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 721
Topic: Hand Trauma & Infection
A 42-year-old carpenter presents with a swollen, painful index finger 3 days after sustaining a puncture wound. Examination reveals a fusiform swollen digit that is held in slight flexion. What is considered the earliest and most sensitive Kanavel sign for pyogenic flexor tenosynovitis?
Correct Answer & Explanation
. Pain with passive extension of the digit
Explanation
Pain with passive extension is considered the earliest and most sensitive of the four Kanavel signs for pyogenic flexor tenosynovitis. The other signs include fusiform swelling, flexed resting posture, and tenderness along the tendon sheath.
Question 722
Topic: 7. Hand and Wrist
A 22-year-old male falls on an outstretched hand and sustains a fracture of the scaphoid proximal pole. He is at high risk for avascular necrosis (AVN). The blood supply to the proximal pole of the scaphoid is primarily derived from which of the following vessels?
Correct Answer & Explanation
. Dorsal carpal branch of the radial artery
Explanation
The scaphoid receives its primary blood supply from the dorsal carpal branch of the radial artery, which enters at the distal pole and flows retrogradely to the proximal pole. Fractures at the proximal pole disrupt this retrograde supply, leading to a high rate of AVN.
Question 723
Topic: 7. Hand and Wrist
A 45-year-old female presents with neck pain radiating down her right arm. Examination reveals weakness in wrist extension, a diminished brachioradialis reflex, and numbness over the dorsal radial aspect of the hand and thumb. Which cervical nerve root is most likely compressed?
Correct Answer & Explanation
. C6
Explanation
Compression of the C6 nerve root causes weakness in wrist extension and elbow flexion, a diminished brachioradialis reflex, and sensory deficits over the lateral forearm and thumb.
Question 724
Topic: Nerve & Tendon
When performing a Zone II flexor tendon repair, which of the following biomechanical factors most significantly increases the tensile strength of the repair?
Correct Answer & Explanation
. Number of core suture strands crossing the repair site
Explanation
The ultimate tensile strength of a flexor tendon repair is directly proportional to the number of core suture strands crossing the repair site. A 4-strand or 6-strand repair allows for safe early active motion protocols.
Question 725
Topic: 7. Hand and Wrist
A 34-year-old carpenter presents with chronic dorsal wrist pain. Radiographs reveal sclerosis and fragmentation of the lunate with preservation of carpal height, and a negative ulnar variance of 3 mm. What is the most appropriate surgical treatment?
Correct Answer & Explanation
. Radial shortening osteotomy
Explanation
The patient has Lichtman Stage IIIA Kienbock's disease with negative ulnar variance. A joint-leveling procedure, such as a radial shortening osteotomy, effectively unloads the radiolunate joint and is the treatment of choice.
Question 726
Topic: Wrist & Carpus
Six weeks after open reduction and internal fixation of a distal radius fracture with a volar locking plate, a patient suddenly loses the ability to actively extend the interphalangeal joint of the thumb. Which technical error most likely caused this complication?
Correct Answer & Explanation
. Over-penetration of a dorsal cortical screw
Explanation
Extensor pollicis longus (EPL) rupture is a known complication of volar plating of the distal radius. It is most commonly caused by over-penetration of dorsal cortical screws, leading to mechanical attrition of the tendon in the third extensor compartment.
Question 727
Topic: 7. Hand and Wrist
During an open carpal tunnel release, the surgeon carefully dissects the distal extent of the transverse carpal ligament to avoid injuring the recurrent motor branch of the median nerve. Which variation of this nerve's anatomy is most common?
Correct Answer & Explanation
. Extraligamentous with recurrent course
Explanation
The extraligamentous with recurrent course is the most common anatomic variation of the motor branch of the median nerve. It branches distal to the transverse carpal ligament and curves back to innervate the thenar musculature.
Question 728
Topic: 7. Hand and Wrist
A 40-year-old male presents with chronic wrist pain and is diagnosed with a stage III scaphoid nonunion advanced collapse (SNAC). Radiographs show arthritis involving the radioscaphoid and capitolunate joints, with a preserved radiolunate joint. What is the most appropriate surgical treatment?
