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7. Hand and Wrist MCQs

Practice Set 242 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 4821

Topic: 7. Hand and Wrist

A 38-year-old female presents with pain and swelling over the dorsal forearm, approximately 4-6 cm proximal to the wrist joint. The pain is exacerbated by repetitive wrist flexion and extension. On examination, there is crepitus over the distal radial forearm. She is diagnosed with intersection syndrome. This condition involves tenosynovitis at the crossing point of which of the following extensor compartments?

. 1st and 2nd compartments
. 2nd and 3rd compartments
. 3rd and 4th compartments
. 1st and 3rd compartments
. 4th and 5th compartments

Correct Answer & Explanation

. 2nd and 3rd compartments

Explanation

Intersection syndrome is an inflammatory tenosynovitis occurring at the anatomic intersection where the muscle bellies of the 1st extensor compartment (Abductor Pollicis Longus and Extensor Pollicis Brevis) cross obliquely over the tendons of the 2nd extensor compartment (Extensor Carpi Radialis Longus and Extensor Carpi Radialis Brevis) in the distal dorsal forearm, typically 4 to 8 cm proximal to Lister's tubercle.

Question 4822

Topic: 7. Hand and Wrist
A 30-year-old male presents with pain in the center of his wrist. MRI reveals Kienböck's disease. Radiographs show lunate sclerosis and collapse, but the overall carpal height is maintained, and there is no fixed rotary subluxation of the scaphoid. His ulnar variance is negative 3 mm. According to the Lichtman classification, what is the stage and most appropriate initial surgical treatment for this patient?
. Stage II; radial shortening osteotomy
. Stage IIIA; radial shortening osteotomy
. Stage IIIB; proximal row carpectomy
. Stage IIIB; scaphoid-trapezium-trapezoid (STT) fusion
. Stage IV; total wrist arthrodesis

Correct Answer & Explanation

. Stage IIIA; radial shortening osteotomy

Explanation

The patient has Lichtman Stage IIIA Kienböck's disease, defined by lunate collapse/fragmentation but with preserved carpal height and normal scaphoid alignment (no fixed rotary subluxation). In a patient with negative ulnar variance, a joint-leveling procedure such as a radial shortening osteotomy unloads the lunate and is the most appropriate surgical treatment. Stage IIIB involves fixed scaphoid subluxation and loss of carpal height, typically requiring salvage procedures like STT fusion or PRC.

Question 4823

Topic: Nerve & Tendon

Which of the following intrinsic hand muscles is innervated by the median nerve in the majority of individuals?

. Adductor pollicis
. First dorsal interosseous
. Deep head of the flexor pollicis brevis
. Superficial head of the flexor pollicis brevis
. Palmaris brevis

Correct Answer & Explanation

. Superficial head of the flexor pollicis brevis

Explanation

The median nerve typically innervates the 'LOAF' muscles: the 1st and 2nd Lumbricals, the Opponens pollicis, the Abductor pollicis brevis, and the superficial head of the Flexor pollicis brevis (FPB). The deep head of the FPB, adductor pollicis, palmaris brevis, and all interossei are normally innervated by the deep motor branch of the ulnar nerve.

Question 4824

Topic: 7. Hand and Wrist

A 50-year-old male construction worker presents with a cold, painful ring finger. He frequently uses the palm of his hand to strike objects into place. Angiography shows an occlusion of the ulnar artery with a characteristic 'corkscrew' appearance of the superficial palmar arch. Which anatomic structure acts as an anvil, contributing to the repetitive intimal trauma of the artery in this syndrome?

. Pisiform
. Hook of the hamate
. Tubercle of the trapezium
. Scaphoid tubercle
. Styloid process of the ulna

Correct Answer & Explanation

. Hook of the hamate

Explanation

The patient has Hypothenar Hammer Syndrome, resulting from repetitive blunt trauma to the hypothenar eminence. The ulnar artery is vulnerable as it exits Guyon's canal because it runs superficially over the hook of the hamate, which acts as a rigid bony anvil against which the artery is repeatedly crushed, leading to intimal damage, thrombosis, and potential embolization to the digital arteries.

