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7. Hand and Wrist MCQs

Practice Set 4 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 61

Topic: 7. Hand and Wrist

A 45-year-old woman presents with neck pain radiating down her arm. She has weakness with wrist extension and a diminished brachioradialis reflex. She reports numbness over her thumb and index finger. Which cervical nerve root is most likely affected?

. C5
. C6
. C7
. C8
. T1

Correct Answer & Explanation

. C5

Explanation

The C6 nerve root provides motor innervation to the wrist extensors and sensory innervation to the thumb and index finger. It serves as the efferent limb of the brachioradialis reflex.

Question 62

Topic: 7. Hand and Wrist
A 1-year-old girl is diagnosed with a congenital scoliosis due to a unilateral unsegmented bar. Because of the high association with other organ system anomalies in the VACTERL association, which two screening tests are mandatory in the routine evaluation of this patient?
. Renal ultrasound and echocardiogram
. Cranial ultrasound and ophthalmologic exam
. Abdominal CT and liver function tests
. Pulmonary function tests and skeletal survey
. Genetic microarray and audiology testing

Correct Answer & Explanation

. Renal ultrasound and echocardiogram

Explanation

Congenital scoliosis is frequently associated with VACTERL sequence anomalies (Vertebral, Anorectal, Cardiac, Tracheoesophageal, Renal, Limb). An echocardiogram (cardiac) and a renal ultrasound (renal) are mandatory screenings to rule out life-threatening associated anomalies.

Question 63

Topic: 7. Hand and Wrist
A newborn is diagnosed with congenital scoliosis secondary to a fully segmented hemivertebra at T8. To evaluate for the most commonly associated concomitant anomalies (VACTERL association), which imaging studies should be ordered?
. Brain MRI and electroencephalogram
. Echocardiogram and renal ultrasound
. Pulmonary function tests and CT chest
. Electromyography and nerve conduction studies
. DEXA scan and skeletal survey

Correct Answer & Explanation

. Echocardiogram and renal ultrasound

Explanation

Congenital scoliosis is frequently part of the VACTERL association (Vertebral, Anorectal, Cardiac, Tracheoesophageal, Renal, Limb). An echocardiogram and renal ultrasound are essential for initial screening.

Question 64

Topic: 7. Hand and Wrist
A newborn is noted to have a congenital thoracic scoliosis due to a fully segmented hemivertebra. Screening ultrasonography reveals a unilateral absent kidney. Which additional diagnostic test is most routinely indicated for this patient to rule out associated VACTERL anomalies?
. Echocardiogram
. Cranial ultrasound
. Pulmonary function tests
. DEXA scan
. Genetic karyotyping

Correct Answer & Explanation

. Echocardiogram

Explanation

Congenital scoliosis is frequently associated with VACTERL anomalies (Vertebral, Anorectal, Cardiac, Tracheoesophageal, Renal, and Limb). An echocardiogram and renal ultrasound are essential screening studies.

Question 65

Topic: Nerve & Tendon

A 7-year-old boy presents with an established nonunion of a lateral condyle fracture of the humerus

that occurred 3 years ago. Which of the following nerve palsies is he at greatest risk of developing?

. Median nerve palsy
. Anterior interosseous nerve palsy
. Radial nerve palsy
. Ulnar nerve palsy
. Musculocutaneous nerve palsy

Correct Answer & Explanation

. Ulnar nerve palsy

Explanation

Lateral condyle nonunions often lead to progressive cubitus valgus deformities. This valgus stretch pulls the ulnar nerve behind the medial epicondyle, classically causing tardy ulnar nerve palsy.

Question 66

Topic: Nerve & Tendon

A 4-year-old child presents with an elbow injury. Radiographs reveal a displaced lateral condyle fracture.

If this fracture goes on to nonunion, which of the following long-term complications is most likely to develop?

. Cubitus varus and median nerve palsy
. Cubitus valgus and tardy ulnar nerve palsy
. Volkmann ischemic contracture
. Premature closure of the entire distal humeral physis
. Posterior interosseous nerve syndrome

Correct Answer & Explanation

. Cubitus valgus and tardy ulnar nerve palsy

Explanation

Nonunion of a lateral condyle fracture typically results in a progressive cubitus valgus deformity due to loss of the lateral column support. Over years, this stretching of the ulnar nerve behind the medial epicondyle can lead to tardy ulnar nerve palsy.

Question 67

Topic: Nerve & Tendon

A 5-year-old boy sustains a lateral condyle fracture of the humerus.

If left untreated, leading to nonunion and progressive deformity, what late neurological complication is he at highest risk of developing?

. Median nerve palsy
. Tardy ulnar nerve palsy
. Radial nerve palsy
. Anterior interosseous nerve syndrome
. Posterior interosseous nerve syndrome

Correct Answer & Explanation

. Tardy ulnar nerve palsy

Explanation

Untreated or nonunited lateral condyle fractures often lead to progressive cubitus valgus deformity. This chronic stretching of the ulnar nerve over the medial epicondyle results in tardy ulnar nerve palsy years later.

