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7. Hand and Wrist MCQs

Practice Set 245 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 4881

Topic: Wrist & Carpus
A 32-year-old manual laborer presents with dorsal wrist pain. Radiographs reveal sclerosis of the lunate without collapse, and an ulnar variance of -3 mm. MRI confirms avascular necrosis of the lunate. Which of the following is the most appropriate initial surgical intervention?
. Proximal row carpectomy
. Scaphocapitate fusion
. Radial shortening osteotomy
. Ulnar lengthening osteotomy
. Vascularized bone graft from the distal radius without joint leveling

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

This patient has Stage II Kienböck's disease (sclerosis of the lunate, normal architecture without collapse) combined with negative ulnar variance. The standard of care to decompress the lunate in the setting of negative ulnar variance is a joint leveling procedure. Radial shortening osteotomy is biomechanically superior and has a lower complication rate compared to ulnar lengthening.

Question 4882

Topic: 7. Hand and Wrist

A term newborn is noted to have fused digits on bilateral hands. The fusion involves the long and ring fingers, with soft tissue connection extending only to the proximal interphalangeal joint, and no bony fusion is present. Which of the following best describes the most common classification and genetic inheritance pattern if this were a familial trait?

. Simple complete syndactyly; Autosomal recessive
. Simple incomplete syndactyly; Autosomal dominant
. Complex complete syndactyly; Autosomal dominant
. Complicated syndactyly; X-linked recessive
. Simple incomplete syndactyly; Sporadic mutation only

Correct Answer & Explanation

. Simple incomplete syndactyly; Autosomal dominant

Explanation

Simple syndactyly involves only soft tissue fusion, whereas complex implies bony fusion. Incomplete means it does not extend to the fingertips. Simple incomplete syndactyly between the 3rd and 4th digits (long and ring fingers) is the most common presentation. When familial, isolated syndactyly typically follows an autosomal dominant inheritance pattern with variable penetrance.

Question 4883

Topic: Nerve & Tendon

A 50-year-old woman complains of burning pain and numbness over the dorsoradial aspect of her right hand, which worsens when she wears tightly cuffed shirts. Examination reveals a positive Tinel's sign over the distal forearm, approximately 8 cm proximal to the radial styloid. Finkelstein's test is negative. Compression of the involved nerve typically occurs between which two structures during forearm pronation?

. Brachioradialis and Extensor Carpi Radialis Longus (ECRL)
. Extensor Carpi Radialis Brevis (ECRB) and Extensor Digitorum Communis (EDC)
. Pronator Teres and Flexor Carpi Radialis (FCR)
. Flexor Digitorum Superficialis (FDS) and Flexor Digitorum Profundus (FDP)
. Abductor Pollicis Longus (APL) and Extensor Pollicis Brevis (EPB)

Correct Answer & Explanation

. Brachioradialis and Extensor Carpi Radialis Longus (ECRL)

Explanation

The clinical picture describes Wartenberg's syndrome, an entrapment neuropathy of the superficial sensory branch of the radial nerve. Compression most classically occurs at the junction of the middle and distal thirds of the forearm, where the nerve emerges from its subfascial location between the brachioradialis and ECRL tendons. This compression is exacerbated during forearm pronation.

Question 4884

Topic: 7. Hand and Wrist

A 41-year-old mechanic presents with an inability to form an 'OK' sign with his thumb and index finger, noting that the distal phalanges remain extended during the attempt. Sensation over the entire hand is completely normal. Which of the following anatomical variants is most classically associated with compression of the affected nerve?

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

Correct Answer & Explanation

. Gantzer's muscle

Explanation

The patient has Anterior Interosseous Nerve (AIN) syndrome, demonstrated by the inability to flex the IP joint of the thumb (FPL) and the DIP joint of the index finger (FDP). The AIN has no cutaneous sensory innervation. Gantzer's muscle, which is an accessory head of the flexor pollicis longus (FPL), is a well-known anatomical variant and a classic cause of AIN compression.

