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7. Hand and Wrist MCQs

Practice Set 262 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 5221

Topic: 7. Hand and Wrist

A 35-year-old male presents with a painless lump in his hand after a minor bump. Radiographs show a well-circumscribed, lytic lesion in the proximal phalanx with stippled calcifications.

What is the most appropriate management for a confirmed non-pathologic, asymptomatic enchondroma in this location?

. Immediate curettage and bone grafting
. Ray amputation
. Observation with serial radiographs
. Neoadjuvant chemotherapy
. Wide local excision

Correct Answer & Explanation

. Observation with serial radiographs

Explanation

Asymptomatic enchondromas in the hand without impending fracture are generally observed. If a pathologic fracture occurs, the fracture is allowed to heal before curettage and grafting are considered.

Question 5222

Topic: 7. Hand and Wrist

A 22-year-old female presents with multiple asymmetrical cartilaginous lesions in her long bones and hands, associated with soft-tissue hemangiomas. Which of the following genetic mutations is most characteristic of her underlying syndrome?

. EXT1
. GNAS
. IDH1
. NF1
. RB1

Correct Answer & Explanation

. IDH1

Explanation

This patient has Maffucci syndrome, characterized by multiple enchondromas and soft-tissue hemangiomas. Both Ollier disease and Maffucci syndrome are frequently associated with somatic mutations in the IDH1 or IDH2 genes.

Question 5223

Topic: 7. Hand and Wrist

A 32-year-old man presents with a 4-month history of increasing right wrist pain and boggy dorsal swelling. Radiographs show increased density and fragmentation of the lunate. This condition is classically associated with which of the following anatomic variants?

. Ulnar-positive variance
. Ulnar-negative variance
. Madelung deformity
. Carpal coalition
. Scapholunate dissociation

Correct Answer & Explanation

. Ulnar-negative variance

Explanation

Correct Answer: BThe patient has Kienbock's disease (osteonecrosis of the lunate), which presents with boggy synovitis of the wrist, decreased range of motion, and often normal radiographs early on. This disease process is classically associated with an ulnar-negative variant. An MRI scan, revealing a low-intensity signal in the lunate, is the best diagnostic tool for early Kienbock's disease.

Question 5224

Topic: 7. Hand and Wrist

A 19-year-old woman sustained the wrist injury shown in the radiographs 6 weeks ago. A decision is made to proceed with surgical fixation. Why is a dorsal approach preferred over a volar approach for this specific fracture pattern?


. It avoids injury to the recurrent motor branch of the median nerve.
. It allows for better visualization and compression of proximal pole fractures.
. It preserves the primary volar blood supply to the scaphoid.
. It prevents postoperative scapholunate advanced collapse (SLAC).
. It allows for simultaneous release of the first dorsal compartment.

Correct Answer & Explanation

. It allows for better visualization and compression of proximal pole fractures.

Explanation

Correct Answer: BDisplaced fractures of the scaphoid are best treated with compression screw fixation. Proximal third (proximal pole) fractures, as seen in this patient, are optimally approached via a dorsal approach to ensure proper reduction and compression. Fractures of the scaphoid waist can be approached either by a volar or a dorsal approach.

Question 5225

Topic: 7. Hand and Wrist

A 32-year-old man presents with increasing right wrist pain, decreased range of motion, and boggy synovitis over the dorsum of the wrist. Radiographs are shown, demonstrating increased density and fragmentation of the lunate. This disease process is classically associated with which of the following anatomic variants?

. Ulnar-positive variance
. Ulnar-negative variance
. Madelung deformity
. Carpal coalition
. Scapholunate dissociation

Correct Answer & Explanation

. Ulnar-negative variance

Explanation

Correct Answer: BThe patient has Kienbock's disease (osteonecrosis of the lunate), which presents with boggy synovitis of the wrist, decreased range of motion, and increased density in the lunate body on radiographs. This disease process is classically associated with an ulnar-negative variant, which is thought to increase shear forces across the lunate.

Question 5226

Topic: 7. Hand and Wrist

A 22-year-old man falls onto an outstretched hand and presents with anatomic snuffbox tenderness. Imaging confirms a non-displaced fracture of the proximal pole of the scaphoid. What is the primary arterial supply to this specific region, and what is its clinical implication?

. Volar carpal branch of the radial artery; requires a volar surgical approach.
. Dorsal carpal branch of the radial artery; prone to avascular necrosis due to retrograde intraosseous flow.
. Ulnar artery deep branch; requires prolonged immobilization.
. Anterior interosseous artery; prone to hypertrophic nonunion.
. Superficial palmar arch; excellent healing potential with conservative care.