Question 4825

Topic: 7. Hand and Wrist
A 45-year-old woman is evaluated for a severe hyperextension injury to her PIP joint. Physical exam reveals a 'swan neck' deformity that is flexible passively but cannot be corrected actively. What is the primary anatomical disruption causing this specific deformity pattern following trauma?
. Rupture of the central slip at the base of the middle phalanx
. Volar plate attenuation or avulsion at the PIP joint
. Rupture of the terminal extensor tendon
. Laceration of the flexor digitorum superficialis (FDS) tendon
. Tightness of the intrinsic muscles

Correct Answer & Explanation

. Volar plate attenuation or avulsion at the PIP joint

Explanation

A swan neck deformity consists of PIP joint hyperextension and DIP joint flexion. Following a traumatic hyperextension injury, it is primarily caused by attenuation or rupture of the volar plate at the PIP joint. This allows the PIP joint to hyperextend, causing the lateral bands to subluxate dorsally to the axis of rotation, increasing extension forces at the PIP and reciprocal flexion forces at the DIP. Central slip rupture causes a boutonnière deformity.

Question 4826

Topic: 7. Hand and Wrist

A 55-year-old female with primary osteoarthritis of the hand presents with pain and deformity at the distal interphalangeal (DIP) joints. On exam, she has prominent dorsal nodules at the base of the distal phalanges. Which of the following is the pathologic hallmark of these specific nodules?

. Urate crystal deposition
. Rheumatoid pannus formation
. Osteophyte formation at the DIP joint
. Osteophyte formation at the PIP joint
. Mucinous degeneration of the extensor tendon

Correct Answer & Explanation

. Osteophyte formation at the DIP joint

Explanation

The dorsal nodules described are Heberden's nodes, which are pathognomonic for osteoarthritis of the hand. They represent marginal osteophyte formation at the distal interphalangeal (DIP) joints. Bouchard's nodes are similar osteophytes found at the proximal interphalangeal (PIP) joints.

Question 4827

Topic: 7. Hand and Wrist
A 32-year-old male with a 5-year history of an untreated scaphoid fracture presents with worsening wrist pain. Radiographs demonstrate advanced arthritis at the radioscaphoid and scaphocapitate joints, while the lunocapitate and radiolunate joints are completely spared. Which of the following is the most appropriate surgical treatment?
. Radial styloidectomy
. Proximal row carpectomy
. Total wrist arthrodesis
. Scaphoid excision and four-corner arthrodesis
. Scaphoid open reduction and internal fixation with vascularized bone grafting

Correct Answer & Explanation

. Scaphoid excision and four-corner arthrodesis

Explanation

This patient has Stage II/III Scaphoid Nonunion Advanced Collapse (SNAC). Scaphoid excision and four-corner arthrodesis is the most appropriate treatment, as proximal row carpectomy is contraindicated when capitate head cartilage is worn.

Question 4828

Topic: 7. Hand and Wrist

During a regional fasciectomy for severe Dupuytren's contracture of the ring finger, the neurovascular bundle is identified and found to be displaced centrally and volarly. Which of the following pathological cords is primarily responsible for this dangerous anatomical shift?

. Pretendinous cord
. Central cord
. Spiral cord
. Natatory cord
. Retrovascular cord

Correct Answer & Explanation

. Spiral cord

Explanation

The spiral cord causes medial and volar displacement of the neurovascular bundle, putting it at high risk of iatrogenic injury during excision. It is formed by the pretendinous band, spiral band, lateral digital sheet, and Grayson's ligament.

Question 4829

Topic: 7. Hand and Wrist

A 65-year-old female with advanced rheumatoid arthritis presents with a sudden inability to actively extend her small and ring fingers at the metacarpophalangeal joints. Examination reveals a prominent, dorsally subluxated distal ulna. What is the most appropriate surgical management?

. Extensor tendon repair with palmaris longus autograft
. Sagittal band reconstruction and synovectomy
. Distal ulna resection (e.g., Darrach) and extensor tendon transfer
. Metacarpophalangeal joint arthroplasty
. Ulnar nerve decompression at the wrist

Correct Answer & Explanation

. Distal ulna resection (e.g., Darrach) and extensor tendon transfer

Explanation

This is Vaughan-Jackson syndrome, characterized by sequential attrition ruptures of the digital extensor tendons from ulnar to radial over a dorsally subluxated distal ulna. Treatment requires addressing the bony prominence and restoring extension via tendon transfer.