Question 4885

Topic: Nerve & Tendon

Following a neglected central slip rupture, a patient develops a chronic Boutonniere deformity. In the pathogenesis of this established deformity, which anatomical structure becomes attenuated, allowing the lateral bands to subluxate volar to the axis of rotation of the proximal interphalangeal (PIP) joint?

. Transverse retinacular ligament
. Oblique retinacular ligament
. Sagittal band
. Triangular ligament
. Volar plate

Correct Answer & Explanation

. Triangular ligament

Explanation

In a Boutonniere deformity, disruption of the central slip eliminates primary PIP extension. Over time, the triangular ligament (which normally holds the lateral bands dorsal to the PIP joint axis) attenuates. This allows the lateral bands to slide volarly, turning them into PIP joint flexors and causing secondary hyperextension of the DIP joint.

Question 4886

Topic: Nerve & Tendon

A 38-year-old avid cyclist presents with profound weakness of the interossei and adductor pollicis muscles, resulting in a positive Froment's sign. He has normal sensation over the volar and dorsal aspects of the small finger and the ulnar half of the ring finger. Hypothenar muscle function is also preserved. Based on this isolated clinical presentation, compression of the ulnar nerve is most likely occurring in which zone of Guyon's canal?

. Zone 1
. Zone 2
. Zone 3
. Proximal to the pisiform
. Deep to the flexor carpi ulnaris aponeurosis

Correct Answer & Explanation

. Zone 3

Explanation

Guyon's canal is divided into three zones. Zone 1 is proximal to the bifurcation (mixed motor and sensory). Zone 2 encompasses the deep motor branch (motor only). Zone 3 encompasses the superficial sensory branch (sensory only). Isolated motor deficits without sensory loss indicate a Zone 2 lesion. Sparing of the hypothenar muscles specifically implies compression in distal Zone 2, after the hypothenar motor branches have taken off.

Question 4887

Topic: Nerve & Tendon
A 20-year-old collegiate football player grabs an opponent's jersey and sustains a forced hyperextension injury to his ring finger while actively flexing. He is unable to actively flex the distal interphalangeal (DIP) joint. Radiographs demonstrate no fracture. Ultrasound reveals the proximal stump of the flexor digitorum profundus (FDP) tendon is retracted into the palm. According to the Leddy-Packer classification, what type of injury is this, and what is the status of the vincula?
. Type I; Vincula are intact
. Type I; Vincula are ruptured
. Type II; Vincula are intact
. Type III; Vincula are ruptured
. Type IV; Vincula are intact

Correct Answer & Explanation

. Type I; Vincula are ruptured

Explanation

A Leddy-Packer Type I Jersey finger involves avulsion of the FDP tendon with proximal retraction all the way into the palm. For the tendon to retract this far, both the vinculum breve and vinculum longum must be ruptured. This severely compromises the tendon's blood supply, requiring urgent surgical repair within 7-10 days to avoid permanent retraction and necrosis.

Question 4888

Topic: 7. Hand and Wrist

A 55-year-old woman sustains a volar shearing fracture of the distal radius (volar Barton's fracture). The carpus subluxates volarly with the fracture fragment. Which of the following intrinsic/extrinsic carpal ligaments remains firmly attached to this volar fragment, pulling the carpus with it?

. Dorsal radiocarpal ligament
. Radioscaphocapitate ligament
. Scapholunate interosseous ligament
. Ulnocarpal ligament
. Volar distal radioulnar ligament

Correct Answer & Explanation

. Radioscaphocapitate ligament

Explanation

In a volar Barton's fracture, the volar marginal rim of the distal radius shears off. The strong volar radiocarpal ligaments, specifically the radioscaphocapitate (RSC) and the long radiolunate (LRL) ligaments, remain firmly attached to this fragment. As the fragment displaces volarly, the intact ligaments pull the entire carpus along with it, leading to the characteristic radiocarpal subluxation.

