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7. Hand and Wrist MCQs

Practice Set 32 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 621

Topic: 7. Hand and Wrist

A 50-year-old man presents with chronic wrist pain and a known untreated scapholunate dissociation from 10 years prior. Radiographs reveal a Scapholunate Advanced Collapse (SLAC) pattern with a dorsal intercalated segment instability (DISI) deformity. Which of the following carpal articulations is characteristically spared from arthritic changes in this condition?

. Scaphotrapezial joint
. Radioscaphoid joint
. Radiolunate joint
. Capitoulnar joint
. Lunotriquetral joint

Correct Answer & Explanation

. Radiolunate joint

Explanation

In SLAC wrist arthritis, the radiolunate joint is characteristically spared, even in advanced stages. This occurs because the spherical lunate maintains a congruent relationship with the spherical lunate fossa of the radius, preventing abnormal contact stresses.

Question 622

Topic: 7. Hand and Wrist

A 38-year-old male sustains a fall onto an outstretched hand, resulting in a radial head fracture. Initial radiographs are shown below. He is managed non-operatively with a sling for comfort and early range of motion. Six weeks later, he presents with persistent, worsening wrist pain, particularly with forearm rotation, and a feeling of instability at the distal radio-ulnar joint (DRUJ). On examination, there is tenderness over the DRUJ and a positive 'shuck test' at the wrist. A follow-up wrist radiograph reveals a positive ulnar variance (proximal migration of the radius). What is the most likely diagnosis?

. Chronic lateral epicondylitis
. Radial head non-union
. Essex-Lopresti lesion
. Heterotopic ossification of the elbow
. Carpal tunnel syndrome

Correct Answer & Explanation

. Essex-Lopresti lesion

Explanation

Correct Answer: CThe patient's presentation of a radial head fracture followed by persistent wrist pain, DRUJ instability (positive shuck test), and radiographic evidence of proximal radial migration (positive ulnar variance) is pathognomonic for an Essex-Lopresti lesion. This complex injury involves a radial head fracture, disruption of the interosseous membrane, and injury to the distal radio-ulnar joint. The radial head is crucial for longitudinal forearm stability, and its injury, combined with interosseous membrane disruption, allows the radius to migrate proximally, leading to DRUJ dysfunction. Radial head non-union would primarily cause elbow pain and might not explain the DRUJ instability and proximal migration. Chronic lateral epicondylitis is an overuse condition of the elbow extensors. Heterotopic ossification causes stiffness but not typically DRUJ instability. Carpal tunnel syndrome is a median nerve compression neuropathy and would present with different symptoms.

Question 623

Topic: Nerve & Tendon

During the surgical exposure for a distal humerus fracture via a posterior approach, which anatomical structure is at highest risk of iatrogenic injury, particularly during posteromedial dissection and mobilization?

. Radial nerve
. Musculocutaneous nerve
. Median nerve
. Ulnar nerve
. Brachial artery

Correct Answer & Explanation

. Ulnar nerve

Explanation

Correct Answer: DThe ulnar nerve is the most vulnerable neurological structure during posterior approaches to the distal humerus. It courses through the cubital tunnel posterior to the medial epicondyle and is often directly exposed, mobilized, and protected (often transposed anteriorly) during complex distal humerus fracture fixation to prevent iatrogenic injury or secondary compression. The radial nerve is at risk more proximally in the humeral shaft or during lateral approaches. The median nerve and brachial artery are anterior and generally protected by muscle bellies. The musculocutaneous nerve is even further anterior and lateral, making it less susceptible during a posterior approach.

Question 624

Topic: Nerve & Tendon

A 19-year-old basketball player presents with a suspected Jersey finger of his small finger. On examination, he has full active flexion of his PIP joint but lacks active flexion of his DIP joint. A modified tabletop test reveals a normal cascade for all fingers except the small finger, which remains extended at the DIP joint. What is the most reliable maneuver to confirm an FDP rupture in this digit?