Correct Answer & Explanation
. Four-corner arthrodesis
Explanation
In Stage III SNAC, the capitolunate joint is arthritic, making a proximal row carpectomy contraindicated due to a lack of a preserved proximal capitate articular surface. A four-corner arthrodesis (capitate, hamate, lunate, triquetrum) with scaphoid excision successfully relies on the preserved radiolunate joint.
Question 729
Topic: 7. Hand and Wrist
A 25-year-old carpenter suffers a laceration to the volar aspect of his index finger at the level of the proximal phalanx, transecting both the FDS and FDP tendons. Into which flexor tendon zone does this injury fall?
Correct Answer & Explanation
. Zone II
Explanation
Zone II, historically referred to as "no man's land", extends from the A1 pulley (distal palmar crease) to the insertion of the flexor digitorum superficialis (FDS) on the middle phalanx. Both the FDS and FDP tendons lie within the tight fibro-osseous flexor sheath in this region.
Question 730
Topic: Nerve & Tendon
A 22-year-old rugby player aggressively grabs an opponent's jersey and feels a pop in his right ring finger. He is unable to actively flex the distal interphalangeal (DIP) joint. On examination, a tender mass is palpable in the proximal palm. According to the Leddy and Packer classification, what is the recommended timeframe for surgical repair?
Correct Answer & Explanation
. Within 7-10 days
Explanation
This is a Type I flexor digitorum profundus (FDP) avulsion (Jersey finger) where the tendon retracts into the palm, compromising its blood supply from the vincula. Early surgical repair within 7-10 days is required to prevent myostatic contracture and tendon necrosis.
Question 731
Topic: Nerve & Tendon
A 40-year-old mechanic presents with an inability to make an "OK" sign, instead forming a flat pinch between his thumb and index finger. Sensation in the hand is completely normal. Compression of which nerve is responsible for this deficit?
Correct Answer & Explanation
. Anterior interosseous nerve
Explanation
The anterior interosseous nerve (AIN) innervates the flexor pollicis longus (FPL), flexor digitorum profundus (FDP) to the index/middle fingers, and pronator quadratus. AIN syndrome causes a pure motor deficit, preventing flexion of the IP joint of the thumb and DIP of the index finger.
Question 732
Topic: 7. Hand and Wrist
When evaluating a patient for early, mild carpal tunnel syndrome, which physical examination test is considered the most sensitive for detecting early sensory deficits?
Correct Answer & Explanation
. Semmes-Weinstein monofilament testing
Explanation
Semmes-Weinstein monofilament testing measures light touch threshold and is the most sensitive test for identifying early sensory nerve compression. Two-point discrimination assesses innervation density and usually remains normal until late in the disease process.
Question 733
Topic: 7. Hand and Wrist
A 32-year-old right-hand dominant male presents with a deep laceration to the volar aspect of his left middle finger, sustained while cutting an avocado. He reports that his finger was tightly flexed around the avocado at the moment of injury. Clinically, he has a complete loss of active PIP and DIP flexion in the affected digit. During surgical planning, the most critical implication of the patient's finger position at the time of injury is:
Correct Answer & Explanation
. The significant proximal retraction of the tendon stumps, requiring extensive exploration.
Explanation
Correct Answer: CThe patient's history of the finger being tightly flexed at the moment of laceration is a critical detail in flexor tendon injuries. When a flexor tendon is lacerated in a flexed position, the distal stump remains near the laceration site. However, once the finger is extended (as it would be during examination or initial wound care), the proximal tendon stump retracts significantly due to the pull of the muscle belly in the forearm. This retraction can be substantial, often pulling the stump proximal to the A1 pulley, into the palm, or even into the distal forearm. Therefore, surgical planning must account for the need for a more extensive proximal exploration, potentially requiring a counter-incision in the palm, to retrieve the retracted proximal tendon stump. This phenomenon is a well-known challenge in Zone II flexor tendon repairs.Option A is incorrect; while digital nerve injuries are common, the position of the finger at injury primarily affects tendon retraction, not necessarily increasing nerve stretch risk. Option B is incorrect; a flexed position does not inherently lead to a partial laceration; a sharp knife can still cause a complete transection. Option D is incorrect; while some pulleys might be less taut, the primary implication is tendon retraction. Option E is incorrect; the timing of repair (primary vs. delayed) is dictated by the time from injury and wound conditions, not solely by the finger's position at injury, although significant retraction can make primary repair more challenging if delayed too long.