Question 4889

Topic: Hand Trauma & Infection

A 27-year-old carpenter presents with a swollen, painful index finger 3 days after a puncture wound. Upon examination, he exhibits all four of Kanavel's cardinal signs for suppurative flexor tenosynovitis. Which of these four signs is considered the earliest and most sensitive indicator of this condition?

. Fusiform swelling of the digit
. Flexed resting posture of the digit
. Tenderness along the flexor tendon sheath
. Pain with passive extension of the digit
. Erythema extending to the palmar crease

Correct Answer & Explanation

. Pain with passive extension of the digit

Explanation

Kanavel's four cardinal signs of purulent flexor tenosynovitis are: 1) fusiform (sausage-like) swelling, 2) flexed resting posture of the digit, 3) exquisite tenderness along the entire course of the flexor tendon sheath, and 4) excruciating pain with passive extension of the digit. Pain with passive extension is historically and clinically considered the earliest and most sensitive sign of the condition.

Question 4890

Topic: 7. Hand and Wrist

Which of the following scenarios represents an absolute contraindication to replantation of an amputated body part?

. A 4-year-old child with a sharp amputation of the index finger through the proximal phalanx
. A 65-year-old man with a guillotine amputation of the thumb at the interphalangeal joint
. A 30-year-old mechanic with an avulsion amputation of the ring finger
. A 40-year-old factory worker with a clean amputation of the forearm at the mid-diaphyseal level and 8 hours of warm ischemia time
. A 25-year-old violinist with amputation of the long and ring fingers through the middle phalanges

Correct Answer & Explanation

. A 40-year-old factory worker with a clean amputation of the forearm at the mid-diaphyseal level and 8 hours of warm ischemia time

Explanation

Replantation of 'macroamputations' (amputations proximal to the radiocarpal joint containing significant muscle mass) is absolutely contraindicated if warm ischemia time exceeds 6 hours. Prolonged ischemia of skeletal muscle leads to irreversible necrosis. Reperfusion after 6 hours of warm ischemia can release massive amounts of myoglobin, potassium, and lactic acid, potentially causing fatal renal failure or arrhythmias. Digits lack muscle bellies and can tolerate up to 12 hours of warm ischemia.

Question 4891

Topic: 7. Hand and Wrist
A 28-year-old laborer presents with dorsal wrist pain. Radiographs reveal sclerosis and fragmentation of the lunate, normal carpal height, and an ulnar variance of -3 mm. There is no evidence of fixed scaphoid rotary subluxation. What is the most appropriate surgical treatment?
. Proximal row carpectomy
. Scaphocapitate fusion
. Lunate excision and silicone arthroplasty
. Radial shortening osteotomy
. Total wrist arthrodesis

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

The patient has Lichtman Stage IIIA Kienböck's disease (lunate fragmentation/collapse, normal carpal height, no fixed scaphoid rotary subluxation). In the presence of ulnar negative variance, a joint-leveling procedure such as a radial shortening osteotomy is the treatment of choice to unload the lunate and halt disease progression. Proximal row carpectomy or limited carpal fusions are reserved for Stage IIIB (fixed scaphoid subluxation) or Stage IV (pancarpal arthritis).

Question 4892

Topic: Nerve & Tendon

In a patient with rheumatoid arthritis, which of the following is the primary initiating anatomic event in the pathogenesis of a classic Type I swan neck deformity?

. Rupture of the central slip
. Attenuation of the PIP joint volar plate and transverse retinacular ligament
. Contracture of the oblique retinacular ligament
. Rupture of the terminal extensor tendon
. Volar subluxation of the MCP joint

Correct Answer & Explanation

. Attenuation of the PIP joint volar plate and transverse retinacular ligament

Explanation

A swan neck deformity is characterized by PIP joint hyperextension and DIP joint flexion. In rheumatoid arthritis, the initiating event is typically synovitis of the PIP joint leading to attenuation of the volar plate and transverse retinacular ligament. This allows the lateral bands to subluxate dorsally, leading to PIP hyperextension, which subsequently causes passive stretching and eventual flexion of the DIP joint. Central slip rupture causes a boutonniere deformity.

