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 481
Topic: Nerve & Tendon
Which median nerve symptom is most common in the acute phase following a Colles fracture?
Correct Answer & Explanation
. Paresthesia in the thumb, index, and middle fingers
Explanation
Correct Answer: CIn the acute phase following a Colles fracture, compression or contusion of the median nerve at the carpal tunnel level is common due to swelling and hematoma. This typically presents as paresthesia (numbness and tingling) in the median nerve distribution: the thumb, index finger, middle finger, and radial half of the ring finger. Thenar muscle atrophy is a sign of chronic median nerve compression. Sensory loss in the ulnar digits indicates ulnar nerve involvement. Wrist drop indicates radial nerve palsy. Tinel's sign over the cubital tunnel relates to ulnar nerve compression at the elbow.
Question 482
Topic: Wrist & Carpus
Which classification system for distal radius fractures emphasizes the involvement of the radiocarpal and radioulnar joints?
Correct Answer & Explanation
. Frykman classification
Explanation
Correct Answer: BThe Frykman classification system is widely used for distal radius fractures and is based on the involvement of the radiocarpal and radioulnar joints (articular vs. extra-articular, and presence/absence of ulnar styloid fracture). The AO classification is more complex and describes fracture patterns by location (metaphyseal), articular involvement (extra-articular, partial articular, complete articular), and comminution. Gartland and Werley primarily assess outcome. Universal classification is another system that considers similar parameters as Frykman. Fernandez classification is based on the mechanism of injury and fracture morphology.
Question 483
Topic: 7. Hand and Wrist
A common late complication of a malunited Colles fracture with significant dorsal angulation and radial shortening is:
Correct Answer & Explanation
. Extensor pollicis longus (EPL) rupture
Explanation
Correct Answer: AA common late complication of a malunited Colles fracture, particularly with significant dorsal angulation, is rupture of the Extensor Pollicis Longus (EPL) tendon. The sharp dorsal prominence of the malunited distal radius can cause attrition and eventual rupture of the EPL tendon as it traverses Lister's tubercle. Avascular necrosis of the scaphoid is typically associated with scaphoid fractures. Acute carpal tunnel syndrome and compartment syndrome are early complications. Ulnar nerve palsy is less directly related to Colles malunion itself.
Question 484
Topic: 7. Hand and Wrist
A 22-year-old male falls onto an outstretched hand and sustains a nondisplaced waist fracture of the scaphoid. What is the primary source of blood supply to the proximal pole of the scaphoid?
Correct Answer & Explanation
. Dorsal carpal branch of the radial artery
Explanation
The dorsal carpal branch of the radial artery supplies 70-80% of the scaphoid, entering distally and traveling in a retrograde fashion to supply the proximal pole. This retrograde blood supply is the primary reason proximal pole fractures are at high risk for avascular necrosis.
Question 485
Topic: 7. Hand and Wrist
A 19-year-old male falls onto an outstretched hand and sustains a fracture of the proximal pole of the scaphoid. He is counseled regarding the high risk of nonunion and avascular necrosis. The primary blood supply to the proximal pole of the scaphoid is derived from which of the following?
Correct Answer & Explanation
. Dorsal carpal branch of the radial artery
Explanation
The dorsal carpal branch of the radial artery provides the dominant blood supply to the scaphoid. It enters distally and flows retrogradely to the proximal pole, making proximal pole fractures highly susceptible to avascular necrosis.
Question 486
Topic: 7. Hand and Wrist
A 45-year-old female undergoes an open carpal tunnel release. To safely decompress the median nerve, the surgeon must be aware of the anatomical variations of the recurrent motor branch. What is the most common anatomical pathway of the recurrent motor branch of the median nerve in relation to the transverse carpal ligament?
Correct Answer & Explanation
. Extraligamentous
Explanation
The extraligamentous pathway is the most common anatomical variant (approximately 50% of cases). The recurrent motor branch exits the median nerve distal to the transverse carpal ligament and recurrently enters the thenar musculature.