Question 68

Topic: 7. Hand and Wrist

A sexually active 21-year-old female presents with migratory polyarthralgia, tenosynovitis of the wrist, and sparse painless pustular skin lesions. Joint aspiration of her knee yields a WBC count of 45,000 cells/mm3. Gram stain is negative. What is the most common underlying host defect associated with disseminated infection by this organism?

. IgA deficiency
. Terminal complement pathway deficiency (C5-C9)
. Chronic granulomatous disease
. HIV infection
. Myeloperoxidase deficiency

Correct Answer & Explanation

. Terminal complement pathway deficiency (C5-C9)

Explanation

The presentation is classic for disseminated gonococcal infection (DGI). Patients with a deficiency in the terminal complement cascade (C5-C9), which forms the membrane attack complex, are at significantly increased risk for recurrent Neisserial infections.

Question 69

Topic: 7. Hand and Wrist

A sexually active 17-year-old female presents with migratory polyarthralgias, pain along the flexor tendons of the wrist, and a few discrete pustular skin lesions on her extremities. She is afebrile. What is the most likely causative organism?

. Staphylococcus aureus
. Streptococcus pyogenes
. Neisseria gonorrhoeae
. Chlamydia trachomatis
. Treponema pallidum

Correct Answer & Explanation

. Neisseria gonorrhoeae

Explanation

Disseminated gonococcal infection (DGI) classically presents in sexually active adolescents with a triad of tenosynovitis, dermatitis (pustular lesions), and migratory polyarthralgia.

Question 70

Topic: Nerve & Tendon

In a pediatric patient with a displaced lateral condyle humerus fracture, which of the following is the most significant clinical risk if the fracture fails to unite?

. Progressive cubitus varus
. Premature closure of the medial epicondyle
. Tardy ulnar nerve palsy
. Acute radial nerve palsy
. Volkmann ischemic contracture

Correct Answer & Explanation

. Tardy ulnar nerve palsy

Explanation

Nonunion of a lateral condyle fracture typically leads to progressive cubitus valgus deformity. Over time, this valgus angulation chronically stretches the ulnar nerve, potentially resulting in tardy ulnar nerve palsy.

Question 71

Topic: Nerve & Tendon

Which of the following is an absolute indication for operative intervention in a pediatric medial epicondyle fracture?

. Displacement greater than 2 mm
. Displacement greater than 5 mm
. Ulnar nerve neurapraxia
. Incarceration of the fragment in the joint
. High-level overhead throwing athlete

Correct Answer & Explanation

. Incarceration of the fragment in the joint

Explanation

Incarceration of the medial epicondyle fragment within the elbow joint block is an absolute indication for surgical extraction and fixation. Other parameters, such as displacement >5 mm or ulnar nerve symptoms, are considered relative indications.

Question 72

Topic: Nerve & Tendon

A 6-year-old child sustains a posteromedially displaced supracondylar fracture of the humerus. Which nerve is most frequently injured due to this specific displacement pattern?

. Median nerve
. Anterior interosseous nerve
. Radial nerve
. Ulnar nerve
. Musculocutaneous nerve

Correct Answer & Explanation

. Radial nerve

Explanation

Posteromedial displacement of the distal fragment causes the proximal fracture spike to displace anterolaterally. This uniquely places the radial nerve at the greatest risk of injury.

Question 73

Topic: 7. Hand and Wrist

A 14-year-old girl presents with progressive wrist pain and limited range of motion. Examination reveals a prominent distal ulna and volar subluxation of the hand. The failure of growth in this specific deformity primarily occurs at which aspect of the distal radius?

. Volar-ulnar
. Volar-radial
. Dorsal-ulnar
. Dorsal-radial
. Central physeal

Correct Answer & Explanation

. Volar-ulnar

Explanation

Madelung deformity is characterized by premature growth arrest of the volar-ulnar aspect of the distal radial physis. This leads to increased volar tilt, ulnar inclination, and relative ulnar overgrowth.

Question 74

Topic: 7. Hand and Wrist

Evaluate the provided clinical image.

A 13-year-old female presents with bilateral wrist deformities. What is the standard surgical intervention for symptomatic, severe manifestations of this condition when a Vickers ligament is identified?

. Darrach procedure
. Suave-Kapandji procedure
. Vickers ligament release with dome osteotomy of the radius
. Proximal row carpectomy
. Ulnar shortening osteotomy only

Correct Answer & Explanation

. Vickers ligament release with dome osteotomy of the radius

Explanation

For severe, symptomatic Madelung deformity in an adolescent with remaining growth, surgical treatment typically involves releasing the tethering Vickers ligament. This is usually combined with a corrective dome osteotomy of the distal radius.

