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 861
Topic: 7. Hand and Wrist
During closed reduction and pinning of a Bennett fracture, the surgeon must overcome specific deforming forces. Which anatomic structure maintains the small anteromedial articular fragment in its anatomic position?
Correct Answer & Explanation
. Volar oblique ligament
Explanation
The anterior oblique ligament (volar oblique ligament) anchors the small anteromedial fragment of a Bennett fracture to the trapezium. The metacarpal shaft is subluxated proximally and dorsally by the abductor pollicis longus.
Question 862
Topic: 7. Hand and Wrist
A 22-year-old man punches a wall and sustains a 5th metacarpal neck fracture (Boxer's fracture). To prevent clinically significant pseudoclawing and functional deficit, what is the generally accepted maximum volar angulation for this specific digit?
Correct Answer & Explanation
. 40 degrees
Explanation
Up to 40-50 degrees of volar angulation is typically acceptable in a 5th metacarpal neck fracture due to the high compensatory mobility of the 5th carpometacarpal joint. Angulation exceeding this requires reduction to prevent pseudoclawing.
Question 863
Topic: 7. Hand and Wrist
A 28-year-old man with chronic wrist pain is diagnosed with Scaphoid Nonunion Advanced Collapse (SNAC). Which of the following joints is characteristically spared from degenerative arthritic changes in a SNAC wrist, allowing for a proximal row carpectomy or four-corner fusion?
Correct Answer & Explanation
. Radiolunate joint
Explanation
In both SLAC and SNAC wrists, the radiolunate joint is characteristically spared from early osteoarthritis due to its concentric, congruent anatomy. This sparing is the mechanical basis for salvage procedures like four-corner fusion.
Question 864
Topic: 7. Hand and Wrist
Which of the following factors independently dictates a 100% amputation rate in high-pressure injection injuries of the hand?
Correct Answer & Explanation
. Injection pressure exceeding 7,000 psi
Explanation
Injection pressures exceeding 7,000 psi are universally associated with a 100% amputation rate due to massive mechanical tissue destruction and widespread dissemination of the injected material.
Question 865
Topic: 7. Hand and Wrist
In proximal phalanx shaft fractures of the hand, what is the typical apex deformity, and which intrinsic muscles are primarily responsible?
Correct Answer & Explanation
. Apex volar angulation; interossei
Explanation
Proximal phalanx fractures typically deform with an apex volar (dorsal angulation) configuration. This is driven by the interossei flexing the proximal fragment and the central slip extending the distal fragment.
Question 866
Topic: 7. Hand and Wrist
A 25-year-old professional boxer sustains a displaced fracture of the 2nd metacarpal neck. What is the maximum acceptable volar angulation for this digit to maintain optimal functional outcome?
Correct Answer & Explanation
. 10 to 15 degrees
Explanation
The 2nd and 3rd carpometacarpal joints are rigidly fixed, tolerating minimal angulation before causing a prominent head in the palm and pseudoclawing. For the 2nd metacarpal neck, maximum acceptable angulation is 10-15 degrees, compared to up to 40-70 degrees in the highly mobile 5th metacarpal.
Question 867
Topic: 7. Hand and Wrist
Which of the following factors is considered the most significant prognostic indicator for the likelihood of eventual amputation following a high-pressure injection injury to the hand?
Correct Answer & Explanation
. Type of material injected
Explanation
While time to surgery (>10 hours) and high pressure (>7,000 PSI) are critical, the type of material injected (e.g., organic solvents/paint thinner vs. water) is the most significant prognostic factor for eventual amputation due to direct, irreversible cytotoxicity.
Question 868
Topic: 7. Hand and Wrist
A 30-year-old male sustains a Bennett fracture. Which muscle is primarily responsible for the proximal and dorsal displacement of the metacarpal shaft?
Correct Answer & Explanation
. Abductor pollicis longus (APL)
Explanation
In a Bennett fracture, the volar ulnar beak fragment remains anatomically held to the trapezium by the anterior oblique ligament. The entire metacarpal shaft is pulled proximally, dorsally, and radially by the uninhibited pull of the abductor pollicis longus (APL).
