Menu

7. Hand and Wrist MCQs

Practice Set 29 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 561

Topic: Nerve & Tendon
During percutaneous pinning of a Gartland Type III supracondylar humerus fracture, the surgeon opts for a medial and lateral crossed pin configuration. Which of the following is the most critical step to minimize the risk of iatrogenic ulnar nerve injury during medial pin placement?
. Inserting the medial pin with the elbow in 90 degrees of flexion.
. Using a smaller diameter K-wire for the medial pin.
. Performing a mini-open technique to palpate and protect the ulnar nerve.
. Inserting the medial pin from a more anterior entry point.
. Ensuring the lateral pin is placed first to stabilize the fracture.

Correct Answer & Explanation

. Performing a mini-open technique to palpate and protect the ulnar nerve.

Explanation

Medial and lateral crossed pins offer theoretically greater stability but carry a higher risk of iatrogenic ulnar nerve injury. Performing a mini-open technique to palpate and protect the ulnar nerve directly is an effective method of protection. Alternatively, the elbow must be fully extended to move the ulnar nerve posteriorly, away from the medial epicondyle.

Question 562

Topic: 7. Hand and Wrist

A 32-year-old right-hand dominant carpenter sustains a clean laceration to the volar aspect of his left ring finger at the level of the proximal phalanx. Examination reveals complete loss of sensation on the ulnar side of the ring finger and a positive Allen's test for the ulnar digital artery of that digit. Doppler ultrasound confirms absent flow in the ulnar proper digital artery. The flexor tendons are intact. Given the surgical anatomy described in the case, which of the following statements best describes the typical anatomical relationship of the proper digital nerve and artery at the mid-phalanx level?

. The proper digital nerve is typically deep and dorsal to the proper digital artery.
. The proper digital nerve and artery are usually found volar to the flexor tendon sheath, with the artery being more superficial.
. The proper digital nerve is generally more superficial and closer to the skin than the artery.
. The proper digital nerve is consistently volar to the proper digital artery throughout the entire digital canal.
. The proper digital nerve and artery are encased within the flexor tendon sheath.

Correct Answer & Explanation

. The proper digital nerve is generally more superficial and closer to the skin than the artery.

Explanation

Correct Answer: CThe case explicitly states under 'Surgical Anatomy & Biomechanics' that 'Distally, their relationship with the arteries can vary, but generally, the nerve is more superficial and closer to the skin than the artery, especially in the mid-phalanx.' This makes the nerve more vulnerable to superficial lacerations at this level.Option A is incorrectbecause while the relationship can vary, the nerve is generally more superficial, not deep and dorsal, at the mid-phalanx. At the DIP joint level, they typically lie dorsally to the digital artery, but this is not the mid-phalanx.Option B is incorrectbecause the nerve is generally more superficial than the artery at the mid-phalanx, not the artery being more superficial. Both are volar to the flexor tendon sheath, but the relative depth differs.Option D is incorrectas the case notes that the relationship 'can vary' distally, and specifically states that at the DIP joint level, the nerve typically lies dorsally to the digital artery, contradicting a consistent volar relationship.Option E is incorrectbecause the case states the neurovascular bundles are 'encased in a delicate fibrofatty sheath within the digital canal, lying volar to the flexor tendon sheath,' not within the sheath itself.

Question 563

Topic: Nerve & Tendon

A 28-year-old patient presents with a 1.5 cm laceration to the radial aspect of the left index finger, sustained 48 hours prior. Examination reveals complete loss of sensation on the radial side of the index finger, with a positive Tinel's sign at the injury site. The digit is well-perfused. Surgical exploration confirms a complete transection of the radial proper digital nerve of the index finger with a 5 mm gap after minimal debridement. Based on the case's guidelines for nerve repair, what is the most appropriate initial surgical management?

. Secondary repair with an autologous nerve graft due to the 5 mm gap.
. Delayed primary repair with a nerve conduit to bridge the gap.
. Epineurial repair (direct primary repair) of the nerve.
. Observation for spontaneous regeneration, as the gap is small.
. Excision of the nerve ends and relocation into a muscle belly to prevent neuroma formation.

Correct Answer & Explanation

. Epineurial repair (direct primary repair) of the nerve.