. Assessing passive range of motion of the DIP joint.
. Palpating for a tender gap in the distal palm.
. Stabilizing the PIP joint and asking the patient to flex the DIP joint.
. Comparing grip strength to the contralateral hand.
. Performing a Finkelstein's test to rule out De Quervain's tenosynovitis.

Correct Answer & Explanation

. Stabilizing the PIP joint and asking the patient to flex the DIP joint.

Explanation

Correct Answer: CThe most reliable maneuver to confirm an FDP rupture is to isolate the action of the FDP tendon. This is done by stabilizing the PIP joint in full extension and asking the patient to actively flex the DIP joint. If the FDP is ruptured, active DIP flexion will be absent. Assessing passive range of motion will typically be full, as the FDP rupture is an active deficit. Palpating a tender gap can be indicative but is not always reliable, especially with swelling. Grip strength is a global measure and not specific enough. Finkelstein's test is for De Quervain's tenosynovitis and is irrelevant in this context.

Question 625

Topic: 7. Hand and Wrist
A 24-year-old rugby player presents 48 hours after sustaining an injury to his left ring finger while tackling an opponent. He reports his finger was forcibly extended while he was gripping the opponent's jersey. On examination, he has swelling and tenderness over the palmar aspect of the distal phalanx. He is unable to actively flex the DIP joint of the ring finger. The remaining fingers show normal cascade. Passive DIP flexion is full. X-rays show no bony avulsion. Which of the following Leddy and Packer types is most likely, and what is the primary concern driving urgent treatment?
. Type II; preservation of tendon vascularity.
. Type III; prevention of further bone retraction.
. Type I; preservation of tendon vascularity.
. Type I; prevention of intrinsic muscle contracture.
. Type IV; reduction of articular incongruity.

Correct Answer & Explanation

. Type I; preservation of tendon vascularity.

Explanation

This scenario describes a classic Type I Jersey finger. A Type I injury involves rupture of the FDP tendon without a bony avulsion, and the tendon typically retracts into the palm, losing its vincula blood supply. The primary concern driving the urgency for repair (ideally within 7-10 days, but sooner if possible) is the preservation of the tendon's intrinsic vascularity to prevent necrosis and facilitate healing. Type II also lacks a bony avulsion but the tendon is retained at the A3 pulley level, often with intact vincula, making it less urgent than Type I. Type III involves a bony avulsion fragment, which prevents further retraction and maintains tendon blood supply, making it less urgent. Type IV involves an avulsed bone fragment with the tendon avulsed from the fragment, and Type V involves an intra-articular fracture with tendon avulsion; these are also distinct from the given scenario.

Question 626

Topic: Nerve & Tendon

Which of the following anatomical structures is MOST critical for providing blood supply to the flexor digitorum profundus (FDP) tendon in the distal finger, particularly relevant in Type I Jersey finger injuries?

. A2 pulley.
. Flexor sheath.
. Vincula tendinum.
. Annular ligaments.
. Lumbrical muscles.

Correct Answer & Explanation

. Vincula tendinum.

Explanation

Correct Answer: CThe vincula tendinum are mesotendinous structures that connect the flexor tendons to the phalanges and provide the primary blood supply to the tendons within the flexor sheath. In a Type I Jersey finger, the FDP tendon avulses distal to the vincula longa and retracts into the palm, often stripping it of its vincula and thus its blood supply, leading to a high risk of tendon necrosis. The A2 pulley is a critical mechanical structure but not primarily a source of blood supply to the tendon itself. The flexor sheath provides an environment, not the primary blood supply. Annular ligaments are the pulleys. Lumbrical muscles have their own blood supply but do not supply the FDP tendon directly.

Question 627

Topic: 7. Hand and Wrist

Regarding the surgical repair of a chronic FDP rupture (presenting 6 months post-injury) in a 35-year-old manual laborer, which of the following is the most appropriate initial management strategy if direct primary repair is not feasible?

. Immediate flexor digitorum profundus (FDP) advancement with concomitant flexor digitorum superficialis (FDS) tenodesis.
. Delayed primary repair with an interpositional tendon graft (e.g., palmaris longus).
. Staged tendon reconstruction using a silicone rod, followed by tendon grafting.
. Amputation of the distal phalanx to prevent stiffness.
. Observation with hand therapy to maximize passive range of motion.