Question 734
Topic: 7. Hand and Wrist
A 32-year-old male presents with a deep laceration to the volar aspect of his left middle finger. Clinical examination reveals a 2.5 cm transverse laceration over the middle phalanx. He is unable to actively flex his PIP and DIP joints, but passive range of motion is full. Sensation is diminished along the radial digital nerve distribution. Based on these findings and the provided image, what is the most likely diagnosis and anatomical zone of injury?
Correct Answer & Explanation
. Complete Flexor Digitorum Superficialis (FDS) and Profundus (FDP) laceration, Zone II
Explanation
The clinical findings are key: complete inability to actively flex both the PIP (proximal interphalangeal) and DIP (distal interphalangeal) joints. The FDS tendon is primarily responsible for PIP flexion, and the FDP tendon is responsible for DIP flexion. Loss of both indicates a complete transection of both tendons. The laceration location 'over the middle phalanx' places the injury squarely in Flexor Tendon Zone II, which extends from the A1 pulley to the FDS insertion on the middle phalanx. The diminished sensation along the radial digital nerve is a common associated injury but does not change the primary tendon diagnosis.
Question 735
Topic: 7. Hand and Wrist
A 28-year-old male presents to the emergency department after sustaining a laceration to the volar aspect of his left ring finger. On examination, he is able to actively flex his PIP joint against resistance, but he has a complete inability to actively flex his DIP joint. Radiographs show a small bony fragment avulsed from the volar base of the distal phalanx. Based on the provided case's differential diagnosis, what is the most likely diagnosis?
Correct Answer: CThe clinical presentation of intact active PIP flexion but absent active DIP flexion, combined with a bony avulsion fragment from the volar base of the distal phalanx on radiographs, is pathognomonic for a Flexor Digitorum Profundus (FDP) avulsion, commonly known as a Jersey Finger. The FDP tendon inserts onto the volar base of the distal phalanx, and its avulsion results in the loss of DIP flexion. The intact PIP flexion indicates that the FDS tendon, which inserts on the middle phalanx and flexes the PIP joint, is functional.Option A is incorrect because a complete Zone II FDS and FDP laceration would result in the loss of both PIP and DIP flexion. Option B is incorrect because a partial FDP laceration would typically present with weakened, but not completely absent, DIP flexion. Option D is incorrect because an isolated digital nerve laceration would primarily cause sensory deficits, not a loss of active tendon function. Option E is incorrect because an extrinsic flexor muscle belly injury would likely affect multiple digits or present with more diffuse weakness, and the specific bony avulsion points away from this diagnosis.
Question 736
Topic: 7. Hand and Wrist
Immediately following the flexor tendon repair, a custom thermoplastic dorsal blocking splint was applied. What is the correct positioning of the hand and digits within this splint to relieve tension on the flexor apparatus and facilitate early active motion?
Correct Answer & Explanation
. Wrist in 20-30 degrees of palmar flexion, MCP joints in 50-70 degrees of flexion, PIP/DIP joints in full extension.
Explanation
Correct Answer: CThe case explicitly details the critical positioning for the dorsal blocking splint: 'Wrist: 20 to 30 degrees of palmar flexion. Metacarpophalangeal (MCP) Joints: 50 to 70 degrees of flexion. Interphalangeal (PIP and DIP) Joints: Full extension (neutral).' This specific position places the flexor tendons in a relaxed state, minimizing tension on the repair site while still allowing for controlled, protected active extension within the splint and passive or place-and-hold flexion exercises as part of an Early Active Motion (EAM) protocol.Options A, B, D, and E describe incorrect or suboptimal splint positions that would either place excessive tension on the repair, limit necessary motion, or not adequately protect the healing tendons.