Correct Answer & Explanation

. Dorsal carpal branch of the radial artery; prone to avascular necrosis due to retrograde intraosseous flow.

Explanation

The proximal pole of the scaphoid relies almost entirely on retrograde intraosseous blood flow from the dorsal carpal branch of the radial artery. Fractures in this region disrupt this blood supply, resulting in high rates of avascular necrosis and nonunion.

Question 5227

Topic: Nerve & Tendon

A 6-year-old boy falls from the monkey bars and sustains a completely displaced, extension-type supracondylar humerus fracture. Radiographs demonstrate posterolateral displacement of the distal fragment. Which nerve is most likely to be injured in this specific fracture pattern, and what is the classic clinical finding?

. Anterior interosseous nerve; inability to flex the IP joint of the thumb and DIP joint of the index finger
. Radial nerve; inability to extend the wrist and digits
. Ulnar nerve; inability to cross the index and middle fingers
. Median nerve; numbness in the volar aspect of the thumb, index, and middle fingers
. Musculocutaneous nerve; weakness in elbow flexion

Correct Answer & Explanation

. Anterior interosseous nerve; inability to flex the IP joint of the thumb and DIP joint of the index finger

Explanation

Correct Answer: AIn extension-type supracondylar humerus fractures, the direction of displacement dictates the structures at risk. Posterolateral displacement of the distal fragment causes the sharp proximal fragment to displace anteromedially, putting the median nerve—specifically its anterior interosseous nerve (AIN) branch—and the brachial artery at greatest risk. AIN palsy is the most common nerve injury in extension-type supracondylar fractures overall. It is a purely motor nerve, and injury results in the inability to flex the interphalangeal (IP) joint of the thumb (flexor pollicis longus) and the distal interphalangeal (DIP) joint of the index finger (flexor digitorum profundus), leading to an abnormal 'A-OK' sign. Posteromedial displacement puts the radial nerve at risk. Flexion-type fractures put the ulnar nerve at risk.

Question 5228

Topic: Nerve & Tendon

A 5-year-old boy sustains a widely displaced extension-type supracondylar humerus fracture. On examination in the emergency department, he is unable to flex the interphalangeal joint of his thumb and the distal interphalangeal joint of his index finger. He has normal two-point discrimination over the palmar aspect of the hand. Which of the following structures is most likely injured, and what is the expected recovery pattern?

. A) Anterior interosseous nerve; requires immediate surgical exploration
. B) Anterior interosseous nerve; typically resolves spontaneously within 3-6 months
. C) Median nerve; requires immediate surgical exploration
. D) Median nerve; typically resolves spontaneously within 3-6 months
. E) Ulnar nerve; typically resolves spontaneously within 3-6 months

Correct Answer & Explanation

. B) Anterior interosseous nerve; typically resolves spontaneously within 3-6 months

Explanation

Correct Answer: BThe patient exhibits a classic "OK sign" deficit, indicating an inability to flex the flexor pollicis longus (FPL) and the flexor digitorum profundus (FDP) to the index finger. This is the hallmark of an anterior interosseous nerve (AIN) palsy. The AIN is a purely motor branch of the median nerve, which aligns with the patient's normal sensation in the hand. AIN injury is the most common neurologic deficit associated with extension-type supracondylar humerus fractures (often due to traction or contusion over the proximal fracture fragment). The vast majority of these injuries are neuropraxias that resolve spontaneously. Observation for 3 to 6 months is the standard of care. Immediate exploration (Option A) is not indicated for isolated, closed nerve injuries in this setting. The median nerve proper (Options C and D) would present with sensory deficits in the palmar thumb, index, and middle fingers. Ulnar nerve injuries (Option E) are more commonly associated with flexion-type supracondylar fractures or iatrogenic injury from medial pin placement.

Question 5229

Topic: Nerve & Tendon

A 6-year-old boy sustained a lateral condyle humerus fracture that was treated nonoperatively with 4 mm of displacement. He now presents 2 years later with a symptomatic nonunion. Which of the following deformities and late nerve palsies are most commonly associated with this complication?

. Cubitus varus and median nerve palsy
. Cubitus valgus and ulnar nerve palsy
. Cubitus varus and ulnar nerve palsy
. Cubitus valgus and median nerve palsy
. Cubitus valgus and radial nerve palsy

Correct Answer & Explanation

. Cubitus valgus and ulnar nerve palsy

Explanation

Nonunion of lateral condyle humerus fractures typically leads to a progressive cubitus valgus deformity. Over time, the valgus alignment stretches the ulnar nerve, resulting in a tardy ulnar nerve palsy.