Question 487
Topic: 7. Hand and Wrist
A 55-year-old male presents with deteriorating handwriting, frequent dropping of objects, and a broad-based gait. On physical examination, flicking the distal phalanx of the middle finger results in reflexive flexion of the thumb and index finger. This clinical sign indicates pathology in which of the following anatomical locations?
Correct Answer & Explanation
. Cervical spinal cord
Explanation
The patient is exhibiting Hoffman's sign, which is an upper motor neuron (UMN) sign indicative of cervical myelopathy (spinal cord compression). It represents hyperreflexia and loss of descending inhibition.
Question 488
Topic: Nerve & Tendon
A 6-year-old boy falls from the monkey bars and sustains an extension-type supracondylar humerus fracture. Upon neurologic examination, he is unable to flex the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger. Which nerve has most likely been injured?
Correct Answer & Explanation
. Anterior interosseous nerve
Explanation
The anterior interosseous nerve (AIN), a branch of the median nerve, is the most commonly injured nerve in extension-type supracondylar humerus fractures. Injury presents as the inability to make an 'OK' sign due to weakness of the flexor pollicis longus and flexor digitorum profundus to the index finger.
Question 489
Topic: 7. Hand and Wrist
A 28-year-old right-hand dominant carpenter sustains a laceration to his left ring finger while using a power saw. On examination, he is unable to actively flex his DIP joint, and his PIP joint flexion is significantly weakened compared to his uninjured digits. Sensation is intact. Radiographs show no bony injury. He is scheduled for surgical repair within 24 hours. Based on the provided case information, which of the following statements regarding his injury and initial management is MOST accurate?
Correct Answer & Explanation
. The A2 and A4 pulleys are the most critical to preserve, and repair of both FDS and FDP is generally recommended in this zone if technically feasible.
Explanation
Correct Answer: CExplanation:The patient's inability to actively flex the DIP joint indicates a laceration of the Flexor Digitorum Profundus (FDP) tendon, as the FDP is solely responsible for DIP flexion. Weakened PIP joint flexion, despite some residual motion, suggests involvement of the Flexor Digitorum Superficialis (FDS) tendon, which is the primary flexor of the PIP joint. The ring finger is a common site for flexor tendon injuries. Given both FDP and FDS involvement, the injury is most likely in Zone II (from the A1 pulley to the FDS insertion), also known as "No Man's Land."Option C is correct:The case explicitly states that the A2 and A4 pulleys are considered biomechanically most critical for maintaining function, and their disruption can lead to significant bowstringing. It also notes that in Zone II, if both FDS and FDP are lacerated, repair of both tendons is generally recommended, especially if more than 50% of the FDS slips are involved, provided it does not add significant bulk.Option A is incorrect:Zone I involves only the FDP, distal to the FDS insertion. Since both FDS and FDP appear to be involved (DIP and PIP flexion deficits), the injury is more consistent with Zone II.Option B is incorrect:While preventing rerupture is a goal, the case emphasizes that post-operative rehabilitation involves controlled motion protocols (e.g., Duran, Kleinert, or Early Active Motion) to minimize adhesion formation, not strict immobilization for 6 weeks, which would lead to severe stiffness.Option D is incorrect:The case states that the typical critical threshold for a secure repair, allowing early active mobilization protocols, is considered to be greater than 45-50 Newtons (N) of tensile strength. 20 N is insufficient for early active motion.Option E is incorrect:The Brunner zig-zag incision is described as the most common and preferred approach for flexor tendon repairs in the digits because it crosses flexion creases obliquely, preventing scar contracture, and allows adequate exposure while protecting neurovascular structures with careful dissection. It is not contraindicated.
Question 490
Topic: 7. Hand and Wrist
A 35-year-old construction worker presents to the emergency department 4 weeks after sustaining a deep laceration to his dominant index finger. He initially delayed seeking medical attention due to personal reasons. On examination, he has a complete loss of active flexion at both the PIP and DIP joints of the index finger. The wound is clean and well-healed. Passive range of motion is significantly limited due to stiffness. Based on the case, what is the MOST appropriate management strategy for this patient?