Question 869
Topic: 7. Hand and Wrist
A 25-year-old boxer sustains a closed, isolated, spiral fracture of the fifth metacarpal shaft. Which clinical finding is an absolute indication for operative intervention?
Correct Answer & Explanation
. Scissoring of the small finger over the ring finger during active flexion
Explanation
Rotational deformities are poorly tolerated in metacarpal fractures. Any degree of finger scissoring (overlap) during active composite flexion indicates significant malrotation and requires operative reduction and fixation.
Question 870
Topic: 7. Hand and Wrist
The patient in the case presented with a right upper trunk brachial plexus birth palsy, primarily involving C5 and C6 nerve roots, characterized by weakness in shoulder abduction/external rotation and elbow flexion, with relative sparing of lower root functions. According to the Narakas classification system, this presentation corresponds to which type of injury?
Correct Answer & Explanation
. Type I (C5-C6)
Explanation
The Narakas classification system categorizes brachial plexus injuries based on the extent of nerve root involvement: Type I (Erb-Duchenne): C5-C6 involvement (most common), characterized by shoulder abduction/external rotation and elbow flexion weakness. The patient's clinical presentation matches the description of a Narakas Type I injury.
Question 871
Topic: Nerve & Tendon
Following resection of the neuromatous segments of the C5 and C6 roots, the surgical team in the case performed interpositional nerve grafting. Which of the following nerves was harvested and utilized as a multi-fascicular cable graft for this procedure?
Correct Answer & Explanation
. Sural nerve
Explanation
Correct Answer: CThe case explicitly states under "Surgical Reconstruction": "The ipsilateral sural nerve was harvested from the calf as a multi-fascicular cable graft, providing sufficient length and caliber." The sural nerve is a commonly used and preferred donor nerve for nerve grafting in brachial plexus injuries due to several advantages:It is a sensory nerve, so its harvest results in minimal functional deficit (a small area of numbness on the lateral foot).It provides sufficient length and multiple fascicles, making it suitable for bridging gaps in larger nerves.Its harvest is relatively straightforward and has low morbidity.The other nerves listed are either motor nerves (radial, ulnar) whose sacrifice would cause significant functional deficit, or cutaneous nerves that may not provide adequate length or fascicular structure for major nerve grafting.
Question 872
Topic: 7. Hand and Wrist
A 55-year-old male presents with a chronic paronychia that has been refractory to oral antibiotics and soaks for several weeks. On examination, there is fluctuance and significant tenderness along the lateral nail fold, suggesting a deeper collection. According to the case, what is the operative indication for this patient's condition?
Correct Answer & Explanation
. C. Abscess formation or osteomyelitis of the distal phalanx.
Explanation
Correct Answer: CThe 'Indications and Contraindications' table in the case specifically addresses occult infections. For 'Occult Infection', the operative indications are listed as: "Abscess formation; osteomyelitis of the distal phalanx; failure of targeted antibiotic therapy." The patient's presentation of refractory chronic paronychia with fluctuance and tenderness, indicating a deeper collection, directly aligns with the indication for abscess formation and failure of antibiotic therapy.Options A and B are listed as non-operative indications for occult infection. Option D is a contraindication for osteoid osteoma surgery, not infection. Option E is a general contraindication for any surgery, but not a specific operative indication for infection.
Question 873
Topic: 7. Hand and Wrist
A 28-year-old female presents with a 1.5 cm, firm, non-tender mass on the volar-radial aspect of her left wrist, which she noticed 3 months ago. She is a graphic designer and reports no pain or functional limitations, only mild cosmetic concern. Physical examination confirms a mobile, transilluminating mass. An Allen's test is normal. Based on the epidemiology and initial management guidelines presented in the case, what is the most appropriate initial recommendation?
Correct Answer & Explanation
. Observation with reassurance, given the potential for spontaneous resolution.