Question 4830

Topic: Nerve & Tendon
A patient presents with intrinsic muscle weakness, clawing of the ring and small fingers, and isolated sensory loss over the volar aspect of the little finger and the ulnar half of the ring finger. Dorsal ulnar sensation is completely intact. Where is the most likely site of ulnar nerve compression?
. Cubital tunnel
. Arcade of Struthers
. Zone I of Guyon's canal
. Zone II of Guyon's canal
. Zone III of Guyon's canal

Correct Answer & Explanation

. Zone I of Guyon's canal

Explanation

Zone I of Guyon's canal contains both the motor and sensory branches of the ulnar nerve before their bifurcation. Compression here causes motor and volar sensory deficits while sparing the dorsal sensory branch, which branches off proximal to the wrist.

Question 4831

Topic: Hand Trauma & Infection

A 30-year-old mechanic presents with an exquisitely painful, swollen index finger following a puncture wound. Which of the following clinical signs (Kanavel's signs) is considered the latest and most reliable indicator of pyogenic flexor tenosynovitis?

. Symmetric uniform swelling of the entire digit
. Flexed resting posture of the digit
. Tenderness isolated to the dorsal distal interphalangeal joint
. Severe pain with passive extension of the digit
. Erythema extending proximally to the palmar crease

Correct Answer & Explanation

. Severe pain with passive extension of the digit

Explanation

Pain with passive extension is typically the most reliable and exquisitely sensitive sign of pyogenic flexor tenosynovitis. The four Kanavel signs are fusiform swelling, flexed posture, tenderness along the flexor sheath, and pain on passive extension.

Question 4832

Topic: 7. Hand and Wrist
A 25-year-old male falls on an outstretched hand. Lateral wrist radiographs show the lunate displaced volarly with a "spilled teacup" appearance, while the capitate remains coaxially aligned with the distal radius. This represents which stage of Mayfield's progressive perilunate instability?
. Stage I
. Stage II
. Stage III
. Stage IV
. Stage V

Correct Answer & Explanation

. Stage IV

Explanation

Mayfield Stage IV instability involves complete dislocation of the lunate volarly (the "spilled teacup" sign) while the capitate reduces dorsally to align with the radius. Stages I-III represent progressive ligamentous disruptions around the lunate without full lunate enucleation.

Question 4833

Topic: 7. Hand and Wrist
A 28-year-old carpenter presents with dorsal wrist pain and grip weakness. Radiographs reveal sclerosis and early fragmentation of the lunate with an ulnar variance of -3 mm. There is no fixed carpal collapse or secondary arthritis. What is the most appropriate surgical intervention?
. Radial shortening osteotomy
. Proximal row carpectomy
. Lunate excision and silastic replacement
. Capitate-hamate arthrodesis
. Total wrist arthrodesis

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

Radial shortening osteotomy is the gold standard for Lichtman Stage II or IIIa Kienbock's disease in patients with ulnar negative variance. It unloads the avascular lunate by shifting forces to the ulnocarpal articulation.

Question 4834

Topic: Nerve & Tendon

A patient complains of an inability to form an "OK" sign, resulting in a flat pinch between the thumb and index finger. Sensation is completely intact globally. Which of the following muscles is typically spared in this specific compression syndrome?

. Flexor digitorum profundus to the index finger
. Flexor pollicis longus
. Pronator quadratus
. Pronator teres
. Flexor digitorum profundus to the middle finger

Correct Answer & Explanation

. Pronator teres

Explanation

Anterior interosseous nerve (AIN) syndrome causes weakness of the flexor pollicis longus, flexor digitorum profundus to the index (and sometimes middle) finger, and pronator quadratus. The pronator teres is innervated by the main trunk of the median nerve proximal to the AIN branching and is spared.

Question 4835

Topic: 7. Hand and Wrist

A 28-year-old boxer sustains a Bennett fracture-dislocation. The primary deforming force causing proximal and dorsal displacement of the first metacarpal shaft is mediated by which of the following tendons?

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

Correct Answer & Explanation

. Abductor pollicis longus

Explanation

In a Bennett fracture, the volar ulnar beak fragment remains anatomically held by the anterior oblique ligament. The first metacarpal shaft is pulled proximally, dorsally, and radially primarily by the force of the abductor pollicis longus (APL).