Correct Answer & Explanation

. Staged tendon reconstruction using a silicone rod, followed by tendon grafting.

Explanation

Correct Answer: CFor chronic FDP ruptures where direct primary repair is not feasible due to significant tendon retraction and shortening, staged tendon reconstruction using a silicone rod (Hunter rod) is often the preferred strategy. The silicone rod creates a pseudosheath, which then facilitates the passage of an autogenous tendon graft (commonly palmaris longus or plantaris) in a second stage. FDP advancement is only feasible for gaps typically less than 1 cm. Delayed primary repair with an interpositional graft is a possibility, but less predictable than staged reconstruction for significant gaps. Amputation is overly aggressive, and observation alone will not restore function in a chronic rupture.

Question 628

Topic: Nerve & Tendon

A patient undergoes FDP repair for a Jersey finger. The post-operative protocol involves early active motion. What is the primary rationale behind initiating early active motion protocols for flexor tendon repairs?

. To prevent re-rupture of the repaired tendon.
. To accelerate bone healing at the insertion site.
. To minimize intrinsic muscle atrophy and improve grip strength.
. To prevent adhesion formation and improve tendon gliding.
. To reduce swelling and pain in the immediate post-operative period.

Correct Answer & Explanation

. To prevent adhesion formation and improve tendon gliding.

Explanation

Correct Answer: DThe primary rationale for early active motion protocols after flexor tendon repair is to promote tendon gliding and prevent the formation of restrictive adhesions within the flexor sheath. Controlled motion helps to maintain the gliding surface between the tendon and the surrounding tissues, which is crucial for achieving a good functional outcome and full range of motion. While it may indirectly help with swelling and muscle atrophy, its main goal is to optimize tendon healing and prevent adhesions, which is a major cause of post-operative stiffness.

Question 629

Topic: 7. Hand and Wrist

During surgical repair of a Jersey finger, care must be taken to preserve the flexor pulley system. Which two pulleys are considered the most critical to maintain for optimal flexor tendon function and to prevent bowstringing?

. A1 and A3 pulleys.
. A2 and A4 pulleys.
. C1 and C2 pulleys.
. A5 and C3 pulleys.
. The FDS decussation.

Correct Answer & Explanation

. A2 and A4 pulleys.

Explanation

Correct Answer: BThe A2 and A4 pulleys are considered the most critical annular pulleys for maintaining the mechanical efficiency of the flexor tendons and preventing bowstringing. The A2 pulley is located over the proximal phalanx, and the A4 pulley is over the middle of the distal phalanx. Their integrity is paramount for normal finger flexion biomechanics. Damage to these pulleys significantly compromises the tendon's leverage and function.

Question 630

Topic: 7. Hand and Wrist

A 45-year-old professional pianist sustains a Jersey finger (Type I) of his long finger. He presents 6 weeks post-injury. What is the most appropriate treatment option at this delayed presentation?

. Primary repair with bone anchor, due to preserved tendon length.
. Non-operative management with extensive hand therapy to regain passive motion.
. FDP advancement, possibly with a flexor tenodesis of the FDS.
. Staged tendon reconstruction using a silicone rod and subsequent tendon graft.
. Amputation of the digit to prevent contracture.

Correct Answer & Explanation

. Staged tendon reconstruction using a silicone rod and subsequent tendon graft.

Explanation

Correct Answer: DAt 6 weeks, a Type I Jersey finger is considered a chronic injury. Significant tendon retraction and shortening would have occurred, making direct primary repair or FDP advancement (which is typically for gaps <1cm) impossible without excessive tension leading to quadriga or re-rupture. Therefore, staged tendon reconstruction using a silicone rod followed by a tendon graft is the most appropriate option to reconstruct the flexor mechanism and restore function. Non-operative management will not restore active DIP flexion. Amputation is a last resort.

Question 631

Topic: Nerve & Tendon

During the primary repair of a Zone II flexor tendon laceration, a surgeon elects to use a multi-strand core suture technique. Which of the following factors is most critical in minimizing gap formation at the repair site during early active rehabilitation?

