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7. Hand and Wrist MCQs

Practice Set 246 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 4901

Topic: 7. Hand and Wrist

A 65-year-old man undergoes fasciectomy for severe Dupuytren's contracture. The surgeon dissects diseased fascia causing a 60-degree flexion contracture of the PIP joint of the small finger. The neurovascular bundle is found displaced centrally, proximally, and superficially. Which of the following fascial cords is primarily responsible for both the PIP joint contracture and this characteristic displacement of the neurovascular bundle?

. Pretendinous cord
. Central cord
. Spiral cord
. Natatory cord
. Lateral cord

Correct Answer & Explanation

. Spiral cord

Explanation

The spiral cord in Dupuytren's disease is formed from the continuation of the pretendinous band, spiral band, lateral digital sheet, and Grayson's ligament. As it contracts, it causes PIP joint flexion and characteristically pulls the neurovascular bundle toward the midline (centrally), proximally, and superficially, placing it at high risk for iatrogenic injury during surgical excision.

Question 4902

Topic: 7. Hand and Wrist

A 42-year-old male presents with inability to flex the IP joint of his right thumb and the DIP joint of his right index finger. He cannot make an 'OK' sign. To clinically differentiate between an Anterior Interosseous Nerve (AIN) palsy and a closed spontaneous rupture of the flexor tendons, which of the following physical examination maneuvers is most useful?

. Tinel's sign at the carpal tunnel
. Assessment of two-point discrimination at the fingertips
. The tenodesis test (passive wrist extension)
. Phalen's test
. Froment's sign

Correct Answer & Explanation

. The tenodesis test (passive wrist extension)

Explanation

The inability to make the 'OK' sign indicates loss of FPL and FDP to the index finger. This can be due to an AIN palsy or tendon ruptures (e.g., in rheumatoid arthritis or Mannerfelt syndrome). The passive tenodesis test differentiates the two: passively extending the wrist will cause spontaneous flexion of the digits if the tendons are intact (AIN palsy). If the tendons are ruptured, the digits will remain extended during passive wrist extension.

Question 4903

Topic: 7. Hand and Wrist

A 28-year-old man sustains a Bennett fracture-dislocation of his right thumb. The volar ulnar fragment of the metacarpal base remains anatomically reduced due to its strong ligamentous attachment, while the metacarpal shaft displaces proximally, radially, and dorsally. Which muscle is primarily responsible for the proximal and dorsal displacement of the metacarpal shaft?

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

Correct Answer & Explanation

. Abductor pollicis longus

Explanation

In a Bennett fracture, the small volar ulnar fragment is held in place by the anterior oblique ligament. The metacarpal shaft is pulled proximally, dorsally, and radially by the deforming force of the Abductor Pollicis Longus (APL), which inserts on the base of the first metacarpal. The Adductor Pollicis pulls the metacarpal head medially, creating a supination deformity.

Question 4904

Topic: Nerve & Tendon

A 35-year-old woman complains of pain, tingling, and numbness over the dorsoradial aspect of her right hand, worsened by tight watchbands and pronation. Tinel's sign is positive over the radial aspect of the mid-forearm. Motor examination is normal. Which two muscles typically compress the involved nerve in this syndrome?

. Brachioradialis and Extensor Carpi Radialis Longus
. Extensor Carpi Radialis Longus and Extensor Carpi Radialis Brevis
. Pronator Teres and Flexor Carpi Radialis
. Abductor Pollicis Longus and Extensor Pollicis Brevis
. Supinator and Brachioradialis

Correct Answer & Explanation

. Brachioradialis and Extensor Carpi Radialis Longus

Explanation

The patient has Wartenberg's syndrome, which is compression of the superficial sensory branch of the radial nerve. The nerve is most commonly compressed as it emerges from beneath the deep fascia between the Brachioradialis (BR) and the Extensor Carpi Radialis Longus (ECRL), especially during pronation, which causes these tendons to scissor together.

Question 4905

Topic: 7. Hand and Wrist

A 30-year-old woodworker amputates his left index finger at the proximal phalanx. The amputated part is properly wrapped in saline-moistened gauze, sealed in a plastic bag, and placed on ice. What is the generally accepted maximum cold ischemia time for a clean, sharp amputation of a digit at this level to remain viable for replantation?