Explanation

Correct Answer: CThe case states under 'Indications for Surgical Intervention' that 'Acute Repair: Indicated for clean lacerations identified within 72 hours, ideally within 24 hours.' The patient presents within 48 hours, making acute primary repair appropriate. For nerve repair technique, the case states 'Epineurial Repair: This is the most common technique for proper digital nerves... The goal is to align the nerve without rotation and achieve precise coaptation of the fascicular bundles.' A 5 mm gap after minimal debridement is generally manageable with direct, tension-free epineurial repair, especially with gentle mobilization, and does not typically necessitate grafting or conduits which are reserved for larger gaps (>1 cm).Option A is incorrectbecause secondary repair is for missed injuries or failed primary repairs (after 3 weeks), and a 5 mm gap is usually amenable to direct repair, not requiring a graft unless significant tension is present after mobilization.Option B is incorrectbecause delayed primary repair is for conditions preventing immediate repair, which is not the case here (48 hours is within the acute window). Conduits are typically considered for smaller gaps, but direct repair is preferred if tension-free.Option D is incorrectas a complete transection of a proper digital nerve requires surgical repair to optimize functional recovery; observation for spontaneous regeneration is not indicated for complete transections.Option E is incorrectbecause excision and relocation are management strategies for painful neuromas, not for acute nerve transections where the goal is to restore continuity and function.

Question 564

Topic: 7. Hand and Wrist

A 55-year-old diabetic patient presents to the emergency department 10 hours after sustaining a severe crush injury to his left small finger. The digit is pale, cold, and has absent capillary refill. Doppler signals are absent over both proper digital arteries. Radiographs show a comminuted fracture of the proximal phalanx. Given the patient's presentation and the information in the case, what is the most critical immediate surgical priority?

. Open reduction and internal fixation of the proximal phalanx fracture.
. Debridement of devitalized soft tissue and delayed primary nerve repair.
. Immediate revascularization of the digit by repairing the proper digital arteries.
. Excision of any potential neuromas and relocation of nerve ends.
. Application of a static splint and observation for 24 hours to assess viability.

Correct Answer & Explanation

. Immediate revascularization of the digit by repairing the proper digital arteries.

Explanation

Correct Answer: CThe case explicitly states under 'Combined Injuries' that 'In cases of combined digital nerve and artery injury, vascular repair takes precedence if the digit is ischemic. Restoring blood flow is critical for tissue viability.' The patient presents with clear signs of critical digital ischemia (pale, cold, absent capillary refill, absent Doppler signals) 10 hours post-injury, which is beyond the 'golden period' for warm ischemia (6-8 hours) but still within a window where revascularization can salvage the digit. Therefore, immediate revascularization is the paramount priority to prevent irreversible tissue damage and potential necrosis.Option A is incorrectbecause while the fracture needs addressing, it is secondary to restoring blood flow in an ischemic digit.Option B is incorrectbecause nerve repair, even delayed primary, is secondary to establishing vascularity. Debridement is important but must be followed by revascularization.Option D is incorrectas neuroma management is for chronic painful conditions, not acute ischemic emergencies.Option E is incorrectbecause observation for 24 hours in an ischemic digit would lead to irreversible necrosis. Immediate intervention is required.

Question 565

Topic: 7. Hand and Wrist

A 60-year-old patient undergoes microvascular repair of a transected proper digital artery in the ring finger following a replantation attempt. Post-operatively, 4 hours later, the digit becomes cool, pale, and capillary refill is sluggish at 4 seconds. Doppler signals are significantly diminished. The nursing staff immediately notifies the surgeon. Based on the case's discussion of complications, what is the most appropriate immediate management step?

. Administer systemic antibiotics and elevate the hand to reduce swelling.
. Apply topical papaverine to the digit and observe for another 6 hours.
. Initiate systemic anticoagulation with low-molecular-weight heparin and aspirin.
. Immediate re-exploration of the anastomosis for thrombectomy and revision.
. Perform a sympathetic block to alleviate vasospasm.

Correct Answer & Explanation

. Immediate re-exploration of the anastomosis for thrombectomy and revision.