Question 5230

Topic: 7. Hand and Wrist

A 55-year-old female with end-stage renal disease presents with diffuse bone pain. Radiographs of her hands are obtained to evaluate for secondary hyperparathyroidism. What is the classic and earliest radiographic hallmark of this condition in the hand?

. Subperiosteal resorption on the radial aspect of the middle phalanges
. Cortical tunneling of the metacarpal shafts
. Acro-osteolysis of the distal phalangeal tufts
. Punched-out lytic lesions with overhanging edges at the DIP joints
. Thickened cortices with prominent trabeculae in the proximal phalanges

Correct Answer & Explanation

. Subperiosteal resorption on the radial aspect of the middle phalanges

Explanation

Secondary hyperparathyroidism classically presents with subperiosteal bone resorption. The earliest and most sensitive radiographic location for this finding is the radial aspect of the middle phalanges of the index and middle fingers.

Question 5231

Topic: 7. Hand and Wrist

A 54-year-old woman with chronic kidney disease presents with diffuse skeletal pain. Radiographs of her hand show characteristic lesions

. Where is the classic earliest location of the subperiosteal resorption associated with this condition?

. Ulnar aspect of proximal phalanges
. Radial aspect of middle phalanges
. Distal tufts
. Carpal bones
. Metacarpal heads

Correct Answer & Explanation

. Radial aspect of middle phalanges

Explanation

The earliest and most classic radiographic finding in hyperparathyroidism is subperiosteal bone resorption. This typically occurs on the radial aspect of the middle phalanges of the index and middle fingers.

Question 5232

Topic: 7. Hand and Wrist

A 10-year-old girl has a projected leg length discrepancy of 4 cm at maturity and is deemed a candidate for percutaneous epiphysiodesis. Which imaging parameter is most critical for accurate timing of the procedure?

. Standing long-leg AP radiograph
. MRI of the knee physes
. AP radiograph of the left hand and wrist
. CT scan of the lower extremities
. Lateral radiograph of the calcaneus

Correct Answer & Explanation

. AP radiograph of the left hand and wrist

Explanation

An AP radiograph of the left hand and wrist is required to determine bone age (via the Greulich and Pyle atlas). Accurate bone age determination is the most critical factor for predicting remaining growth and timing an epiphysiodesis.

Question 5233

Topic: 7. Hand and Wrist

A 12-year-old girl requires an epiphysiodesis for a predicted leg length discrepancy of 3.5 cm. To accurately calculate the timing of the procedure using the Green-Anderson growth remaining charts, bone age is determined using which standard imaging modality?

. Anteroposterior radiograph of the left hand and wrist
. Lateral radiograph of the cervical spine
. Anteroposterior radiograph of the pelvis (Risser stage)
. Anteroposterior radiograph of the left knee
. Dual-energy X-ray absorptiometry (DEXA) scan

Correct Answer & Explanation

. Anteroposterior radiograph of the left hand and wrist

Explanation

The Greulich and Pyle atlas, which is commonly used to determine bone age for the Green-Anderson charts, is based on a standard anteroposterior (AP) radiograph of the left hand and wrist.

Question 5234

Topic: 7. Hand and Wrist

A 6-year-old boy sustains a widely displaced extension-type supracondylar humerus fracture. He subsequently develops severe, unrelenting forearm pain exacerbated by passive finger extension. If left untreated, this condition will most likely progress to a contracture primarily involving which of the following muscle groups?

. Wrist extensors and supinators
. Wrist flexors and forearm pronators
. Intrinsic muscles of the hand
. Biceps brachii and brachialis
. Triceps brachii and anconeus

Correct Answer & Explanation

. Wrist flexors and forearm pronators

Explanation

Correct Answer: Wrist flexors and forearm pronatorsThe patient is presenting with signs of acute compartment syndrome, a feared complication of supracondylar humerus fractures. If untreated, the ischemia leads to muscle necrosis and subsequent fibrosis, known as Volkmann's ischemic contracture. The deep flexor compartment of the forearm (specifically the flexor digitorum profundus and flexor pollicis longus) is most severely affected due to its proximity to the anterior interosseous artery and median nerve, leading to a classic flexion contracture of the wrist and fingers.

Question 5235

Topic: 7. Hand and Wrist

A 42-year-old avid cyclist presents with numbness in the small finger and ulnar half of the ring finger, consistent with Guyon's canal syndrome. Which of the following structures forms the lateral boundary of this anatomic canal?