. 6 hours
. 12 hours
. 24 hours
. 36 hours
. 48 hours

Correct Answer & Explanation

. 24 hours

Explanation

Digits do not contain muscle belly, which makes them highly tolerant of ischemia compared to major limb amputations. A properly cooled digit can tolerate cold ischemia for up to 24 hours (and sometimes longer) and still be viable for replantation. In contrast, major limb amputations (proximal to the radiocarpal joint, containing muscle) tolerate only about 6 hours of warm ischemia or 12 hours of cold ischemia before irreversible muscle necrosis occurs.

Question 4906

Topic: 7. Hand and Wrist

A 6-month-old infant is evaluated for congenital syndactyly of the hands. The parents are inquiring about the planned surgical management. Which of the following principles regarding congenital syndactyly and its surgical reconstruction is correct?

. The first webspace is the most commonly involved site.
. Complete simple syndactyly of the ring and small fingers should be released at 18-24 months of age.
. Complex syndactyly involves conjoined neurovascular bundles but separate bone structures.
. Release of border digits (thumb-index or ring-small) should be performed earlier, typically at 6 months of age, to prevent angular deformities.
. Full-thickness skin grafts are rarely required if properly designed dorsal rectangular flaps are utilized.

Correct Answer & Explanation

. Release of border digits (thumb-index or ring-small) should be performed earlier, typically at 6 months of age, to prevent angular deformities.

Explanation

Syndactyly of border digits (first webspace: thumb-index; fourth webspace: ring-small) involves fingers with significantly different growth rates. If left tethered, the longer digit will develop a severe flexion and angular deformity. Therefore, border digits are released early, typically at 6 months. The 3rd webspace is most commonly involved. Complex syndactyly involves bony fusion. Full-thickness skin grafts are almost always required to cover the resultant defects.

Question 4907

Topic: Nerve & Tendon
A 25-year-old rugby player presents 4 days after grabbing an opponent's jersey. He cannot actively flex the DIP joint of his ring finger. Radiographs show no fractures. On ultrasound, the flexor digitorum profundus (FDP) tendon stump is identified at the level of the proximal interphalangeal (PIP) joint. According to the Leddy-Packer classification, what is the type of this injury and the status of the vincula?
. Type I; Vincula entirely ruptured, tendon in palm
. Type II; Vincula longus intact, tendon at PIP joint
. Type III; Vincula intact, large bony fragment trapped at A4 pulley
. Type IV; Tendon avulsed from fracture fragment
. Type V; Extra-articular avulsion fracture

Correct Answer & Explanation

. Type II; Vincula longus intact, tendon at PIP joint

Explanation

Leddy-Packer Type II 'jersey finger' involves the tendon retracting to the level of the PIP joint. The long vinculum remains intact, preventing further proximal retraction into the palm, which preserves some of its blood supply. Type I retracts to the palm (vincula ruptured). Type III involves a large bony fragment trapped at the A4 pulley.

Question 4908

Topic: Wrist & Carpus

A 45-year-old gymnast complains of chronic ulnar-sided wrist pain that worsens with pronation and ulnar deviation. Radiographs reveal ulnar positive variance and cystic changes in the lunate and triquetrum. MRI confirms tears of the central TFCC articular disc but demonstrates that the distal radioulnar joint (DRUJ) is perfectly congruent without arthritic changes. Which of the following surgical procedures is most appropriate?

. Ulnar shortening osteotomy
. Hemiresection interposition arthroplasty (Bowers procedure)
. Darrach procedure
. Ulnar head replacement
. Sauve-Kapandji procedure

Correct Answer & Explanation

. Ulnar shortening osteotomy

Explanation

Ulnar shortening osteotomy is the treatment of choice for ulnar impaction syndrome in patients with positive ulnar variance and a congruent, non-arthritic DRUJ. It effectively unloads the ulnocarpal joint and tightens the ulnocarpal ligaments. If significant DRUJ arthritis were present, a salvage procedure like a Sauve-Kapandji or Darrach procedure would be considered instead.