Explanation

Correct Answer: DThe case describes 'Thrombosis of Arterial Repair' as a 'surgical emergency.' It states: 'Signs include a cool, pale, or cyanotic digit, sluggish capillary refill, and absent Doppler signals. Immediate re-exploration is warranted. The anastomosis is opened, any thrombus is removed (thrombectomy), and the anastomosis is revised after ensuring healthy vessel ends.' The patient's symptoms are classic for arterial thrombosis, requiring urgent surgical intervention.Option A is incorrectbecause antibiotics are for infection, and elevation might worsen perfusion in an already compromised digit.Option B is incorrectbecause while topical papaverine can help with vasospasm, the signs here (cool, pale, sluggish refill, diminished Doppler) are more indicative of thrombosis, which requires surgical intervention, not just observation.Option C is incorrectbecause while systemic anticoagulation and antiplatelet agents are often used post-operatively to prevent re-thrombosis, they are not the primary immediate treatment for an acute, established thrombosis that is compromising digital viability. Surgical revision is paramount.Option E is incorrectbecause a sympathetic block is primarily for vasospasm, but the clinical picture here strongly suggests thrombosis, which is a mechanical obstruction requiring surgical correction.

Question 566

Topic: Nerve & Tendon

A 48-year-old patient is recovering from a repair of a complete transection of the ulnar proper digital nerve of the small finger. Three weeks post-operatively, the patient complains of severe hypersensitivity and shooting pain in the small finger, particularly when touching the scar. Examination reveals a positive Tinel's sign at the repair site and significant allodynia. Conservative management with NSAIDs and topical analgesics has provided minimal relief. According to the case, which of the following is a recognized surgical option for managing this complication?

. Immediate revision neurorrhaphy with a nerve conduit.
. Excision of the painful neuroma and relocation of the nerve end into a well-vascularized, soft tissue bed.
. Systemic administration of high-dose corticosteroids to reduce inflammation.
. Application of a dynamic splint to promote early motion and desensitization.
. Observation for 3 more months, as this is a normal part of nerve regeneration.

Correct Answer & Explanation

. Excision of the painful neuroma and relocation of the nerve end into a well-vascularized, soft tissue bed.

Explanation

Correct Answer: BThe patient's symptoms (severe hypersensitivity, shooting pain, positive Tinel's, allodynia, and failure of conservative management) are highly suggestive of a painful traumatic neuroma. The case, under 'Neuroma Excision and Management,' lists several surgical options: 'For symptomatic neuromas, surgical options include: ... Excision and Relocation: The neuroma is excised, and the nerve end is transposed into a well-vascularized, soft tissue bed (e.g., muscle, bone tunnel) away from external pressure.' This directly addresses the described complication.Option A is incorrectbecause revision neurorrhaphy with a conduit is for nerve gaps or failed repairs, not specifically for a painful neuroma where the goal is to manage the nerve stump.Option C is incorrectas systemic corticosteroids are not a primary treatment for painful neuromas and carry significant side effects.Option D is incorrectbecause while desensitization is part of rehabilitation, a dynamic splint is for motion, and this patient's severe pain and allodynia suggest a more aggressive approach is needed after conservative failure.Option E is incorrectas severe, debilitating pain and allodynia are not a 'normal part of nerve regeneration' and warrant intervention, especially after conservative measures fail.

Question 567

Topic: 7. Hand and Wrist

A 22-year-old musician undergoes repair of a complete transection of the radial proper digital nerve of the middle finger. Post-operatively, the hand therapist initiates rehabilitation. Based on the case's post-operative protocols, what is the primary goal of the initial immobilization phase (first 3-4 weeks)?

. To achieve full active range of motion of all digital joints.
. To begin aggressive strengthening exercises for grip and pinch.
. To protect the nerve repair from tension and external forces and control edema.
. To initiate advanced sensory re-education, including graphesthesia and stereognosis.
. To prevent cold intolerance through early desensitization techniques.

Correct Answer & Explanation

. To protect the nerve repair from tension and external forces and control edema.