Explanation
Correct Answer: CThe case explicitly states that a significant proportion of ganglions (reported as high as 50% in some series) can undergo spontaneous resolution. Therefore, observation with reassurance is considered a valid and often preferred initial strategy for asymptomatic or minimally symptomatic lesions. The patient in the vignette is asymptomatic with only mild cosmetic concern, making observation the most appropriate first-line recommendation.Option A is incorrect because immediate surgical excision is typically reserved for symptomatic, functionally limiting, or diagnostically uncertain lesions, not solely for mild cosmetic concern in an otherwise asymptomatic patient.Option B, aspiration, is a reasonable first-line treatment for symptomatic patients who wish to defer or avoid surgery, but it has a significantly higher recurrence rate (30-70%) compared to surgery. For an asymptomatic patient, it's not the most appropriate initial step.Option D, MRI, is generally reserved for cases with diagnostic uncertainty, very large/deeply seated ganglions, or suspicion of other tumor types. Given the classic presentation (firm, mobile, transilluminating mass), ultrasound would be the preferred initial imaging if diagnostic confirmation were needed, but observation is still primary for an asymptomatic lesion.Option E, splinting, is a non-operative measure that can be considered for mild, intermittent pain or as part of an initial conservative trial, but for an asymptomatic mass, observation is simpler and often sufficient.
Question 874
Topic: 7. Hand and Wrist
A 35-year-old male presents with a painful volar wrist ganglion located just radial to the FCR tendon. Pre-operative planning is underway for surgical excision. Which of the following anatomical structures is considered the single most critical to identify and meticulously protect during this procedure, and what pre-operative test is mandatory to assess its patency?
Correct Answer & Explanation
. Radial artery; Allen's test
Explanation
Correct Answer: CThe case explicitly states, 'The Radial Artery: This represents the single most critical structure to identify and meticulously protect during volar wrist ganglion excision.' It also emphasizes, 'Allen's Test: This is an absolutely mandatory assessment for all volar wrist masses, particularly those located on the radial side. It evaluates the patency of the ulnar artery and the collateral circulation to the hand.' Injury to the radial artery, especially in a hand with dominant radial supply, can lead to severe ischemic consequences.Option A is incorrect. While the palmar cutaneous branch of the median nerve is the most common nerve injured, it is not considered the 'single most critical structure' in terms of potential for limb-threatening complications. Tinel's test assesses nerve irritation, not arterial patency.Option B is incorrect. The FCR tendon is a crucial anatomical landmark but not a critical structure in the same sense as the radial artery. Finkelstein's test assesses for De Quervain's tenosynovitis.Option D is incorrect. The median nerve proper is deep and typically not in direct contiguity with a volar ganglion, though careful dissection is needed. Phalen's test assesses for carpal tunnel syndrome.Option E is incorrect. The superficial radial nerve branches are less commonly directly involved in volar wrist ganglion excision compared to dorsal approaches. Two-point discrimination assesses sensory function.
Question 875
Topic: 7. Hand and Wrist
During surgical excision of a volar wrist ganglion, a surgeon makes the initial skin incision. As the subcutaneous tissue is dissected, a small nerve is encountered superficially, just ulnar to the FCR tendon. The surgeon recognizes this as a structure highly susceptible to iatrogenic injury during this stage of the procedure. Which nerve is most likely being described, and what is its primary clinical significance if injured?
Correct Answer & Explanation
. Palmar cutaneous branch of the median nerve; painful neuroma formation or dysesthesia in the radial palm.
Explanation
Correct Answer: CThe case states, 'Critical First Step: Immediately upon incising the skin and subcutaneous tissue, proactively identify and protect the palmar cutaneous branch of the median nerve. This nerve often courses superficially and can be inadvertently incised or mistaken for fibrous tissue if not specifically anticipated. It typically lies ulnar to the FCR tendon but can have variable courses.' It further notes that injury can lead to 'painful neuroma formation or chronic dysesthesia within its sensory distribution' (radial palm).Option A is incorrect. The superficial radial nerve is less commonly directly involved involarwrist ganglion excision, and its sensory distribution is the radial dorsum of the hand and thumb, not the radial palm.Option B is incorrect. The median nerve proper lies deeper, beneath the flexor retinaculum, and while motor weakness of thenar muscles is a consequence of median nerve injury, it's not the nerve most susceptible to injury during the initial superficial dissection for a volar ganglion.Option D is incorrect. The ulnar nerve is located on the ulnar side of the wrist and is not typically at risk during a radial volar ganglion excision. Its sensory distribution is the ulnar 1.5 digits.Option E is incorrect. The radial nerve's motor branch (posterior interosseous nerve) is in the forearm and not typically at risk during a volar wrist ganglion excision. Wrist drop is a consequence of radial nerve palsy, not specific to this procedure.