Question 4909

Topic: Wrist & Carpus
A 50-year-old manual laborer presents with chronic progressive wrist pain years after an untreated scapholunate ligament tear. Radiographs reveal advanced arthritis involving the radioscaphoid joint and the capitolunate joint. The radiolunate joint is characteristically spared. What is the Watson stage of this patient's wrist, and what is the preferred salvage procedure?
. Stage II SLAC; treated with proximal row carpectomy
. Stage III SLAC; treated with scaphoid excision and four-corner fusion
. Stage III SLAC; treated with proximal row carpectomy
. Stage IV SLAC; treated with scaphoid excision and four-corner fusion
. Stage II SLAC; treated with total wrist arthrodesis

Correct Answer & Explanation

. Stage IV SLAC; treated with scaphoid excision and four-corner fusion

Explanation

Scapholunate advanced collapse (SLAC) Stage III involves arthritis of the radioscaphoid and capitolunate joints, while the radiolunate joint is spared. Because the capitate head is arthritic, a proximal row carpectomy (PRC) is contraindicated (as the arthritic capitate would articulate with the lunate fossa). Scaphoid excision and four-corner fusion is the preferred salvage procedure for Stage III SLAC.

Question 4910

Topic: Nerve & Tendon

A 38-year-old female presents with severe, episodic pain in her left index finger, exquisitely sensitive to cold. Physical exam reveals point tenderness over the nail bed. The pain is relieved by inflating a blood pressure cuff on the ipsilateral arm. What is the name of the clinical test described that relieves the patient's pain?

. Love's pin test
. Hildreth's test
. Tinel's sign
. Finkelstein's test
. Grind test

Correct Answer & Explanation

. Hildreth's test

Explanation

Hildreth's test is the relief of pain from a glomus tumor when a tourniquet (or blood pressure cuff) is inflated proximal to the lesion. Glomus tumors are benign hamartomas presenting with a classic triad of cold hypersensitivity, paroxysmal pain, and pinpoint tenderness. Love's pin test involves eliciting severe localized pain using the head of a pin directly over the lesion.

Question 4911

Topic: 7. Hand and Wrist
A 30-year-old mechanic presents with dorsal wrist pain. X-rays show sclerosis of the lunate with coronal fracturing and fragmentation, but carpal height is maintained and the scaphoid does not demonstrate a fixed ring sign. Ulnar variance is negative. What is the Lichtman stage of this disease, and what is a widely accepted initial surgical option?
. Stage II; Radial shortening osteotomy
. Stage IIIA; Radial shortening osteotomy
. Stage IIIB; Proximal row carpectomy
. Stage IIIA; Proximal row carpectomy
. Stage IV; Vascularized bone graft

Correct Answer & Explanation

. Stage IIIA; Radial shortening osteotomy

Explanation

Lichtman Stage IIIA is defined by lunate collapse/fragmentation without fixed scaphoid rotation or carpal collapse. Because the patient has negative ulnar variance, a joint-leveling procedure such as a radial shortening osteotomy is indicated. It effectively unloads the lunate to halt progression of Kienböck's disease. Stage IIIB (fixed scaphoid rotation/carpal collapse) typically requires salvage procedures like PRC or STT fusion.

Question 4912

Topic: 7. Hand and Wrist

A 28-year-old male sustains a midshaft radius fracture. After open reduction and internal fixation of the radius, the distal radioulnar joint (DRUJ) remains dorsally dislocated and is irreducible despite anatomic restoration of the radius. What is the most common anatomic structure blocking reduction of the DRUJ in this Galeazzi fracture-dislocation?

. Extensor carpi ulnaris (ECU) tendon
. Flexor pollicis longus (FPL) tendon
. Extensor digiti minimi (EDM) tendon
. Ulnar nerve
. Pronator quadratus

Correct Answer & Explanation

. Extensor carpi ulnaris (ECU) tendon

Explanation

In a Galeazzi fracture-dislocation, if the DRUJ is irreducible after anatomic fixation of the radius, an interposed soft tissue structure must be suspected. The most common structure blocking reduction is the Extensor Carpi Ulnaris (ECU) tendon. The ECU tendon can subluxate and become trapped in the DRUJ. The EDM tendon or median nerve can also block reduction, but the ECU is the most frequent offender.

