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7. Hand and Wrist MCQs

Practice Set 248 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 4941

Topic: 7. Hand and Wrist

Which of the following intrinsic carpal ligaments is considered the primary stabilizer of the proximal pole of the scaphoid, and when completely torn, leads to a dorsal intercalated segment instability (DISI) deformity?

. Scaphotrapezial ligament
. Radioscaphocapitate ligament
. Dorsal intercarpal ligament
. Scapholunate interosseous ligament (dorsal band)
. Lunotriquetral interosseous ligament

Correct Answer & Explanation

. Scapholunate interosseous ligament (dorsal band)

Explanation

The scapholunate interosseous ligament (SLIL) is the primary stabilizer between the scaphoid and the lunate. It is divided into dorsal, membranous, and volar regions. The dorsal band is the thickest, strongest, and most critical for preventing scapholunate dissociation and the subsequent dorsal intercalated segment instability (DISI) deformity.

Question 4942

Topic: Wrist & Carpus

During the surgical approach for a perilunate dislocation, the surgeon evaluates the volar wrist capsule and identifies the Space of Poirier. This anatomic weak point, which is frequently disrupted in perilunate injuries, is located between which two volar ligaments?

. Radioscaphocapitate and long radiolunate ligaments
. Long radiolunate and short radiolunate ligaments
. Palmar lunotriquetral and capitotriquetral ligaments
. Radioscaphocapitate and volar scapholunate ligaments
. Ulnolunate and ulnotriquetral ligaments

Correct Answer & Explanation

. Radioscaphocapitate and long radiolunate ligaments

Explanation

The Space of Poirier is a relative weakness in the palmar radiocarpal joint capsule located between the radioscaphocapitate (RSC) and long radiolunate (LRL) ligaments. It overlies the volar aspect of the midcarpal joint (capitolunate articulation) and is the site where the lunate typically escapes volarly during a perilunate/lunate dislocation.

Question 4943

Topic: Wrist & Carpus

A 60-year-old woman is scheduled for a volar plating of a distal radius fracture. She has a high risk profile for developing Complex Regional Pain Syndrome (CRPS) Type I. Which of the following prophylactic medications, started at the time of injury or surgery, has been shown in some studies to decrease the risk of developing CRPS?

. Gabapentin 300 mg daily
. Vitamin C 500 mg daily
. Amitriptyline 25 mg daily
. Prednisone 10 mg daily
. Alendronate 70 mg weekly

Correct Answer & Explanation

. Vitamin C 500 mg daily

Explanation

Vitamin C (ascorbic acid), typically dosed at 500 mg daily for 50 days following a distal radius fracture, has been shown in some randomized controlled trials to significantly reduce the incidence of Complex Regional Pain Syndrome (CRPS) Type I. While gabapentin and amitriptyline are used to treat neuropathic pain, they are not established as standard prophylaxis for CRPS.

Question 4944

Topic: 7. Hand and Wrist

A 35-year-old man presents with his index finger locked in 30 degrees of flexion at the metacarpophalangeal (MCP) joint after a minor twisting injury. He can actively flex the finger further, but he absolutely cannot extend it, either actively or passively. Radiographs are negative for fracture. What is the most common anatomical cause for this specific clinical entity?

. Entrapment of the proper collateral ligament behind the metacarpal head condyle
. Interposition of the volar plate into the MCP joint space
. Rupture and subluxation of the sagittal band
. Bony loose body within the joint space
. Triggering of the flexor digitorum superficialis at the A1 pulley

Correct Answer & Explanation

. Entrapment of the proper collateral ligament behind the metacarpal head condyle

Explanation

A locked MCP joint (most commonly affecting the index finger) typically occurs when the prominent radial condyle of the metacarpal head catches the proper collateral ligament or accessory collateral ligament. The joint is locked in flexion (usually around 30 degrees) and resists both active and passive extension, while further flexion is often preserved. Volar plate interposition can happen but is less common and usually prevents flexion.

Question 4945

Topic: 7. Hand and Wrist
A 48-year-old laborer undergoes a four-corner fusion (capitate, hamate, lunate, triquetrum) with scaphoid excision for Scaphoid Nonunion Advanced Collapse (SNAC) stage III. Following complete rehabilitation, what is the anticipated remaining range of motion of the wrist relative to the uninjured contralateral side?
. 20% flexion/extension and 30% radioulnar deviation
. 50% flexion/extension and 50% radioulnar deviation
. 80% flexion/extension and 80% radioulnar deviation
. 100% flexion/extension but zero radioulnar deviation
. Minimal to zero motion; it functions essentially as a total wrist arthrodesis

Correct Answer & Explanation

. 50% flexion/extension and 50% radioulnar deviation

Explanation

A four-corner fusion (scaphoid excision and fusion of the lunate, capitate, hamate, and triquetrum) is a salvage procedure for SNAC and SLAC wrists. Biomechanical studies and clinical outcomes show that this procedure preserves approximately 50% of normal wrist flexion/extension arc and 50% of radioulnar deviation, while maintaining roughly 80% of grip strength.

