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7. Hand and Wrist MCQs

Practice Set 247 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 4921

Topic: 7. Hand and Wrist

A 35-year-old mechanic sustains a severe crush injury to his right hand. Examination reveals a tense, swollen hand with the fingers resting in a slightly flexed position. Intracompartmental pressure testing indicates compartment syndrome. How many discrete fascial compartments are recognized in the hand, and which surgical approach effectively releases the interosseous compartments?

. 7 compartments; released via two dorsal longitudinal incisions
. 10 compartments; released via two dorsal longitudinal incisions
. 10 compartments; released via four dorsal longitudinal incisions
. 14 compartments; released via two dorsal longitudinal incisions
. 14 compartments; released via four volar longitudinal incisions

Correct Answer & Explanation

. 10 compartments; released via two dorsal longitudinal incisions

Explanation

There are 10 recognized discrete fascial compartments in the hand: 4 dorsal interosseous, 3 volar interosseous, the thenar compartment, the hypothenar compartment, and the adductor pollicis compartment. The seven interosseous compartments can be efficiently decompressed using two dorsal longitudinal incisions placed over the index and ring (2nd and 4th) metacarpals.

Question 4922

Topic: 7. Hand and Wrist

A 29-year-old butcher sustains a deep laceration to the mid-palm, transecting the superficial palmar arch. Which of the following best describes the primary arterial supply and the typical anatomical location of the superficial palmar arch in the hand?

. Predominantly supplied by the radial artery; located superficial to the flexor tendons and palmar aponeurosis
. Predominantly supplied by the ulnar artery; located superficial to the flexor tendons and deep to the palmar aponeurosis
. Predominantly supplied by the ulnar artery; located deep to the flexor tendons and superficial to the interossei
. Predominantly supplied by the radial artery; located deep to the flexor tendons and deep to the palmar aponeurosis
. Equal supply from radial and ulnar arteries; located deep to the adductor pollicis muscle

Correct Answer & Explanation

. Predominantly supplied by the ulnar artery; located superficial to the flexor tendons and deep to the palmar aponeurosis

Explanation

The superficial palmar arch is primarily formed by the main continuation of the ulnar artery, with a variable contribution from the superficial palmar branch of the radial artery. Anatomically, it is located superficial to the flexor tendons and lumbrical muscles, but deep to the palmar aponeurosis. Conversely, the deep palmar arch is primarily formed by the radial artery and lies deep to the flexor tendons.

Question 4923

Topic: 7. Hand and Wrist

During a fasciectomy for Dupuytren's disease affecting the ring finger, the surgeon notes that the neurovascular bundle is displaced toward the midline of the digit and superficially into the palm. Which pathological fascial cord is primarily responsible for this specific displacement?

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

Correct Answer & Explanation

. Spiral cord

Explanation

The spiral cord is responsible for displacing the neurovascular bundle centrally, superficially, and proximally. It is formed by the confluence of the pretendinous band, spiral band, lateral digital sheet, and Grayson's ligament. This anatomy is critical to understand during fasciectomy to prevent iatrogenic digital nerve injury.

Question 4924

Topic: 7. Hand and Wrist

A 60-year-old patient with severe, chronic carpal tunnel syndrome presents with isolated profound thenar wasting and complete loss of palmar abduction of the thumb. The surgeon plans a Camitz tendon transfer to restore function. Which muscle-tendon unit is utilized in this specific transfer?

. Palmaris longus
. Extensor indicis proprius
. Flexor digitorum superficialis of the ring finger
. Abductor digiti minimi
. Extensor carpi radialis longus

Correct Answer & Explanation

. Palmaris longus

Explanation

The Camitz transfer utilizes the palmaris longus tendon, often harvested with a strip of palmar fascia to increase length, transferred to the abductor pollicis brevis (APB). It is an excellent transfer for restoring palmar abduction (essential in severe median nerve palsy) and is frequently performed concurrently with carpal tunnel release.

Question 4925

Topic: Wrist & Carpus

A 28-year-old tennis player presents with persistent ulnar-sided wrist pain and clicking. MRI reveals an isolated tear of the foveal attachment of the triangular fibrocartilage complex (TFCC). On examination, the distal radioulnar joint (DRUJ) is grossly unstable compared to the contralateral side. What is the most appropriate surgical management?