. Pisiform
. Hook of the hamate
. Volar carpal ligament
. Transverse carpal ligament
. Flexor carpi ulnaris tendon

Correct Answer & Explanation

. Hook of the hamate

Explanation

Correct Answer: Hook of the hamateGuyon's canal (the ulnar tunnel) is a fibro-osseous tunnel at the wrist through which the ulnar nerve and artery pass. The boundaries are: the volar carpal ligament (roof), the transverse carpal ligament and pisohamate ligament (floor), the pisiform (medial wall), and the hook of the hamate (lateral wall). Compression here, often seen in cyclists ('handlebar palsy'), affects the ulnar nerve.

Question 5236

Topic: 7. Hand and Wrist

Guyon's canal syndrome involves compression of the ulnar nerve at the wrist. Which of the following structures forms the floor of this anatomical canal?

. Volar carpal ligament
. Transverse carpal ligament and pisohamate ligament
. Hook of the hamate and pisiform
. Flexor retinaculum and palmar aponeurosis
. Flexor carpi ulnaris tendon

Correct Answer & Explanation

. Transverse carpal ligament and pisohamate ligament

Explanation

Correct Answer: BGuyon's canal is a fibro-osseous tunnel at the ulnar aspect of the wrist. The roof is formed by the volar carpal ligament. The floor is formed by the transverse carpal ligament (flexor retinaculum) and the pisohamate ligament. The medial (ulnar) boundary is the pisiform, and the lateral (radial) boundary is the hook of the hamate.

Question 5237

Topic: 7. Hand and Wrist

Stable, non-displaced scaphoid fractures are at risk of nonunion due to the bone's precarious blood supply. Which of the following best describes the primary arterial supply to the proximal pole of the scaphoid?

. Volar carpal branch of the radial artery entering distally
. Dorsal carpal branch of the radial artery entering distally and flowing retrogradely
. Ulnar artery branches entering the proximal pole directly
. Anterior interosseous artery entering the waist
. Superficial palmar arch branches entering proximally

Correct Answer & Explanation

. Dorsal carpal branch of the radial artery entering distally and flowing retrogradely

Explanation

Correct Answer: Dorsal carpal branch of the radial artery entering distally and flowing retrogradelyThe primary blood supply to the scaphoid comes from the dorsal carpal branch of the radial artery, which enters the bone at the dorsal ridge near the distal pole and flows retrogradely to supply the proximal pole. This retrograde blood supply makes proximal pole fractures highly susceptible to avascular necrosis and nonunion.

Question 5238

Topic: 7. Hand and Wrist

A 45-year-old female presents with numbness in her ring and small fingers along with weakness in finger abduction. However, she maintains normal sensation over the dorso-ulnar aspect of her hand. Where is the most likely site of nerve compression?

. Cubital tunnel
. Arcade of Struthers
. Guyon's canal
. Carpal tunnel
. Spiral groove

Correct Answer & Explanation

. Guyon's canal

Explanation

Sparing of the dorsal ulnar cutaneous nerve, which branches from the ulnar nerve approximately 5-8 cm proximal to the wrist, localizes the compression to the wrist (Guyon's canal). Cubital tunnel syndrome typically presents with dorsal sensory deficits.

Question 5239

Topic: 7. Hand and Wrist

A 24-year-old man falls on an outstretched hand and sustains a displaced fracture of the proximal pole of the scaphoid. He is at high risk for avascular necrosis. The primary blood supply to the scaphoid enters at which of the following locations?

. Proximal pole via the radial artery
. Volar tubercle via the ulnar artery
. Dorsal ridge via branches of the radial artery
. Distal pole via the anterior interosseous artery
. Waist via the deep palmar arch

Correct Answer & Explanation

. Dorsal ridge via branches of the radial artery

Explanation

The primary blood supply to the scaphoid is retrograde, entering the dorsal ridge via the dorsal carpal branch of the radial artery. This retrograde flow leaves proximal pole fractures highly susceptible to ischemia and avascular necrosis.

Question 5240

Topic: 7. Hand and Wrist

Which of the following describes the characteristic forearm deformity frequently observed in patients with Multiple Hereditary Exostoses (MHE)?

. Proximal radioulnar synostosis with fixed supination
. Ulnar shortening with secondary bowing of the radius and ulnar deviation of the carpus
. Madelung deformity featuring excessive volar tilt of the distal radius
. Isolated dorsal dislocation of the radial head
. Overgrowth of the ulna leading to positive ulnar variance and ulnocarpal impaction

Correct Answer & Explanation

. Ulnar shortening with secondary bowing of the radius and ulnar deviation of the carpus

Explanation

Osteochondromas frequently affect the distal ulna in MHE, causing relative growth arrest (ulnar shortening). The continuously growing radius becomes tethered, leading to radial bowing, radial head dislocation, and ulnar deviation of the hand.

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