Question 737
Topic: 7. Hand and Wrist
A 62-year-old male of Northern European descent presents with progressive flexion deformities of his right hand. He reports difficulty fully extending his ring and little fingers, which interferes with donning gloves and washing his face. On examination, he has a positive tabletop test for both the ring and little fingers. Goniometry reveals a 40-degree flexion contracture at the MCP joint of the ring finger and a 50-degree flexion contracture at the PIP joint of the little finger. He has a history of well-controlled type 2 diabetes and occasional alcohol consumption. Based on the provided case information, which of the following statements regarding his condition and potential management is most accurate?
Correct Answer & Explanation
. The presence of a positive tabletop test and significant MCP and PIP joint contractures are clear indications for surgical intervention, with regional fasciectomy being the gold standard.
Explanation
Correct Answer: CExplanation:Option C is correct.The case explicitly states that a positive tabletop test, an MCP joint contracture of 30 degrees or greater, and any PIP joint contracture of 15-20 degrees or greater (or any causing functional deficit) are accepted indications for surgical intervention. This patient meets all these criteria with a positive tabletop test, a 40-degree MCP contracture, and a 50-degree PIP contracture, both causing functional impairment. Regional fasciectomy is described as the gold standard surgical procedure for established Dupuytren's contracture, supported by high-level evidence for efficacy in correction and long-term functional improvement.Option A is incorrect.The case states that 'any degree of PIP joint flexion contracture is often considered significant, as these are more difficult to correct and have a greater impact on fine motor skills.' A 50-degree PIP contracture is highly significant and often more functionally debilitating than an MCP contracture of similar magnitude due to the PIP joint's uniaxial nature and propensity for adaptive shortening. Both contractures warrant surgical consideration.Option B is incorrect.The introduction and epidemiology section clearly lists diabetes mellitus and excessive alcohol consumption as associated risk factors for Dupuytren's contracture. While they are risk factors, they also influence surgical planning, as diabetes can affect wound healing and increase infection risk, and alcohol consumption can impact overall health and recovery.Option D is incorrect.While PNA is a less invasive option, the case states it is 'suitable for isolated cords, particularly MCP contractures, in elderly or less active patients' and is associated with 'higher recurrence rates compared to fasciectomy.' For significant MCP and PIP contractures, especially with functional impairment, fasciectomy is generally preferred for its more definitive correction and lower recurrence rates. The patient's PIP contracture is particularly challenging for PNA.Option E is incorrect.While age and comorbidities are considered, the presence of significant functional impairment and contractures meeting surgical thresholds generally indicates that the benefits of surgery outweigh the risks, provided the patient is medically fit. The case mentions 'well-controlled type 2 diabetes,' suggesting he may be a suitable surgical candidate after appropriate medical clearance. Observation is typically for mild contractures without functional deficit or isolated nodules.
Question 738
Topic: 7. Hand and Wrist
A 55-year-old carpenter presents with a progressive flexion contracture of his left ring finger. He reports difficulty gripping tools and shaking hands. Physical examination reveals a dense cord extending from the palm into the ring finger, causing a 60-degree flexion contracture at the PIP joint and a 10-degree flexion contracture at the MCP joint. During surgical planning, the surgeon anticipates the most challenging aspect of the dissection will be related to the specific cord type causing the PIP contracture. Based on the surgical anatomy described, which cord type is most likely responsible for the significant PIP contracture and poses the highest risk to the neurovascular bundle?
Correct Answer & Explanation
. Spiral cord
Explanation
Correct Answer: DExplanation:Option D is correct.The surgical anatomy section explicitly states that 'Spiral cords... are the most common cause of PIP joint flexion contracture and represent the most challenging anatomical distortion.' It further details that a spiral cord 'pulls the neurovascular bundle volarly and centrally/medially (relative to the affected finger), making it highly susceptible to injury during dissection.' For the ring finger, the neurovascular bundle is typically displaced ulnarly and superficially, increasing the risk during dissection.Option A is incorrect.Pretendinous cords primarily cause MCP joint flexion contracture and lie superficial to the flexor tendons and neurovascular bundles in the palm. While they can contribute to overall contracture, they are not the primary cause of significant PIP contractures and do not typically displace the neurovascular bundle in the same complex manner as spiral cords.Option B is incorrect.Natatory cords form from the natatory ligaments in the web spaces and restrict finger abduction, causing web space contracture. They do not directly cause PIP joint flexion contracture.Option C is incorrect.Central cords arise directly from the palmar aponeurosis and extend distally, inserting into the middle phalanx, directly causing PIP joint contracture. While they cause PIP contracture, the text describes them as lying superficial to the flexor tendons but deep to the neurovascular bundles at the PIP level, making them less prone to directly displacing the neurovascular bundle superficially and medially compared to spiral cords, which are highlighted as the 'most challenging anatomical distortion' due to their specific displacement pattern.Option E is incorrect.Retrovascular cords are less common and cause DIP joint contracture, passing dorsal to the neurovascular bundles. They are not the primary cause of PIP joint contractures.