Correct Answer & Explanation
. A staged flexor tendon reconstruction using a Hunter rod (silastic implant).
Explanation
Correct Answer: CExplanation:The patient presents 4 weeks post-injury with complete loss of active flexion and significant passive stiffness. The case states that "Prolonged Delay: Beyond 3-4 weeks, significant tendon retraction, muscle contracture, and fibrosis can make primary repair impossible without excessive tension. Tendon grafting or two-stage reconstruction using a Hunter rod (silastic implant) may be necessary."Option C is correct:Given the 4-week delay and likely significant tendon retraction and fibrosis, a primary repair is unlikely to be feasible without excessive tension, which would lead to repair failure. A staged flexor tendon reconstruction using a Hunter rod (silastic implant) is the most appropriate approach for chronic tears with significant retraction and fibrosis, as outlined in the Indications & Contraindications table.Option A is incorrect:Immediate primary repair is indicated for acute lacerations (within 7-10 days, or up to 3 weeks for delayed primary repair). At 4 weeks, the conditions for primary repair are typically no longer met.Option B is incorrect:Delayed primary repair is generally feasible up to 3 weeks. Beyond this, the challenges of retraction and fibrosis make it less viable.Option D is incorrect:While hand therapy is crucial post-operatively, it cannot restore tendon continuity. Attempting aggressive passive range of motion without addressing the tendon laceration would be ineffective and potentially harmful.Option E is incorrect:Excision of the A2 and A4 pulleys is generally avoided as they are critical for preventing bowstringing. While some pulley incision may be necessary for access during acute repair, complete excision is not a standard approach, especially not to facilitate a repair that is already likely contraindicated due to delay.
Question 491
Topic: 7. Hand and Wrist
A 42-year-old chef undergoes repair of a complete flexor digitorum profundus (FDP) laceration in Zone I of his small finger. Post-operatively, he is placed in a dorsal blocking splint and begins a controlled passive motion (Duran) protocol. Which of the following statements accurately describes a key principle or characteristic of the Duran protocol as outlined in the case?
Correct Answer & Explanation
. It requires the patient to passively flex and extend the DIP and PIP joints using the uninjured hand.
Explanation
Correct Answer: CExplanation:The case provides a clear description of the Duran protocol under the "Post-Operative Rehabilitation Protocols" section.Option C is correct:The case states: "Duran Protocol (Controlled Passive Motion): Description: Passive flexion and extension of the DIP and PIP joints within the limits of the dorsal blocking splint, typically 10 repetitions, 4-5 times per day. The patient uses the uninjured hand to passively flex and extend the injured digit's IP joints. No active muscle contraction of the repaired tendon."Option A is incorrect:This describes a key feature of the Kleinert protocol, not Duran.Option B is incorrect:The Duran protocol is a controlled passive motion protocol, meaning there is "No active muscle contraction of the repaired tendon." Active contraction is characteristic of Early Active Motion protocols.Option D is incorrect:The case notes that Early Active Motion (EAM) protocols historically had slightly higher rerupture rates, but modern EAM protocols, when applied to adequately strong repairs, show comparable rerupture rates to passive protocols. Duran, being a passive protocol, is generally considered to have a lower immediate rerupture risk compared to early active protocols, though it carries a higher risk of stiffness if not performed diligently.Option E is incorrect:The protective phase, which includes the Duran protocol, aims to protect the repair and minimize adhesions. Full active range of motion is a gradual process achieved over weeks to months, not within the first week.
Question 492
Topic: 7. Hand and Wrist
A 60-year-old diabetic patient undergoes flexor tendon repair of the ring finger. Three weeks post-operatively, he presents with increasing pain, swelling, redness, and purulent discharge from the surgical site. He also has limited active and passive range of motion. Based on the case, what is the MOST appropriate initial management for this complication?
Correct Answer & Explanation
. Surgical debridement, IV antibiotics, wound culture, and possible tendon debridement.