Question 4913

Topic: 7. Hand and Wrist

To distinguish between intrinsic muscle tightness and joint capsule contracture in a patient with a suspected intrinsic-plus hand, the examiner performs the Bunnell-Littler test. The PIP joint has 30 degrees of flexion when the MCP joint is held in full extension. When the MCP joint is flexed to 90 degrees, the PIP joint can now flex to 90 degrees. What do these findings indicate?

. Extrinsic extensor tightness
. Extrinsic flexor tightness
. Intrinsic muscle tightness
. PIP joint capsular contracture
. Sagittal band rupture

Correct Answer & Explanation

. Intrinsic muscle tightness

Explanation

The Bunnell-Littler test assesses intrinsic tightness. When the MCP joint is extended, the intrinsic muscles are put on stretch; if PIP flexion is limited in this position but improves when the MCP joint is flexed (which relaxes the intrinsics), intrinsic tightness is confirmed. If PIP flexion was restricted equally regardless of MCP position, it would indicate a fixed joint capsular contracture.

Question 4914

Topic: 7. Hand and Wrist

A 25-year-old male presents with a complex dorsal dislocation of the index finger MCP joint. Pucker sign is visible in the distal palmar crease. Closed reduction fails. During an open reduction using a volar approach, which of the following structures is most at risk of iatrogenic transection because it is displaced and stretched tightly just deep to the skin over the prominent metacarpal head?

. Proper digital nerve to the radial side of the index finger
. Proper digital nerve to the ulnar side of the index finger
. Flexor digitorum profundus tendon
. Radial proper digital artery
. First lumbrical muscle

Correct Answer & Explanation

. Proper digital nerve to the radial side of the index finger

Explanation

In a complex dorsal dislocation of the index MCP joint, the metacarpal head buttonholes through the volar structures (between the lumbrical radially and the flexor tendons ulnarly). The radial digital nerve is displaced volarly and stretched tightly directly over the prominent metacarpal head just beneath the skin. A volar surgical approach places this nerve at exceedingly high risk of transection during the initial skin incision.

Question 4915

Topic: 7. Hand and Wrist

A 42-year-old male sustains a severe bite to his hand while breaking up a dog fight. Examination shows a deep puncture wound over the thenar eminence. He has no drug allergies. What is the most common pathogen involved in this specific injury, and what is the empiric oral antibiotic of choice?

. Eikenella corrodens; Cephalexin
. Pasteurella multocida; Amoxicillin-clavulanate
. Staphylococcus aureus; Clindamycin
. Capnocytophaga canimorsus; Metronidazole
. Bartonella henselae; Azithromycin

Correct Answer & Explanation

. Pasteurella multocida; Amoxicillin-clavulanate

Explanation

The most common pathogen isolated from dog and cat bites is Pasteurella multocida. The empiric oral antibiotic of choice for animal bites to the hand is Amoxicillin-clavulanate (Augmentin), which provides excellent coverage for Pasteurella, anaerobes, and Staphylococcus species. Eikenella corrodens is the classic pathogen associated with human 'fight bite' injuries.

Question 4916

Topic: 7. Hand and Wrist

A 32-year-old competitive rower presents with pain, swelling, and crepitus on the dorsal radial aspect of the distal forearm, approximately 4-5 cm proximal to the radiocarpal joint. The pain is exacerbated by resisted wrist extension and thumb extension. This condition is caused by friction at the intersection of which two extensor compartments?

. First compartment crossing over the second compartment
. Second compartment crossing over the third compartment
. Third compartment crossing over the second compartment
. First compartment crossing over the third compartment
. Third compartment crossing over the fourth compartment

Correct Answer & Explanation

. First compartment crossing over the second compartment

Explanation

Intersection syndrome is an inflammatory tenosynovitis occurring at the friction point where the muscle bellies of the first dorsal extensor compartment (abductor pollicis longus and extensor pollicis brevis) cross obliquely over the tendons of the second dorsal extensor compartment (extensor carpi radialis longus and extensor carpi radialis brevis). It typically presents 4-5 cm proximal to the wrist joint.