Question 739
Topic: 7. Hand and Wrist
A 70-year-old male presents for follow-up after a regional fasciectomy for a severe Dupuytren's contracture of his small finger 6 months ago. He initially achieved excellent correction, but now reports a gradual return of a flexion deformity at the PIP joint. On examination, he has a 35-degree PIP joint contracture, and the skin over the previous incision appears somewhat tethered. He also has Garrod's pads on his knuckles. Based on the provided information, which of the following statements regarding his current condition and future management is most appropriate?
Correct Answer & Explanation
. Given the recurrence and presence of Garrod's pads, a dermofasciectomy with full-thickness skin grafting should be considered for definitive management.
Explanation
Correct Answer: BExplanation:Option B is correct.The 'Summary of Key Literature / Guidelines' section states that 'Dermofasciectomy: Reserved for recurrent disease, aggressive forms, or cases with significant skin involvement.' It also notes that 'The resulting skin defect necessitates skin grafting, usually with a full-thickness graft. This technique has a lower recurrence rate compared to standard fasciectomy.' The presence of Garrod's pads (extra-digital manifestation) indicates a more aggressive form of the disease, further supporting the consideration of dermofasciectomy for recurrence. The tethered skin also suggests skin involvement, which dermofasciectomy addresses.Option A is incorrect.While rehabilitation is crucial, recurrence is an inherent characteristic of Dupuytren's disease, especially in aggressive forms, and is not solely attributable to inadequate therapy. The text states, 'Dupuytren's disease is a genetic condition, and recurrence is an inherent characteristic, not a failure of surgery.'Option C is incorrect.PNA is associated with higher recurrence rates and is generally considered for less severe, isolated cords, or as a temporizing measure. For significant recurrence after a fasciectomy, a more definitive surgical approach like dermofasciectomy is often preferred, especially given the PIP joint involvement which is harder to treat with PNA.Option D is incorrect.The 'Complications & Management' table and 'Summary of Key Literature / Guidelines' section both state that recurrence rates after fasciectomy are significant, ranging from '20-50% (by 5-10 years).' This indicates that recurrence is a common characteristic of the disease, not a sign of misdiagnosis.Option E is incorrect.While further surgery carries risks, the text indicates that 'Revision surgery (often dermofasciectomy with skin grafting) for significant, symptomatic recurrence' is a management strategy. Observation is typically for mild, asymptomatic cases, which a 35-degree PIP contracture is not.
Question 740
Topic: 7. Hand and Wrist
A 48-year-old male presents with a 25-degree flexion contracture of his right ring finger MCP joint and a 10-degree flexion contracture of the PIP joint. He is able to flatten his hand completely on a tabletop. He reports no functional limitations but is concerned about the progression of the disease, as his father had severe Dupuytren's. He is otherwise healthy. Based on the provided indications, what is the most appropriate initial management strategy?
Correct Answer & Explanation
. Observation with regular follow-up, as the contractures do not meet conventional surgical thresholds and he has no functional impairment.
Explanation
The patient has an MCP contracture of 25 degrees (below 30) and a PIP contracture of 10 degrees (below 15-20), a negative tabletop test, and no functional limitations. Therefore, observation with regular follow-up is the most appropriate initial management. The contractures do not meet the conventional surgical thresholds (MCP ≥ 30 degrees, PIP ≥ 15-20 degrees), and there is no functional impairment.
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