. Arthroscopic debridement of the TFCC central disk
. Open or arthroscopically-assisted foveal reattachment of the TFCC
. Ulnar shortening osteotomy
. Darrach procedure
. Wafer procedure

Correct Answer & Explanation

. Open or arthroscopically-assisted foveal reattachment of the TFCC

Explanation

A tear of the foveal attachment (the deep fibers of the radioulnar ligaments) of the TFCC is the primary cause of DRUJ instability (Palmer class 1B). Because the DRUJ is unstable, simple debridement is inadequate. Surgical repair via open or arthroscopic foveal reattachment (e.g., using bone anchors or transosseous sutures) is required to restore DRUJ stability.

Question 4926

Topic: Wrist & Carpus

A 60-year-old woman with severe rheumatoid arthritis presents with a sudden inability to actively extend her ring and small fingers at the metacarpophalangeal (MCP) joints. The tenodesis effect is completely absent. What is the most likely underlying etiology of this condition?

. Posterior interosseous nerve syndrome secondary to elbow synovitis
. Vaughan-Jackson syndrome
. Subluxation of the extensor tendons into the ulnar valleys
. Ischemic contracture of the extensor muscle bellies
. Rupture of the central slips at the PIP joints

Correct Answer & Explanation

. Vaughan-Jackson syndrome

Explanation

The abrupt loss of active finger extension in a rheumatoid patient with absent tenodesis effect is diagnostic of extensor tendon rupture. Vaughan-Jackson syndrome describes the sequential rupture of the extensor tendons, typically starting ulnarly (EDM and EDC to the small finger) and progressing radially. It is caused by attrition over a dorsally subluxated distal ulna (caput ulnae) due to DRUJ destruction.

Question 4927

Topic: 7. Hand and Wrist
A 30-year-old manual laborer presents with dorsal wrist pain. Radiographs reveal sclerosis and a coronal fracture of the lunate, but the carpal height is strictly maintained and there is no fixed scaphoid rotary subluxation. According to the Lichtman classification of Kienböck's disease, what is the correct stage?
. Stage I
. Stage II
. Stage IIIA
. Stage IIIB
. Stage IV

Correct Answer & Explanation

. Stage IIIA

Explanation

In the Lichtman classification for Kienböck's disease: Stage I has normal radiographs (changes on MRI). Stage II shows lunate sclerosis. Stage IIIA shows lunate collapse or fracture, but carpal height is maintained and the scaphoid is normally aligned. Stage IIIB shows lunate collapse with fixed scaphoid rotary subluxation and decreased carpal height. Stage IV involves radiocarpal or midcarpal arthrosis.

Question 4928

Topic: 7. Hand and Wrist

A 30-year-old carpenter sustains a volar oblique fingertip amputation of the index finger. The distal phalanx bone is exposed, and there is significantly more palmar soft tissue loss than dorsal. Which of the following local flaps is most appropriate for providing sensate coverage of this defect?

. V-Y advancement flap (Atasoy)
. Cross-finger flap
. Thenar flap
. Moberg advancement flap
. Radial forearm flap

Correct Answer & Explanation

. Cross-finger flap

Explanation

A cross-finger flap is indicated for volar oblique amputations where local advancement flaps (like V-Y Atasoy) lack sufficient tissue. The Atasoy (V-Y) flap is ideal for dorsal oblique or transverse amputations. The Moberg flap is strictly reserved for the thumb due to the robust dorsal blood supply of the thumb allowing dual neurovascular volar advancement.

Question 4929

Topic: 7. Hand and Wrist

Nerve conduction studies for a patient with suspected ulnar neuropathy at the elbow demonstrate preserved motor responses in the first dorsal interosseous (FDI) muscle when the ulnar nerve is stimulated at the wrist, but a markedly decreased amplitude when stimulated at the elbow. A Martin-Gruber anastomosis is suspected. Where does this anomalous neural connection cross from the median to the ulnar nerve?

. In the mid-arm
. In the forearm
. At the level of the wrist crease
. Within the carpal tunnel
. In the deep palm

Correct Answer & Explanation

. In the forearm

Explanation

The Martin-Gruber anastomosis is an anomalous connection between the median and ulnar nerves that occurs in the forearm. It typically involves motor fibers from the median nerve (or AIN) crossing over to join the ulnar nerve, eventually innervating intrinsic hand muscles (most commonly the FDI) that are ordinarily ulnar-innervated. This can confound EMG/NCS findings in ulnar neuropathy.

Question 4930

Topic: 7. Hand and Wrist

A 22-year-old boxer sustains a Y-shaped intra-articular fracture at the base of the first metacarpal (Rolando fracture). Which muscle acts as the primary deforming force, causing proximal, dorsal, and radial displacement of the main metacarpal shaft fragment?