Question 4836

Topic: 7. Hand and Wrist

A 35-year-old mechanic complains of ulnar-sided wrist pain with a clunking sensation. Lateral radiographs demonstrate a volar intercalated segment instability (VISI) pattern. This deformity is most strongly associated with an acute rupture of which of the following structures?

. Scapholunate interosseous ligament
. Lunotriquetral interosseous ligament
. Radioscaphocapitate ligament
. Dorsal radiocarpal ligament
. Triangular fibrocartilage complex

Correct Answer & Explanation

. Lunotriquetral interosseous ligament

Explanation

A VISI deformity is characterized by abnormal volar flexion of the lunate. It is most classically associated with disruption of the lunotriquetral (LT) interosseous ligament, which untethers the lunate from the triquetrum, allowing the scaphoid to pull the lunate volarward.

Question 4837

Topic: 7. Hand and Wrist

A 42-year-old carpenter presents with cold intolerance, pain, and a pulsatile mass over the hypothenar eminence. Angiography reveals a characteristic "corkscrew" appearance of the involved artery. Which anatomical structure is the primary site of arterial injury in this condition?

. Superficial palmar arch deep to the palmar aponeurosis
. Ulnar artery in Guyon's canal as it passes over the hook of the hamate
. Radial artery in the anatomic snuffbox
. Common palmar digital artery at the metacarpal neck
. Deep palmar arch traversing the interossei

Correct Answer & Explanation

. Ulnar artery in Guyon's canal as it passes over the hook of the hamate

Explanation

Hypothenar hammer syndrome involves thrombosis or true aneurysm of the ulnar artery. This typically occurs as the artery passes superficially over the hook of the hamate in Guyon's canal, rendering it vulnerable to repetitive blunt trauma.

Question 4838

Topic: 7. Hand and Wrist

During a trigger finger release of the middle finger, the surgeon must be careful to preserve essential pulleys to prevent bowstringing of the flexor tendons. Which two annular pulleys are critical biomechanical restraints that must be maintained?

. A1 and A2
. A2 and A4
. A3 and A5
. A1 and A5
. A2 and A3

Correct Answer & Explanation

. A2 and A4

Explanation

The A2 pulley (located over the proximal half of the proximal phalanx) and A4 pulley (located over the middle third of the middle phalanx) are the major biomechanical restraints to flexor tendon bowstringing. Trigger finger release exclusively divides the A1 pulley.

Question 4839

Topic: Hand Trauma & Infection

A 29-year-old presents with a severely swollen, erythematous, and throbbing volar distal pad of the index finger, consistent with a felon. If surgical drainage is performed, which anatomical consideration is crucial regarding the fibrous septa of the retinaculum cutis?

. They must be completely preserved to maintain pulp contour
. They should be sharply divided to decompress the individual pulp spaces
. They only exist in the proximal phalanx and do not affect fingertip incisions
. They transmit the primary venous drainage and bleeding is excessive if cut
. They are contiguous with the flexor tendon sheath, increasing the risk of pyogenic flexor tenosynovitis

Correct Answer & Explanation

. They should be sharply divided to decompress the individual pulp spaces

Explanation

A felon is a closed-space infection of the volar fingertip pulp. The pulp is divided into multiple small, discrete compartments by vertical fibrous septa; adequate surgical drainage requires disrupting these septa to fully decompress the purulent material.

Question 4840

Topic: Wrist & Carpus

A 19-year-old gymnast presents with persistent ulnar-sided wrist pain exacerbated by forearm rotation. MRI confirms a Palmer Class 1B tear of the triangular fibrocartilage complex (TFCC). This specific tear pattern involves detachment from which structure?

. Radial sigmoid notch
. Lunate and triquetrum
. Ulnar fovea and base of ulnar styloid
. Volar ulnocarpal ligaments
. Extensor carpi ulnaris subsheath

Correct Answer & Explanation

. Ulnar fovea and base of ulnar styloid

Explanation

A Palmer Class 1B TFCC tear represents a traumatic avulsion of the TFCC from its peripheral ulnar attachment (fovea or base of the ulnar styloid). Since this peripheral area is well-vascularized, it has excellent healing potential following direct surgical repair.

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