Question 4946

Topic: 7. Hand and Wrist
A 30-year-old male is diagnosed with Lichtman Stage IIIA Kienböck's disease (lunate collapse without scaphoid rotation or fixed carpal instability). Radiographs demonstrate a negative ulnar variance of 2 mm. Which of the following is the most appropriate surgical treatment for this patient?
. Radial shortening osteotomy
. Capitate shortening osteotomy
. Proximal row carpectomy
. Total wrist arthrodesis
. Scaphoid-trapezium-trapezoid (STT) fusion

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

In Kienböck's disease (avascular necrosis of the lunate), the treatment depends on the Lichtman stage and ulnar variance. For early stages with lunate fragmentation/collapse but no carpal instability (Stage II or IIIA) in a patient with negative ulnar variance, joint leveling procedures, particularly a radial shortening osteotomy, are considered the gold standard. This unloads the lunate by re-distributing axial loads to the ulnocarpal joint.

Question 4947

Topic: Nerve & Tendon

A 45-year-old cyclist reports numbness and tingling strictly isolated to the volar aspect of his right small finger and the volar-ulnar half of his ring finger. Sensation over the dorso-ulnar aspect of his hand is perfectly normal. He also exhibits intrinsic muscle weakness (positive Wartenberg sign and Froment sign). Where is the most likely site of compression?

. Cubital tunnel
. Arcade of Struthers
. Guyon's canal (Zone 1)
. Guyon's canal (Zone 2)
. Guyon's canal (Zone 3)

Correct Answer & Explanation

. Guyon's canal (Zone 1)

Explanation

The dorsal ulnar cutaneous nerve branches off the ulnar nerve ~5-8 cm proximal to the wrist. Because his dorso-ulnar sensation is preserved, the lesion must be at or distal to the wrist (Guyon's canal). Guyon's canal has 3 zones. Zone 1 (proximal to bifurcation) contains both motor and sensory fibers. Zone 2 contains only the deep motor branch. Zone 3 contains only the superficial sensory branch. Since he has BOTH sensory (volar digits) and motor deficits, the compression is in Zone 1.

Question 4948

Topic: 7. Hand and Wrist

A 5-year-old child sustains a deep palmar friction burn from a treadmill. The wound requires debridement and grafting. To prevent an adduction contracture of the first web space during the healing process, what is the optimal splinting position for the thumb?

. Full adduction and retropulsion
. Palmar abduction and extension
. Opposition to the small finger with PIP joints flexed
. Thumb interphalangeal joint in 30 degrees of flexion with MCP in neutral
. Wrist in 45 degrees of flexion with the thumb resting in neutral

Correct Answer & Explanation

. Palmar abduction and extension

Explanation

Palmar burns are highly prone to severe contractures during wound healing. The first web space is particularly vulnerable to adduction contracture, which severely limits hand function (grasp and pinch). The optimal splinting position to maximize the thumb web space and counteract the scar contraction force is positioning the thumb in palmar abduction and extension.

Question 4949

Topic: 7. Hand and Wrist

A 42-year-old woman with advanced systemic sclerosis (scleroderma) presents with severe, medically refractory Raynaud's phenomenon and multiple chronic ischemic digital ulcers. She has failed trials of calcium channel blockers, PDE-5 inhibitors, and intravenous prostaglandins. Which of the following surgical interventions is most likely to improve digital perfusion and facilitate ulcer healing in this patient?

. Digital sympathectomy via adventitial stripping of the common and proper digital arteries
. Proximal row carpectomy to decrease compartmental pressure
. A1 pulley release of the affected digits
. Microvascular toe-to-hand transfer
. Carpal tunnel release alone

Correct Answer & Explanation

. Digital sympathectomy via adventitial stripping of the common and proper digital arteries

Explanation

In patients with severe, medically refractory Raynaud's phenomenon or scleroderma who develop ischemic digital ulcers, surgical periarterial sympathectomy (digital sympathectomy) is indicated. This involves stripping the adventitia of the common and proper digital arteries, which interrupts the overactive sympathetic nerve fibers that run in the adventitia, thereby relieving vasospasm, reducing pain, and promoting ulcer healing.