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

Correct Answer & Explanation

. Abductor pollicis longus

Explanation

In both Bennett and Rolando fractures, the main metacarpal shaft fragment is displaced proximally, dorsally, and radially by the pull of the Abductor Pollicis Longus (APL). The adductor pollicis pulls the distal aspect of the metacarpal towards the palm, creating an apex dorsal angulation.

Question 4931

Topic: 7. Hand and Wrist

During a primary repair of a lacerated flexor digitorum profundus (FDP) tendon in Zone II, the surgeon must vent parts of the flexor sheath to facilitate tendon gliding. However, specific pulleys must be preserved to prevent bowstringing of the tendon. Which two pulleys are biomechanically the most critical and must be maintained?

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

Correct Answer & Explanation

. A2 and A4

Explanation

The A2 pulley (located over the proximal phalanx) and the A4 pulley (located over the middle phalanx) are the most biomechanically critical components of the flexor tendon sheath. They are essential to prevent bowstringing of the flexor tendons and must be preserved or reconstructed.

Question 4932

Topic: 7. Hand and Wrist

A full-term newborn is noted to have a complete simple syndactyly between the middle and ring fingers. To optimize hand function and minimize growth disturbances, at what age is surgical separation typically recommended for this specific web space?

. 1-3 months
. 6-9 months
. 12-18 months
. 3-4 years
. 5-6 years

Correct Answer & Explanation

. 12-18 months

Explanation

Surgical release of syndactyly for central digits (middle/ring fingers) is generally performed between 12-18 months of age. Syndactyly involving border digits (thumb/index or ring/small) creates a larger length discrepancy during growth and is typically released earlier (around 6 months) to prevent progressive angular deformity.

Question 4933

Topic: Wrist & Carpus
Which of the following radiographic parameters is most strongly associated with the biomechanical pathogenesis of Kienböck's disease?
. Positive ulnar variance
. Negative ulnar variance
. Increased radial inclination
. Decreased volar tilt of the distal radius
. Lunotriquetral coalition

Correct Answer & Explanation

. Negative ulnar variance

Explanation

Negative ulnar variance (ulna is shorter than the radius) was classically described by Hultén as being strongly associated with Kienböck's disease (avascular necrosis of the lunate). This anatomy increases shear forces and load transmission directly onto the lunate from the radius.

Question 4934

Topic: 7. Hand and Wrist
A 55-year-old man presents with chronic wrist pain. Radiographs demonstrate narrowing and osteophyte formation at the radioscaphoid joint and the capitolunate joint, accompanied by proximal migration of the capitate. The radiolunate joint is completely spared. What is the correct Watson stage of this Scapholunate Advanced Collapse (SLAC) wrist?
. Stage I
. Stage II
. Stage III
. Stage IV
. Stage V

Correct Answer & Explanation

. Stage III

Explanation

The SLAC wrist staging by Watson is progressive: Stage I involves only the radial styloid. Stage II involves the entire radioscaphoid fossa. Stage III involves the capitolunate joint (with capitate proximal migration). Stage IV (in some classifications) involves pancarpal arthritis. The preservation of the radiolunate joint is the hallmark of SLAC/SNAC arthropathy due to its spherical congruency.

Question 4935

Topic: 7. Hand and Wrist
During a surgical fasciectomy for Dupuytren's contracture, the surgeon must carefully release the contracted fascial cords while protecting the digital neurovascular bundles. Which of the following normal fascial structures is typically spared from disease involvement and remains dorsal to the neurovascular bundle?
. Spiral band
. Natatory ligament
. Cleland's ligament
. Grayson's ligament
. Pretendinous band

Correct Answer & Explanation

. Grayson's ligament

Explanation

In Dupuytren's disease, Cleland's ligaments are generally spared. They are located dorsal to the neurovascular bundles and help stabilize the digital skin during flexion/extension. Conversely, Grayson's ligaments are located volar to the neurovascular bundles and are frequently involved in the disease process, pulling the neurovascular bundle centrally and superficially when contracted.

Question 4936

Topic: 7. Hand and Wrist

A 25-year-old basketball player 'jams' his finger and presents with a swollen proximal interphalangeal (PIP) joint. He has no gross deformity but complains of pain. The examiner flexes the PIP joint 90 degrees over the edge of a table and asks the patient to extend the middle phalanx against resistance. The patient demonstrates weak PIP extension, and the distal interphalangeal (DIP) joint remains rigid rather than floppy. Which test was performed, and what does it diagnose?