Explanation

Correct Answer: CThe case, under 'Post-Operative Rehabilitation Protocols - Initial Immobilization & Protection,' clearly states the goal: 'Protect the nerve and/or artery repair from tension and external forces, control edema, and manage pain.' It also specifies splinting to minimize tension on the repaired nerve.Option A is incorrectbecause full active range of motion is a later goal, not during the initial immobilization phase where protection is paramount.Option B is incorrectas aggressive strengthening is part of the later stages of rehabilitation, after initial healing and controlled motion have been established.Option D is incorrectbecause advanced sensory re-education (graphesthesia, stereognosis) is for later stages, after protective sensation returns and basic discrimination is achieved.Option E is incorrectbecause while cold intolerance is a common complication, its prevention is not the primary goal of initial immobilization. Desensitization is part of early sensory re-education, but the main focus of the initial phase is protection.

Question 568

Topic: 7. Hand and Wrist
A 35-year-old patient underwent repair of a proper digital nerve laceration 18 months ago. Despite diligent hand therapy, the patient reports persistent difficulty distinguishing textures and identifying objects without visual input, with a static two-point discrimination (2PD) of 12 mm in the affected fingertip. The patient also complains of significant cold intolerance. Based on the literature, which statement best reflects the expected long-term outcomes for digital nerve repair?
. Achieving excellent sensory recovery (2PD < 6mm) is common, and cold intolerance is rare.
. Good recovery (2PD 6-15mm, protective sensation) is common, but cold intolerance is a frequent sequela.
. Complete return to normal sensation is expected within 12 months, and cold intolerance resolves spontaneously.
. If 2PD is >10mm, it indicates a failed repair requiring mandatory revision surgery.
. Sensory recovery typically plateaus at 6 months, and further improvement is unlikely.

Correct Answer & Explanation

. Good recovery (2PD 6-15mm, protective sensation) is common, but cold intolerance is a frequent sequela.

Explanation

Achieving 'excellent' sensory recovery (2PD < 6mm) is challenging and occurs in only 20-50% of repairs. 'Good' recovery (2PD 6-15mm, protective sensation) is more common and represents a functionally acceptable outcome. The literature consistently highlights the high incidence of cold intolerance following digital nerve injuries, regardless of the quality of nerve repair, with rates ranging from 30-70%.

Question 569

Topic: Nerve & Tendon

A 50-year-old patient presents with a 2 cm laceration to the volar aspect of the thumb, sustained 3 days ago. Examination reveals complete loss of sensation on the radial side of the thumb. The common digital nerves arise from the median and ulnar nerves in the palm. Based on the anatomical description in the case, which nerve is primarily responsible for the sensory innervation of the radial side of the thumb?

. The ulnar nerve via a common digital nerve.
. The median nerve via a proper digital nerve directly from the median nerve.
. The radial nerve via its superficial branch.
. The median nerve via a common digital nerve that bifurcates.
. The ulnar nerve via a proper digital nerve directly from the ulnar nerve.

Correct Answer & Explanation

. The median nerve via a proper digital nerve directly from the median nerve.

Explanation

Correct Answer: BThe 'Surgical Anatomy & Biomechanics' section states: 'Each digit, excluding the thumb and the radial aspect of the index finger which have specific innervation from the median nerve, typically receives two proper digital nerves and two proper digital arteries.' This indicates that the thumb's innervation is somewhat distinct. Specifically, the radial side of the thumb is innervated by a proper digital nerve that branches directly from the median nerve, not via a common digital nerve that then bifurcates for the thumb. The median nerve gives rise to three common digital nerves, but the thumb's innervation is mentioned as a specific exception.Option A is incorrectbecause the ulnar nerve primarily innervates the small finger and the ulnar side of the ring finger.Option B is correctas per the case's specific exclusion for the thumb's innervation.Option C is incorrectbecause while the radial nerve innervates the dorsum of the hand and some dorsal digits, its contribution to the volar aspect of the thumb is not described as primary for the proper digital nerve.Option D is incorrectbecause the case implies a direct innervation for the thumb from the median nerve, rather than through a common digital nerve that then bifurcates, which is the pattern for other digits.Option E is incorrectas the ulnar nerve does not innervate the radial side of the thumb.

Question 570

Topic: 7. Hand and Wrist

A 24-year-old male sustains a proximal pole scaphoid fracture. Operative fixation is planned. Which of the following describes the most appropriate surgical approach and rationale?