. The use of a braided absorbable core suture material.
. Placing the core suture volar to the tendon's mid-axial line.
. The number of core suture strands crossing the repair site.
. Routine venting of the A2 pulley to decrease glide resistance.
. Delaying physical therapy mobilization for 3 weeks.

Correct Answer & Explanation

. The number of core suture strands crossing the repair site.

Explanation

The biomechanical strength and resistance to gap formation in a flexor tendon repair are most directly correlated with the number of core suture strands crossing the repair site and adequate core purchase length. Epitendinous sutures further increase repair strength and smooth the gliding surface.

Question 632

Topic: 7. Hand and Wrist

A 28-year-old boxer sustains a Bennett fracture. Radiographs demonstrate that the main metacarpal shaft is displaced proximally, dorsally, and radially. Which muscle is primarily responsible for this specific deforming force on the metacarpal shaft?

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

Correct Answer & Explanation

. Abductor pollicis longus

Explanation

In a Bennett fracture, the abductor pollicis longus (APL) pulls the metacarpal shaft proximally, dorsally, and radially. The adductor pollicis exerts a supinating and ulnar-directed force on the distal metacarpal, while the volar ulnar beak fragment remains tethered by the anterior oblique ligament.

Question 633

Topic: Nerve & Tendon

A 30-year-old rugby player presents with an inability to actively flex the distal interphalangeal (DIP) joint of his ring finger. MRI demonstrates a flexor digitorum profundus (FDP) avulsion retracted completely into the palm. Within what maximum timeframe should this specific injury ideally be surgically repaired to prevent permanent tendon retraction and necrosis?

. 24 to 48 hours
. 7 to 10 days
. 3 to 4 weeks
. 6 to 8 weeks
. 3 months

Correct Answer & Explanation

. 7 to 10 days

Explanation

This describes a Leddy and Packer Type I FDP avulsion (Jersey finger), where the tendon retracts into the palm, disrupting both the long and short vincula. It requires surgical repair within 7-10 days before the tendon undergoes contracture and ischemic necrosis.

Question 634

Topic: 7. Hand and Wrist

A 25-year-old chef sustains a knife laceration to the volar aspect of the proximal phalanx, transecting both the FDS and FDP tendons. To safely allow an early active motion protocol following Zone II flexor tendon repair, what is the minimum recommended number of core suture strands crossing the repair site?

. 2 strands
. 4 strands
. 6 strands
. 8 strands
. Epitenon suture only

Correct Answer & Explanation

. 4 strands

Explanation

Biomechanical studies have consistently demonstrated that a 4-strand core suture technique provides the minimum tensile strength required to safely withstand the forces of early active motion protocols. A 2-strand repair is generally considered too weak and carries a higher risk of rupture with active flexion.

Question 635

Topic: 7. Hand and Wrist
A 28-year-old male presents with advanced SNAC (Scaphoid Nonunion Advanced Collapse) wrist, classified as Stage III (involving radioscaphoid and capitolunate arthritis, but sparing the radiolunate joint). Which of the following is the most appropriate surgical intervention?
. Radial styloidectomy
. Proximal row carpectomy (PRC)
. Four-corner fusion with scaphoid excision
. Total wrist arthrodesis
. Scaphoid ORIF with vascularized bone graft

Correct Answer & Explanation

. Four-corner fusion with scaphoid excision

Explanation

Stage III SNAC wrists involve arthritis at both the radioscaphoid and capitolunate joints, while the radiolunate joint remains preserved. Four-corner fusion with scaphoid excision relies on the preserved radiolunate joint, whereas PRC is contraindicated because the capitate head (which would articulate with the lunate fossa) is already arthritic.

Question 636

Topic: 7. Hand and Wrist

An untreated closed disruption of the extensor tendon central slip at the proximal interphalangeal (PIP) joint will most likely progress to a Boutonniere deformity. Which biomechanical sequence accurately describes the pathogenesis of this deformity?