Question 4950

Topic: Wrist & Carpus

An orthopedic researcher conducts a randomized controlled trial comparing two types of cast materials for distal radius fractures. The study fails to find a statistically significant difference, although a true clinical difference exists in reality. Which of the following would have most effectively decreased the probability of committing this Type II error?

. Decreasing the sample size of the trial
. Decreasing the statistical significance level (alpha) from 0.05 to 0.01
. Increasing the sample size to power the study adequately
. Utilizing a per-protocol analysis instead of an intention-to-treat analysis
. Increasing the random measurement error of the outcomes

Correct Answer & Explanation

. Increasing the sample size to power the study adequately

Explanation

A Type II error (beta) occurs when a study fails to reject a false null hypothesis (a false negative). The probability of avoiding a Type II error is known as statistical power (Power = 1 - beta). Increasing the sample size is the most direct and practical method to increase a study's statistical power, thereby decreasing the risk of a Type II error.

Question 4951

Topic: 7. Hand and Wrist

To minimize occupational radiation exposure during orthopedic procedures utilizing a C-arm fluoroscope, which of the following intraoperative configurations exposes the operating surgeon's hands to the highest dose of scatter radiation?

. Positioning the X-ray tube below the operating table and the image intensifier above
. Positioning the X-ray tube above the patient and the image intensifier below
. Utilizing precise tight collimation to the area of interest
. Maximizing the distance between the patient and the X-ray tube
. Utilizing pulsed fluoroscopy instead of continuous mode

Correct Answer & Explanation

. Positioning the X-ray tube above the patient and the image intensifier below

Explanation

In fluoroscopy, the majority of the radiation exposure to the surgical team is scatter radiation reflecting back from the patient. Because the beam is most intense as it exits the X-ray tube and strikes the patient, positioning the X-ray tube above the patient directs the highest intensity of scatter outward toward the upper bodies and hands of the operating personnel. The preferred, safer setup is the X-ray tube below the table.

Question 4952

Topic: 7. Hand and Wrist
A 26-year-old carpenter presents with progressive dorsal wrist pain and decreased grip strength. Radiographs reveal sclerosis and early collapse of the lunate, with an ulnar variance of negative 3 mm. There is no evidence of radiocarpal osteoarthritis. Which of the following surgical interventions is most appropriate?
. Proximal row carpectomy
. Total wrist arthrodesis
. Radial shortening osteotomy
. Ulnar lengthening osteotomy
. Lunate excision and silastic implant arthroplasty

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

The clinical and radiographic findings describe Kienböck's disease (avascular necrosis of the lunate) with negative ulnar variance and no osteoarthritis (Lichtman Stage II or IIIA). The primary goal of surgery in this stage is to unload the lunate. Joint-leveling procedures, particularly a radial shortening osteotomy, are the treatment of choice for symptomatic patients with negative ulnar variance to redistribute loads away from the radiolunate joint.

Question 4953

Topic: Nerve & Tendon

During an exploration of a Zone II flexor tendon injury, the anatomical relationship of the flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) is evaluated. At what anatomical level does the FDS tendon bifurcate to allow the FDP tendon to pass superficially?

. A1 pulley
. A2 pulley
. C1 pulley
. A3 pulley
. A4 pulley

Correct Answer & Explanation

. A2 pulley

Explanation

The FDS tendon bifurcates at the level of the A1 pulley, allowing the FDP to pass superficially. The two slips of the FDS then reunite dorsal to the FDP tendon at Camper's chiasm, which is located at the level of the A2 pulley, before finally inserting on the middle phalanx.

Question 4954

Topic: Nerve & Tendon

During the physical examination of a patient with severe cubital tunnel syndrome, the examiner observes that the patient's small finger rests in a persistently abducted position. This finding (Wartenberg's sign) is caused by the unopposed action of which muscle?

. Abductor digiti minimi
. Extensor digiti minimi
. Third palmar interosseous
. Fourth dorsal interosseous
. Lumbrical to the small finger

Correct Answer & Explanation

. Third palmar interosseous

Explanation

Wartenberg's sign is the persistent abduction of the small finger seen in severe ulnar neuropathy. It occurs because the ulnar-innervated third palmar interosseous muscle (which normally adducts the small finger) is weak, leaving the radial-innervated extensor digiti minimi (and the extensor digitorum communis to the small finger) unopposed. These extensors have a naturally abducted line of pull.

Question 4955

Topic: 7. Hand and Wrist

To prevent bowstringing of the flexor tendons in the hand following a flexor tendon repair, preservation or reconstruction of which of the following combinations of pulleys is considered absolutely essential?