. Watson test for scapholunate instability
. Elson test for central slip rupture
. Boyes test for terminal extensor tendon injury
. Bouvier test for intrinsic tightness
. Sweater finger test for FDP avulsion

Correct Answer & Explanation

. Elson test for central slip rupture

Explanation

The Elson test is used to detect early/acute central slip ruptures before a boutonniere deformity fully develops. When the PIP is flexed to 90 degrees over a table edge, the central slip normally initiates extension while the lateral bands are lax (causing a 'floppy' DIP). If the central slip is ruptured, PIP extension is weak or absent, and the effort is transmitted through the lateral bands, causing the DIP joint to become rigid or hyperextend.

Question 4937

Topic: 7. Hand and Wrist

A 42-year-old carpenter presents with cold intolerance and rest pain in his right long and ring fingers. Exam reveals a pulsatile mass in the hypothenar eminence and a positive modified Allen test demonstrating ulnar artery occlusion. What is the primary anatomic etiology of this specific syndrome?

. Repetitive compression of the radial artery against the scaphoid
. Repetitive compression of the ulnar artery against the hook of the hamate
. Vasospasm from hyperactive sympathetic tone in the stellate ganglion
. Entrapment of the superficial palmar arch by the palmar aponeurosis
. Thrombosis secondary to a cervical rib

Correct Answer & Explanation

. Repetitive compression of the ulnar artery against the hook of the hamate

Explanation

The scenario describes Hypothenar Hammer Syndrome (HHS). HHS is caused by repetitive blunt trauma to the hypothenar eminence (often from using the heel of the hand as a hammer). The underlying pathomechanism is compression and injury of the superficial branch of the ulnar artery against the bony prominence of the hook of the hamate, leading to intimal damage, aneurysm formation, or thrombosis.

Question 4938

Topic: 7. Hand and Wrist

A 30-year-old factory worker sustains a volar tactile pad amputation of his right thumb. The defect measures 1.5 x 1.5 cm and exposes bone. The surgeon selects a classic Moberg advancement flap for coverage. Which of the following best describes the blood supply of this specific flap?

. Random pattern vascularity from the subdermal plexus
. Axial supply from the first dorsal metacarpal artery
. Bipedicled axial supply from both volar digital neurovascular bundles
. Venous flow-through mechanism from dorsal veins
. Perforator supply from the princeps pollicis artery

Correct Answer & Explanation

. Bipedicled axial supply from both volar digital neurovascular bundles

Explanation

The classic Moberg flap is a volar rectangular advancement flap used for thumb tip amputations (up to 1.5 - 2 cm). It relies on a bipedicled axial blood supply provided by both the radial and ulnar volar digital neurovascular bundles. It is unique to the thumb because the dorsal blood supply to the thumb tip is robust enough to prevent dorsal skin necrosis when the volar tissues are advanced.

Question 4939

Topic: 7. Hand and Wrist
According to the Leddy and Packer classification of flexor digitorum profundus (FDP) avulsion injuries (Jersey finger), what specific anatomic presentation characterizes a Type III injury?
. The tendon retracts into the palm and requires repair within 7-10 days
. The tendon retracts to the level of the PIP joint and is held by the intact long vinculum
. A large bony avulsion fragment retracts to the level of the A4 pulley
. The tendon avulsion is accompanied by simultaneous FDS rupture
. An extra-articular fracture of the distal phalanx shaft occurs with tendon entrapment

Correct Answer & Explanation

. A large bony avulsion fragment retracts to the level of the A4 pulley

Explanation

In the Leddy and Packer classification of FDP avulsions: Type I retracts to the palm (blood supply disrupted, early repair needed). Type II retracts to the PIP joint level (caught at camper's chiasm, long vinculum intact). Type III involves a large bony fragment that gets caught at the A4 pulley (level of the middle phalanx), preventing further proximal retraction.

Question 4940

Topic: Hand Trauma & Infection

A 28-year-old nurse presents with a painful, erythematous, and swollen index finger pulp. Exam shows multiple coalescing vesicles filled with clear fluid on the volar pad. The pulp is tense, but no focal fluctuance is felt. What is the most appropriate initial management?

. Urgent bedside incision and drainage followed by oral antibiotics
. Formal surgical debridement in the operating room
. Oral acyclovir and application of a dry dressing
. Local corticosteroid injection to reduce inflammation
. Partial nail plate removal and eponychial marsupialization

Correct Answer & Explanation

. Oral acyclovir and application of a dry dressing

Explanation

The patient has a herpetic whitlow, a viral infection of the distal finger caused by Herpes Simplex Virus (HSV 1 or 2). It classically presents with coalescing vesicles. It is typically self-limiting but can be treated with oral acyclovir. Incision and drainage is strictly contraindicated as it provides no benefit, delays healing, and carries a high risk of secondary bacterial superinfection.

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