. Volar approach to preserve the dorsal carpal branch of the radial artery
. Dorsal approach to allow perpendicular screw placement and avoid volar ligamentous injury
. Volar approach to allow direct visualization of the scapholunate interosseous ligament
. Dorsal approach because the proximal pole lacks articular cartilage dorsally
. Percutaneous volar approach to minimize disruption of the radioscaphocapitate ligament

Correct Answer & Explanation

. Dorsal approach to allow perpendicular screw placement and avoid volar ligamentous injury

Explanation

Proximal pole scaphoid fractures are best approached dorsally. This allows for a screw trajectory that is perpendicular to the fracture plane and avoids division of the stout volar radioscaphocapitate ligament.

Question 571

Topic: 7. Hand and Wrist

During a fasciectomy for severe Dupuytren's contracture, the surgeon dissects out the spiral cord. The spiral cord displaces the neurovascular bundle in which direction?

. Dorsal and lateral
. Volar and central (midline)
. Volar and lateral
. Dorsal and central
. Proximal and lateral

Correct Answer & Explanation

. Volar and central (midline)

Explanation

The spiral cord in Dupuytren's disease typically displaces the digital neurovascular bundle volar and central (towards the midline of the digit), placing it at high risk for iatrogenic injury during surgical excision.

Question 572

Topic: 7. Hand and Wrist

A 42-year-old carpenter presents with the inability to make an "A-OK" sign with his right hand, instead demonstrating a flattened pinch. Sensation in the hand is completely normal. Compression of which of the following nerves is the most likely cause?

. Posterior interosseous nerve
. Anterior interosseous nerve
. Recurrent motor branch of the median nerve
. Deep branch of the ulnar nerve
. Superficial radial nerve

Correct Answer & Explanation

. Anterior interosseous nerve

Explanation

The Anterior Interosseous Nerve (AIN) innervates the flexor pollicis longus, flexor digitorum profundus (index/middle), and pronator quadratus. AIN syndrome presents with a purely motor deficit (flattened pinch), with no sensory loss.

Question 573

Topic: Hand Trauma & Infection

A 28-year-old skier presents with a painful, swollen thumb after falling on an outstretched hand with the pole in his palm. MRI confirms a complete rupture of the ulnar collateral ligament (UCL) of the thumb MCP joint with a Stener lesion. What anatomical structure is interposed in a Stener lesion?

. Abductor pollicis brevis tendon
. Extensor pollicis longus tendon
. Adductor pollicis aponeurosis
. Flexor pollicis brevis aponeurosis
. Volar plate

Correct Answer & Explanation

. Adductor pollicis aponeurosis

Explanation

A Stener lesion occurs when the torn proximal end of the ulnar collateral ligament displaces superficial to the adductor pollicis aponeurosis. This interposition prevents spontaneous healing and necessitates surgical repair.

Question 574

Topic: 7. Hand and Wrist
According to the Mayfield progressive stages of perilunate instability, what is the final stage (Stage IV) of the injury progression?
. Scapholunate interosseous ligament rupture
. Lunocapitate dislocation
. Lunotriquetral interosseous ligament rupture
. Volar dislocation of the lunate into the carpal tunnel
. Dorsal displacement of the entire carpus

Correct Answer & Explanation

. Volar dislocation of the lunate into the carpal tunnel

Explanation

Mayfield described a sequential four-stage progression of perilunate instability. Stage I: Scapholunate disruption. Stage II: Lunocapitate disruption. Stage III: Lunotriquetral disruption. Stage IV: The lunate dislocates completely, usually volarly into the carpal tunnel.

Question 575

Topic: 7. Hand and Wrist

A 24-year-old male falls on an outstretched hand and sustains a fracture through the proximal pole of the scaphoid. This region of the scaphoid is at the highest risk for avascular necrosis due to its blood supply. Which artery provides the primary vascular contribution to the proximal pole?

. Superficial palmar branch of the radial artery
. Dorsal carpal branch of the radial artery
. Volar carpal branch of the radial artery
. Anterior interosseous artery
. Ulnar artery via the deep palmar arch

Correct Answer & Explanation

. Dorsal carpal branch of the radial artery

Explanation

The scaphoid is primarily supplied by the dorsal carpal branch of the radial artery, which enters distally and provides retrograde blood flow to the proximal pole. This retrograde supply makes proximal pole fractures highly susceptible to avascular necrosis and nonunion.