Explanation
Correct Answer: CExplanation:The patient's symptoms (increasing pain, swelling, redness, purulent discharge) are classic signs of a deep surgical site infection. The case addresses "Infection" as a complication.Option C is correct:The case states under "Complications & Management" for deep/purulent infection: "Surgical debridement, IV antibiotics, wound culture, possible tendon debridement/excision (leading to reconstruction)." This aggressive approach is necessary to control the infection and prevent further damage to the tendon and surrounding tissues.Option A is incorrect:Aggressive hand therapy would be contraindicated in the presence of an active infection, as it could worsen inflammation, spread the infection, and potentially lead to rerupture due to compromised tissue strength.Option B is incorrect:While antibiotics are necessary, oral antibiotics alone are often insufficient for deep or purulent infections following tendon repair. Surgical debridement is crucial to remove infected tissue and foreign material (suture).Option D is incorrect:While rerupture is a possible complication, the primary signs here point to infection. Re-repairing an infected tendon is highly likely to fail and worsen the infection. The infection must be controlled first.Option E is incorrect:A dynamic traction splint is part of rehabilitation for tendon gliding, but it is not appropriate in the setting of an acute infection.
Question 493
Topic: 7. Hand and Wrist
A 30-year-old patient undergoes flexor tendon repair of the middle finger in Zone II. Post-operatively, the hand therapist initiates an Early Active Motion (EAM) protocol. Which of the following is a key characteristic or advantage of EAM protocols, as highlighted in the case, compared to controlled passive motion protocols?
Correct Answer & Explanation
. They involve controlled, gentle active muscle contraction, leading to greater tendon excursion and theoretically reduced adhesions.
Explanation
Correct Answer: CExplanation:The case discusses the advantages and characteristics of Early Active Motion (EAM) protocols in the "Post-Operative Rehabilitation Protocols" section.Option C is correct:The case states: "Early Active Motion (EAM) Protocols... Rationale: Active muscle contraction leads to greater tendon excursion, theoretically reducing adhesions more effectively and leading to faster return of active range of motion." It also mentions that EAM protocols generally demonstrate superior outcomes in terms of active ROM and quicker return to function compared to CPM.Option A is incorrect:The case notes: "While some early EAM protocols had slightly higher rerupture rates historically, modern EAM protocols, when applied to adequately strong repairs, show comparable rerupture rates to passive protocols." So, asignificantlyhigher rate is not accurate for modern EAM.Option B is incorrect:EAM protocols involve controlledmotion, not strict continuous immobilization. Immobilization is characteristic of older, less effective protocols or for very tenuous repairs.Option D is incorrect:EAM protocols require astrongrepair (e.g., 4-6 strand core suture with epitendinous repair) with tensile strength typically greater than 45-50 N, not weak repairs.Option E is incorrect:This describes controlled passive motion (CPM) protocols like Duran, not EAM. EAM involves controlled active muscle contraction.
Question 494
Topic: 7. Hand and Wrist
A 48-year-old patient presents with a "jersey finger" injury, where he forcibly hyperextended his ring finger while grabbing an opponent's jersey, resulting in an avulsion of the FDP tendon from its insertion. This injury is classified as a Zone I flexor tendon injury. According to the case, what is a common method for repairing this specific type of injury?
Correct Answer & Explanation
. Reattaching the FDP to the distal phalanx using techniques like a pull-out suture or suture anchors.
Explanation
Correct Answer: BExplanation:The case specifically addresses Zone I injuries, including FDP avulsions (jersey finger), under "Specific Considerations by Zone."Option B is correct:The case states: "Zone I (FDP Avulsions): Often involve a bony fragment (e.g., 'jersey finger'). Repair involves reattaching the FDP to the distal phalanx (e.g., using a pull-out suture technique through the nail plate, suture anchors, or direct repair if a large bony fragment is present)."Option A is incorrect:Primary repair of FDP to FDS is not the standard for a Zone I FDP avulsion. The FDS inserts more proximally on the middle phalanx.Option C is incorrect:Excision of the FDP would result in permanent loss of DIP flexion, which is not the goal of treatment.Option D is incorrect:A two-stage reconstruction using a Hunter rod is typically reserved for chronic, irreparable tears or failed primary repairs, not acute avulsions.Option E is incorrect:The A2 pulley is located on the proximal phalanx, and repairing the FDP to it would not restore DIP joint function.