Question 4893

Topic: 7. Hand and Wrist

A 24-year-old male sustained a C5-C6 brachial plexus root avulsion injury 4 months ago. He has no elbow flexion but normal hand and wrist function. An Oberlin transfer is planned. Which of the following describes the donor and recipient nerves in this procedure?

. Medial pectoral nerve to musculocutaneous nerve
. Fascicles of the ulnar nerve to the biceps branch of the musculocutaneous nerve
. Thoracodorsal nerve to the biceps branch of the musculocutaneous nerve
. Intercostal nerves to the musculocutaneous nerve
. Fascicles of the median nerve to the brachialis branch of the musculocutaneous nerve

Correct Answer & Explanation

. Fascicles of the ulnar nerve to the biceps branch of the musculocutaneous nerve

Explanation

The classic Oberlin transfer involves taking redundant fascicles from the ulnar nerve (typically those supplying the FCU) and coapting them directly to the motor branch of the biceps (from the musculocutaneous nerve) to restore elbow flexion in upper trunk brachial plexus injuries. A double fascicular transfer (Mackinnon) adds median nerve fascicles to the brachialis branch.

Question 4894

Topic: 7. Hand and Wrist

A 45-year-old mechanic presents with cold intolerance, pain, and ischemic changes in his right ring and small fingers. He frequently uses the heel of his hand to strike objects at work. Angiography reveals occlusion of the ulnar artery at the level of the wrist. The arterial injury is most likely occurring adjacent to which of the following osseous structures?

. Pisiform
. Hook of the hamate
. Triquetrum
. Tubercle of the trapezium
. Base of the 5th metacarpal

Correct Answer & Explanation

. Hook of the hamate

Explanation

This patient has hypothenar hammer syndrome, caused by repetitive blunt trauma to the hypothenar eminence. The ulnar artery (superficial palmar arch) is vulnerable to crushing against the hook of the hamate as it exits Guyon's canal, leading to thrombosis, aneurysm formation, and distal embolization.

Question 4895

Topic: 7. Hand and Wrist

A 32-year-old diabetic patient presents with a purulent flexor tenosynovitis of the small finger. Two days later, despite antibiotics, he develops swelling, pain, and tenderness along the flexor tendon sheath of the thumb. The infection most likely spread from the small finger to the thumb via which of the following anatomic spaces?

. Midpalmar space
. Thenar space
. Space of Parona
. Subaponeurotic space
. Guyon's canal

Correct Answer & Explanation

. Space of Parona

Explanation

The patient has developed a 'horseshoe abscess.' The flexor tendon sheath of the small finger communicates with the ulnar bursa, and the flexor sheath of the thumb communicates with the radial bursa. In the distal forearm, the radial and ulnar bursae communicate via the Space of Parona, which lies deep to the flexor tendons and superficial to the pronator quadratus.

Question 4896

Topic: 7. Hand and Wrist

A 30-year-old cyclist presents with profound weakness of the dorsal and volar interossei, lumbricals to the ring and small fingers, and adductor pollicis in his right hand. He has completely normal sensation over the entire hand, including the hypothenar eminence and the small finger. A compressive lesion in Guyon's canal is suspected. In which zone of Guyon's canal is the compression most likely located?

. Zone 1
. Zone 2
. Zone 3
. Zone 4
. Proximal to the canal

Correct Answer & Explanation

. Zone 3

Explanation

Guyon's canal is divided into three zones. Zone 1 is proximal to the bifurcation and contains both motor and sensory fibers; compression here causes mixed deficits. Zone 2 contains only the deep motor branch; compression here causes isolated motor deficits (interossei, lumbricals 3/4, adductor pollicis), which matches this patient's presentation. Zone 3 contains the superficial sensory branch; compression here causes isolated sensory deficits.