Question 576

Topic: 7. Hand and Wrist
A 22-year-old rugby player presents with an inability to actively flex the DIP joint of his right ring finger after a tackle. Radiographs reveal a large bony avulsion fragment at the volar base of the distal phalanx that is retracted to the level of the DIP joint. What is the Leddy-Packer classification and optimal timing for repair?
. Type I; within 7 to 10 days
. Type II; within 3 to 4 weeks
. Type III; within 3 to 4 weeks
. Type III; requires urgent repair within 24 hours
. Type IV; late reconstruction

Correct Answer & Explanation

. Type III; within 3 to 4 weeks

Explanation

A large bony avulsion fragment caught at the A4 pulley or DIP joint is a Leddy-Packer Type III jersey finger. Because the fragment is large and prevents proximal retraction of the tendon into the palm, its blood supply is relatively preserved, allowing for repair within a few weeks.

Question 577

Topic: 7. Hand and Wrist

A 25-year-old rugby player presents with an inability to actively flex the distal interphalangeal (DIP) joint of his ring finger. Palpation reveals a tender mass in the palm. Radiographs are negative. Within what time frame must surgical intervention be performed to allow for direct repair of the tendon to the distal phalanx?

. Within 24 hours
. Within 7 to 10 days
. Within 3 to 4 weeks
. Within 6 to 8 weeks
. Delayed reconstruction is the only option

Correct Answer & Explanation

. Within 7 to 10 days

Explanation

This is a Type I Jersey finger (FDP avulsion retracted into the palm). Due to compromised blood supply from the avulsed vincula, direct repair should be performed within 7 to 10 days to prevent tendon necrosis and irreversible muscle contracture.

Question 578

Topic: 7. Hand and Wrist
A 45-year-old male presents with chronic wrist pain and a history of a remote scaphoid fracture. Radiographs demonstrate a scaphoid nonunion with radioscaphoid arthritis, but the capitolunate joint is spared. Which of the following is the most appropriate surgical treatment?
. Proximal row carpectomy (PRC)
. Scaphoid excision and four-corner fusion
. Total wrist arthrodesis
. Vascularized bone grafting of the scaphoid
. Radial styloidectomy

Correct Answer & Explanation

. Scaphoid excision and four-corner fusion

Explanation

This patient has Stage II/III scaphoid nonunion advanced collapse (SNAC). Since the proximal capitate is spared in this scenario, a scaphoid excision and four-corner fusion is an excellent motion-preserving option.

Question 579

Topic: 7. Hand and Wrist

During a ligament reconstruction and tendon interposition (LRTI) procedure for thumb carpometacarpal (CMC) arthritis, the flexor carpi radialis (FCR) tendon is commonly utilized. The primary goal of the ligament reconstruction portion of this procedure is to recreate the function of which of the following ligaments?

. Dorsal radial ligament
. Palmar oblique ligament (anterior oblique ligament)
. Intermetacarpal ligament
. Ulnar collateral ligament
. Radial collateral ligament

Correct Answer & Explanation

. Palmar oblique ligament (anterior oblique ligament)

Explanation

The palmar oblique ligament (also known as the anterior oblique ligament or beak ligament) is the primary static stabilizer of the thumb CMC joint. LRTI aims to recreate this ligament to prevent dorsal subluxation and proximal subsidence of the first metacarpal.

Question 580

Topic: 7. Hand and Wrist

A 65-year-old female presents with severe, long-standing carpal tunnel syndrome and marked thenar atrophy. Which of the following muscles is most likely atrophied, reflecting profound median nerve denervation?

. Adductor pollicis
. Flexor pollicis brevis (deep head)
. Abductor pollicis brevis
. First dorsal interosseous
. Palmaris brevis

Correct Answer & Explanation

. Abductor pollicis brevis

Explanation

The recurrent motor branch of the median nerve innervates the thenar muscles: the abductor pollicis brevis (APB), opponens pollicis, and the superficial head of the flexor pollicis brevis. Severe carpal tunnel syndrome characteristically causes profound atrophy of the APB.

Test Yourself

Switch to an interactive, timed exam simulation to truly master this topic.

On this Page