Question 75

Topic: 7. Hand and Wrist

A 6-year-old boy falls from the monkey bars and sustains a completely displaced extension-type supracondylar fracture of the humerus. On physical examination, he is unable to make an "A-OK" sign with his thumb and index finger. Sensation in the hand is intact. Which nerve is most likely injured?

. Radial nerve
. Ulnar nerve
. Anterior interosseous nerve
. Posterior interosseous nerve
. Median nerve (main trunk)

Correct Answer & Explanation

. Anterior interosseous nerve

Explanation

The anterior interosseous nerve (AIN) is the most commonly injured nerve in extension-type supracondylar humerus fractures. It is a motor nerve only; injury results in the inability to flex the IP joint of the thumb and the DIP joint of the index finger.

Question 76

Topic: Nerve & Tendon

A 4-year-old child sustains a lateral condyle fracture of the humerus. The fracture is displaced by 4 mm. If left untreated, what is the most common long-term clinical deformity and potential neurological complication?

. Cubitus varus and median nerve palsy
. Cubitus valgus and tardy ulnar nerve palsy
. Cubitus varus and radial nerve palsy
. Extension deficit and AIN palsy
. Flexion deficit and musculocutaneous nerve palsy

Correct Answer & Explanation

. Cubitus valgus and tardy ulnar nerve palsy

Explanation

Displaced lateral condyle fractures have a high rate of nonunion if not fixed properly. This can lead to progressive cubitus valgus deformity, which stretches the ulnar nerve over time, causing tardy ulnar nerve palsy.

Question 77

Topic: Nerve & Tendon

A 2-year-old child presents with a right thumb that is locked in flexion at the interphalangeal joint. A nodule is palpable at the volar aspect of the MCP joint. What is the recommended initial management?

. Immediate surgical release of the A1 pulley
. Corticosteroid injection into the tendon sheath
. Observation and passive stretching exercises
. Splinting in full extension for 6 weeks
. Surgical release of the A2 pulley

Correct Answer & Explanation

. Observation and passive stretching exercises

Explanation

Pediatric trigger thumb resolves spontaneously in approximately 30% of cases within the first few years of life. Initial management is observation and stretching; A1 pulley release is reserved for cases failing to resolve by age 2 to 3.

Question 78

Topic: 7. Hand and Wrist

Which of the following physical examination findings is most specific for diagnosing a severe Volkmann ischemic contracture in the upper extremity?

. Loss of elbow flexion
. Intrinsic minus posture of the hand with rigid PIP flexion
. Wrist fixed in extension with MP joint extension
. Wrist fixed in flexion, with finger extension only possible when the wrist is passively flexed
. Inability to abduct the thumb with profound sensory loss over the hypothenar eminence

Correct Answer & Explanation

. Loss of elbow flexion

Explanation

Volkmann ischemic contracture results from untreated compartment syndrome, leading to necrosis and fibrosis of the deep volar forearm flexors. The classic finding is a wrist fixed in flexion, and the fingers can only be passively extended if the wrist is maximally flexed (tenodesis effect).

Question 79

Topic: 7. Hand and Wrist

A 1-year-old child is diagnosed with complex syndactyly of the long and ring fingers. What is the fundamental difference between simple and complex syndactyly?

. Simple syndactyly involves only the skin and soft tissues, whereas complex involves bone fusion.
. Complex syndactyly includes complete webbing to the fingertip, whereas simple does not.
. Complex syndactyly is syndromic, whereas simple is isolated.
. Simple syndactyly occurs in the hands, whereas complex occurs in the feet.
. Complex syndactyly involves neurovascular anomalies, whereas simple does not.

Correct Answer & Explanation

. Simple syndactyly involves only the skin and soft tissues, whereas complex involves bone fusion.

Explanation

In simple syndactyly, adjacent digits are joined only by skin and soft tissue. In complex syndactyly, there is an osseous or cartilaginous connection between the adjacent phalanges.

Question 80

Topic: 7. Hand and Wrist

Macrodactyly of the hand in a child is a rare congenital anomaly characterized by overgrowth of all tissue elements. Which nerve territory is most frequently affected, and what systemic condition must be ruled out?

. Ulnar nerve; Marfan syndrome
. Median nerve; Neurofibromatosis type 1
. Radial nerve; Klippel-Trenaunay syndrome
. Posterior interosseous nerve; Proteus syndrome
. Anterior interosseous nerve; Tuberous sclerosis

Correct Answer & Explanation

. Ulnar nerve; Marfan syndrome

Explanation

Macrodactyly most commonly affects the median nerve distribution in the hand. It is often associated with lipofibromatous hamartoma of the median nerve and is strongly associated with Neurofibromatosis type 1 and PIK3CA-related overgrowth spectrum (e.g., Proteus syndrome).

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