Question 495
Topic: 7. Hand and Wrist
A 33-year-old patient undergoes flexor tendon repair of the small finger. Post-operatively, the surgeon and hand therapist decide to implement a Kleinert protocol. Which of the following is a characteristic feature of the Kleinert protocol, as described in the case?
Correct Answer & Explanation
. It utilizes a dynamic traction system to passively flex the digits, with active extension against resistance.
Explanation
Correct Answer: BExplanation:The case provides a clear description of the Kleinert protocol under the "Post-Operative Rehabilitation Protocols" section.Option B is correct:The case states: "Kleinart Protocol (Controlled Passive Motion with Dynamic Traction): Description: Utilizes a dynamic traction system (rubber band attached to the fingernail and a wrist strap) to passively flex the digits into the palm. The patient actively extends the digits against the resistance of the rubber band to the limits of the dorsal blocking splint."Option A is incorrect:This describes a synergistic wrist motion exercise, which is part of some Early Active Motion (EAM) protocols, not Kleinert.Option C is incorrect:This describes a "place and hold" exercise, which is also part of some EAM protocols, not Kleinert.Option D is incorrect:The Kleinert protocol is a controlledmotionprotocol, not strict immobilization.Option E is incorrect:While Kleinert is a passive motion protocol, it still requires a reasonably strong repair. The case does not specify a very low tensile strength requirement for Kleinert; rather, it emphasizes that EAM protocols require strong repairs (45-50 N).
Question 496
Topic: 7. Hand and Wrist
A 28-year-old carpenter lacerates the volar aspect of his index finger at the level of the proximal phalanx, transecting both the flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) tendons. According to the Verdan classification, which zone of flexor tendon injury does this represent?
Correct Answer & Explanation
. Zone II
Explanation
Zone II (historically known as "no man's land") extends from the proximal edge of the A1 pulley to the insertion of the FDS on the middle phalanx. It contains both the FDS and FDP tendons within the tight fibro-osseous sheath.
Question 497
Topic: 7. Hand and Wrist
During a flexor tendon repair in Zone II, careful preservation or reconstruction of the flexor sheath is attempted. Which two annular pulleys are the most critical to preserve to prevent bowstringing and mechanical disadvantage?
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 pulleys. Loss of these pulleys leads to tendon bowstringing and significant loss of active flexion.
Question 498
Topic: 7. Hand and Wrist
Flexor tendons within the digital synovial sheaths of the hand rely on specific mechanisms for nutrition and healing. Which of the following accurately describes their primary mode of nutritional supply?
Correct Answer & Explanation
. A combination of both synovial fluid diffusion and limited vascularity via the vincula
Explanation
Flexor tendons in the digital sheath exhibit a dual mechanism for nutrition: diffusion from the synovial fluid (which is the primary source) and direct perfusion via the segmental blood supply of the vincula.
Question 499
Topic: Nerve & Tendon
The origin of the lumbrical muscles from the flexor digitorum profundus (FDP) tendons serves as the functional anatomic boundary between which two flexor tendon zones in the hand?
Correct Answer & Explanation
. Zones II and III
Explanation
Zone II begins at the proximal edge of the A1 pulley, which corresponds to the distal palmar crease where the lumbrical muscles originate from the FDP tendons. Zone III is located proximal to this boundary, strictly within the palm.
Question 500
Topic: 7. Hand and Wrist
Following a primary flexor tendon repair in the hand, the healing process goes through inflammatory, fibroblastic, and remodeling phases. At what post-operative timeframe is the repaired tendon statistically at its weakest, increasing the risk of spontaneous rupture?
Correct Answer & Explanation
. Days 7-21
Explanation
The tensile strength of a repaired flexor tendon drops significantly during the inflammatory phase as the ends soften. It reaches its weakest point between 1 and 3 weeks (days 7-21) before the fibroblastic phase begins to increase structural strength.
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