. Volar subluxation of the lateral bands causing PIP flexion and DIP hyperextension.
. Dorsal subluxation of the lateral bands causing PIP hyperextension and DIP flexion.
. Attentuation of the terminal tendon leading to compensatory PIP flexion.
. Rupture of the flexor digitorum superficialis leading to unopposed PIP extension.
. Contracture of the oblique retinacular ligament causing DIP flexion.

Correct Answer & Explanation

. Volar subluxation of the lateral bands causing PIP flexion and DIP hyperextension.

Explanation

A central slip rupture allows the lateral bands to subluxate volarly to the axis of rotation of the PIP joint, converting them into PIP flexors. Their continued pull on the distal phalanx simultaneously causes hyperextension of the DIP joint, creating the classic Boutonniere deformity.

Question 637

Topic: 7. Hand and Wrist
A 21-year-old rugby player sustains a 'Jersey finger' injury, avulsing the flexor digitorum profundus (FDP) tendon of the ring finger. Imaging reveals no fracture, but ultrasound shows the tendon retracted completely into the palm. According to the Leddy and Packer classification, what type is this injury, and what is the status of the vincular blood supply?
. Type I (tendon retracted to palm, absent vincular supply)
. Type II (tendon retracted to PIP joint, intact vincula longus)
. Type III (bony avulsion trapped at A4 pulley, intact vincula brevis)
. Type IV (associated with an intra-articular distal phalanx fracture)
. Type V (tendon retracted to wrist with associated lumbrical tear)

Correct Answer & Explanation

. Type I (tendon retracted to palm, absent vincular supply)

Explanation

Leddy and Packer Type I injuries involve an FDP tendon that retracts into the palm, rupturing both the vincula brevis and longus, severely compromising its blood supply. These injuries require urgent repair (typically within 7-10 days) before the tendon undergoes permanent ischemic contracture.

Question 638

Topic: Hand Trauma & Infection

A 42-year-old diabetic patient presents with a swollen, acutely painful index finger. Which of the following is considered the most reliable, earliest, and most sensitive Kanavel sign for diagnosing purulent flexor tenosynovitis?

. A flexed resting posture of the digit
. Fusiform swelling of the entire digit
. Tenderness strictly along the flexor tendon sheath
. Severe pain with passive extension of the digit
. Erythema extending onto the volar pad

Correct Answer & Explanation

. Severe pain with passive extension of the digit

Explanation

While all four Kanavel signs indicate purulent flexor tenosynovitis, pain with passive extension is recognized as the earliest and most sensitive sign. The inflammation of the sheath causes exquisite pain when the tendon is stretched by passive finger extension.

Question 639

Topic: Wrist & Carpus
A 40-year-old mechanic complains of chronic dorsal wrist pain. Radiographs demonstrate a scapholunate gap of 4 mm, a 'cortical ring sign', and narrowing of the radioscaphoid articulation, while the midcarpal joint is preserved. This radiographic pattern is most consistent with which stage of Scapholunate Advanced Collapse (SLAC)?
. Stage II SLAC
. Pre-dynamic SLAC
. Stage I SLAC
. Stage III SLAC
. Stage IV SLAC

Correct Answer & Explanation

. Stage II SLAC

Explanation

SLAC staging follows a predictable pattern of arthritic progression. Stage I involves the radial styloid; Stage II involves the entire radioscaphoid fossa; and Stage III progresses to involve the capitolunate joint. The midcarpal joint is preserved here, placing it in Stage II.

Question 640

Topic: 7. Hand and Wrist

In a Bennett fracture of the thumb metacarpal base, what muscle is primarily responsible for the proximal and dorsal displacement of the main metacarpal shaft fragment?

. Abductor pollicis longus (APL)
. Extensor pollicis brevis (EPB)
. Adductor pollicis
. Flexor pollicis longus (FPL)
. Opponens pollicis

Correct Answer & Explanation

. Abductor pollicis longus (APL)

Explanation

In a Bennett fracture, the volar-ulnar beak fragment remains attached to the anterior oblique ligament. The main metacarpal shaft fragment is displaced proximally, dorsally, and radially by the strong pull of the abductor pollicis longus (APL) tendon.

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