood supply to the scaphoid, explaining its propensity for nonunion and avascular necrosis?

. The superficial palmar arch supplies the proximal pole in a retrograde fashion
. The volar carpal branch of the radial artery enters the distal pole and supplies the scaphoid in a retrograde fashion
. The dorsal carpal branch of the radial artery enters the dorsal ridge and supplies the proximal pole in a retrograde fashion
. The anterior interosseous artery enters the waist of the scaphoid directly
. The deep palmar arch supplies both poles symmetrically via dual intraosseous vessels

Correct Answer & Explanation

. The dorsal carpal branch of the radial artery enters the dorsal ridge and supplies the proximal pole in a retrograde fashion

Explanation

The scaphoid's blood supply is highly precarious. Approximately 70-80% of the blood supply comes from the dorsal carpal branch of the radial artery, which enters the scaphoid at the dorsal ridge (near the waist/distal third) and supplies the proximal pole in a retrograde fashion. Consequently, fractures at the waist or proximal pole disrupt this retrograde flow, putting the proximal fragment at high risk for avascular necrosis and nonunion.

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