Question 4897

Topic: 7. Hand and Wrist
A 45-year-old man presents with chronic wrist pain. Radiographs reveal a scaphoid nonunion with arthritic changes involving the radioscaphoid joint and the capitolunate joint. The radiolunate joint is spared. The proximal pole of the capitate demonstrates severe eburnation. Which of the following is the most appropriate surgical treatment?
. Scaphoid excision and four-corner arthrodesis
. Proximal row carpectomy
. Radial styloidectomy and scaphoid nonunion takedown with bone grafting
. Total wrist arthroplasty
. Distal radius core decompression

Correct Answer & Explanation

. Scaphoid excision and four-corner arthrodesis

Explanation

This patient has Scaphoid Nonunion Advanced Collapse (SNAC) Stage III (involving the radioscaphoid and capitolunate joints). Proximal row carpectomy (PRC) relies on a healthy articulation between the lunate fossa of the radius and the proximal capitate. Because the capitate head demonstrates severe eburnation (arthritis), PRC is contraindicated. Therefore, scaphoid excision and four-corner fusion (capitate, hamate, lunate, triquetrum) is the treatment of choice, as the radiolunate joint is spared.

Question 4898

Topic: 7. Hand and Wrist
A 22-year-old rugby player cannot actively flex his ring finger DIP joint after grabbing an opponent's jersey. Radiographs show no fractures. On examination, the avulsed flexor digitorum profundus (FDP) tendon is palpable in the palm. Which of the following statements regarding this specific injury pattern is true?
. The tendon is held at the level of the PIP joint by the intact vincula longus.
. The injury is classified as a Leddy and Packer Type III.
. Surgical repair should be performed within 7 to 10 days to prevent permanent tendon retraction and ischemia.
. This injury represents an avulsion fracture of the distal phalanx that typically requires only splinting.
. Two-stage tendon reconstruction is immediately indicated.

Correct Answer & Explanation

. Surgical repair should be performed within 7 to 10 days to prevent permanent tendon retraction and ischemia.

Explanation

This is a Leddy and Packer Type I Jersey finger, characterized by retraction of the FDP tendon into the palm. This extensive retraction ruptures both the vincula brevis and longus, severely compromising the blood supply to the tendon. Because of the ischemia and rapid contracture, primary repair must be performed early, ideally within 7 to 10 days. Type II retracts to the PIP level (vincula longus intact), and Type III is a large bony avulsion caught at the A4 pulley.

Question 4899

Topic: 7. Hand and Wrist

A 25-year-old gymnast presents with ulnar-sided wrist pain after a fall on an extended, pronated wrist. MRI demonstrates a peripheral tear of the triangular fibrocartilage complex (TFCC) at its insertion onto the fovea of the ulnar styloid. According to the Palmer classification, what type of injury is this?

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

Correct Answer & Explanation

. Class 1B

Explanation

The Palmer classification divides TFCC tears into traumatic (Class 1) and degenerative (Class 2). Class 1A is a central perforation. Class 1B is an ulnar avulsion (with or without ulnar styloid fracture), which occurs in the vascular zone and is amenable to repair. Class 1C is a distal avulsion (carpal attachment). Class 1D is a radial avulsion.

Question 4900

Topic: 7. Hand and Wrist

During a flexor tenolysis procedure in a manual laborer, the surgeon notes significant scarring of the annular pulley system. To prevent bowstringing of the flexor tendons and significant loss of digital flexion mechanics, which two annular pulleys are mechanically the most important to preserve or reconstruct?

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

Correct Answer & Explanation

. A2 and A4

Explanation

The A2 (located over the proximal phalanx) and A4 (located over the middle phalanx) pulleys are the most robust and mechanically critical pulleys in the digit. Their preservation or reconstruction is vital to prevent bowstringing of the flexor tendons, which would result in a substantial loss of active motion and mechanical disadvantage.

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