. A1 and A3
. A2 and A4
. A1 and A5
. A3 and C1
. C2 and C3

Correct Answer & Explanation

. A2 and A4

Explanation

The A2 and A4 pulleys are the major biomechanical pulleys in the digital flexor sheath, preventing bowstringing. They arise directly from the periosteum of the proximal and middle phalanges, respectively. Loss of these pulleys leads to clinically significant bowstringing, drastically decreasing tendon excursion efficiency and active interphalangeal joint flexion.

Question 4956

Topic: 7. Hand and Wrist

A 40-year-old typist complains of aching pain in the proximal volar forearm and numbness in the thumb, index, and middle fingers. Phalen's test is negative at the wrist, but resisted pronation of the forearm reliably exacerbates the numbness. Sensation over the thenar eminence is diminished. What is the most likely diagnosis?

. Cubital tunnel syndrome
. Anterior interosseous nerve syndrome
. Carpal tunnel syndrome
. Pronator syndrome
. Thoracic outlet syndrome

Correct Answer & Explanation

. Pronator syndrome

Explanation

The patient's symptoms denote Pronator syndrome, a proximal median nerve compression neuropathy. It is distinguished from carpal tunnel syndrome (CTS) by the presence of proximal forearm pain, aggravation by resisted pronation, and importantly, decreased sensation over the thenar eminence (innervated by the palmar cutaneous branch of the median nerve, which branches proximal to the carpal tunnel and is therefore spared in CTS).

Question 4957

Topic: 7. Hand and Wrist
Following a flexor tendon repair in the hand, the tendon undergoes predictable biological stages of healing. During which phase does the ultimate tensile strength of the tendon reach its maximum level?
. Inflammatory phase
. Fibroblastic phase
. Remodeling phase
. Hemostasis phase
. Resorptive phase

Correct Answer & Explanation

. Remodeling phase

Explanation

The remodeling phase (also known as the maturation phase) occurs from approximately 6 weeks up to 1 year. During this time, Type III collagen is replaced by Type I collagen along the axis of tension, maximizing tensile strength.

Question 4958

Topic: 7. Hand and Wrist

A new diagnostic clinical test for carpal tunnel syndrome correctly identifies 90 out of 100 patients who have the condition, and returns a negative result for 80 out of 100 patients who do not have it. What is the sensitivity of this new clinical test?

. 80%
. 85%
. 90%
. 95%
. 100%

Correct Answer & Explanation

. 90%

Explanation

Sensitivity is the true positive rate, calculated as True Positives divided by the sum of True Positives and False Negatives. Since the test correctly identifies 90 out of 100 patients with the disease, its sensitivity is 90%.

Question 4959

Topic: 7. Hand and Wrist
A 45-year-old manual laborer presents with chronic wrist pain and a history of an untreated scaphoid fracture 5 years ago. Radiographs reveal a scaphoid nonunion with advanced arthritic changes at the radioscaphoid and capitolunate joints. The radiolunate joint remains completely spared. Which of the following motion-preserving procedures is most appropriate?
. Proximal row carpectomy (PRC)
. Four-corner fusion with scaphoid excision
. Radioscapholunate (RSL) fusion
. Total wrist arthrodesis
. Scaphoid excision alone

Correct Answer & Explanation

. Four-corner fusion with scaphoid excision

Explanation

The clinical picture describes Stage III SNAC (Scaphoid Non-union Advanced Collapse) wrist, characterized by involvement of the radioscaphoid and capitolunate joints. Because the capitolunate joint is arthritic, a proximal row carpectomy (PRC) is contraindicated (as the capitate head would articulate with the lunate fossa). The best motion-preserving option is a four-corner fusion (capitate, hamate, triquetrum, lunate) with scaphoid excision.

Question 4960

Topic: 7. Hand and Wrist

During a flexor tendon repair in Zone II of the hand, maintaining the integrity of the pulley system is crucial to prevent bowstringing. Which two pulleys are the most biomechanically critical and should be preserved or reconstructed if injured?

. A1 and A3
. A2 and A4
. A1 and A5
. A3 and C1
. A2 and C2

Correct Answer & Explanation

. A2 and A4

Explanation

The flexor tendon pulley system prevents bowstringing of the tendons during finger flexion. The A2 pulley (located over the proximal phalanx) and the A4 pulley (located over the middle phalanx) are the most biomechanically critical for flexor tendon function and must be preserved or reconstructed to maintain the mechanical advantage of the flexor tendons.

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