Question 4917

Topic: 7. Hand and Wrist
A pediatric patient is evaluated for an extra thumb on the right hand. Radiographs show a complete duplication of the proximal and distal phalanges of the thumb, with a single normal-appearing metacarpal. Both proximal phalanges articulate with the single metacarpal head. According to the Wassel classification of radial polydactyly, what type is this?
. Type II
. Type III
. Type IV
. Type V
. Type VI

Correct Answer & Explanation

. Type IV

Explanation

The Wassel classification describes thumb duplication (radial polydactyly). Type IV involves a duplicated proximal and distal phalanx sitting on a single metacarpal. It is the most common type, accounting for roughly 40-50% of cases. Type I is a bifid distal phalanx, Type II is a duplicated distal phalanx, and Type III is a bifid proximal phalanx.

Question 4918

Topic: 7. Hand and Wrist

A 40-year-old carpenter presents with severe pain, swelling, and erythema along the volar small finger extending into the palm and distal forearm following a puncture wound. He has pain with passive extension of the small finger. The infection is confirmed as pyogenic flexor tenosynovitis of the small finger. Into which space does the ulnar bursa most commonly communicate, potentially leading to a 'horseshoe abscess'?

. Midpalmar space
. Thenar space
. Radial bursa
. Space of Parona
. Deep posterior compartment of the forearm

Correct Answer & Explanation

. Radial bursa

Explanation

A 'horseshoe abscess' occurs when an infection spreads from the ulnar bursa (which envelops the flexor tendons of the small finger) directly to the radial bursa (which envelops the flexor pollicis longus tendon), or vice versa. These two bursae communicate in the proximal palm/carpal tunnel region in approximately 50-80% of individuals.

Question 4919

Topic: Nerve & Tendon

A 24-year-old male sustained a C6-C7 brachial plexus root avulsion injury 6 months ago. He has absent finger and thumb extension but maintains strong elbow flexion, shoulder abduction, active wrist flexion, and intact median nerve intrinsic function. A nerve transfer is planned to restore thumb and finger extension. Which of the following is the most appropriate nerve transfer for this purpose?

. Anterior interosseous nerve to deep motor branch of ulnar nerve
. Median nerve fascicles to pronator teres transferred to the anterior interosseous nerve
. Flexor carpi ulnaris branches of ulnar nerve transferred to posterior interosseous nerve
. Median nerve branches to flexor digitorum superficialis (FDS) transferred to the posterior interosseous nerve (PIN)
. Musculocutaneous nerve transferred to the radial nerve

Correct Answer & Explanation

. Median nerve branches to flexor digitorum superficialis (FDS) transferred to the posterior interosseous nerve (PIN)

Explanation

In patients with a lower brachial plexus injury or radial nerve palsy who have intact median nerve function, a classic Mackinnon nerve transfer utilizes the redundant branches of the median nerve to the flexor digitorum superficialis (FDS) (or flexor carpi radialis) transferred directly to the posterior interosseous nerve (PIN). This is highly effective for restoring active finger and thumb extension.

Question 4920

Topic: 7. Hand and Wrist

A 28-year-old skier falls while holding a ski pole, forcibly abducting his right thumb. He presents with pain and 45 degrees of laxity to valgus stress testing at 30 degrees of MCP flexion, with no endpoint. Ultrasound confirms a complete tear of the ulnar collateral ligament (UCL) and a Stener lesion. What defines a Stener lesion anatomically?

. The ruptured UCL displaces superficial to the adductor pollicis aponeurosis
. The ruptured UCL displaces deep to the adductor pollicis aponeurosis
. The ruptured UCL displaces superficial to the abductor pollicis brevis
. The radial collateral ligament is interposed between the UCL and the proximal phalanx
. The volar plate avulses and blocks reduction of the MCP joint

Correct Answer & Explanation

. The ruptured UCL displaces superficial to the adductor pollicis aponeurosis

Explanation

A Stener lesion occurs when the completely torn ulnar collateral ligament (UCL) of the thumb MCP joint displaces proximally and superficially to the adductor pollicis aponeurosis. The aponeurosis becomes interposed between the torn ends of the UCL and its insertion on the proximal phalanx, preventing spontaneous healing and thus serving as an absolute indication for surgical repair.

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