Question 876
Topic: 7. Hand and Wrist
A 42-year-old patient undergoes surgical excision of a recurrent volar wrist ganglion. During the procedure, the surgeon meticulously dissects the ganglion, carefully protecting the radial artery and palmar cutaneous nerve. To minimize the risk of future recurrence, what is the most crucial step the surgeon must perform?
Correct Answer & Explanation
. Excise the entire ganglion, its stalk, and a small cuff of the underlying joint capsule.
Explanation
Correct Answer: CThe case explicitly states, 'Key to Preventing Recurrence: The definitive step for minimizing recurrence is the complete excision of the stalk along with a small, elliptical cuff of the surrounding joint capsule from which it originates.' It further notes, 'The primary surgical objective is the complete excision of the entire cyst, including its stalk, back to its point of origin from the underlying joint capsule.'Option A, capsulodesis, is a procedure to stabilize a joint, not directly related to ganglion recurrence prevention.Option B is incorrect. While the capsular defect is typically left open, this is a consequence of the excision, not the primary action to prevent recurrence. Theexcisionof the stalk and capsule is what prevents recurrence.Option D, corticosteroid injection, is a non-operative treatment option with high recurrence rates and is not part of the surgical technique to prevent recurrence.Option E, repairing the FCR tendon sheath, is not mentioned as a step to prevent ganglion recurrence. The FCR tendon is a landmark, and its sheath is not the origin of the ganglion.
Question 877
Topic: 7. Hand and Wrist
A 30-year-old musician presents with a volar wrist ganglion that causes persistent, debilitating pain during violin practice, significantly impacting her ability to perform. She has undergone two attempts at aspiration with temporary relief, but the ganglion has recurred each time. Physical examination reveals a tender, firm mass. An Allen's test is normal. Based on the case, what is the most appropriate next step in management?
Correct Answer & Explanation
. Surgical excision of the ganglion.
Explanation
Correct Answer: CThe case outlines clear operative indications: 'Persistent or severe pain: When pain is debilitating, unremitting, unresponsive to adequate non-operative measures, or significantly impacts daily activities, occupational function, or sleep quality.' It also lists 'Recurrence after aspiration: Documented recurrence following one or more attempts at non-operative aspiration' as an operative indication. This patient meets both criteria, with debilitating pain impacting her occupation and recurrence after two aspirations.Option A is incorrect. While aspiration is a non-operative option, the patient has already failed two attempts, making further aspiration less likely to provide definitive relief and delaying definitive treatment.Option B is incorrect. While psychological support can be part of comprehensive pain management, it is not the primary next step for a surgically amenable lesion causing debilitating pain and functional limitation.Option D is incorrect. Opioid analgesics are not a definitive treatment for a structural problem like a ganglion and carry risks of dependence. Continued observation is inappropriate given the severity of symptoms and failure of conservative measures.Option E is incorrect. Prolonged immobilization with a cast is not a standard or effective treatment for symptomatic volar wrist ganglions, especially after failed aspirations, and could lead to stiffness.
Question 878
Topic: 7. Hand and Wrist
A 60-year-old patient undergoes surgical excision of a volar wrist ganglion. Six months post-operatively, the patient returns with a palpable, tender mass at the site of the previous surgery, confirmed by ultrasound to be a recurrent ganglion. According to the case, what is the most common reason for ganglion recurrence after surgical excision?
Correct Answer & Explanation
. Incomplete excision of the capsular stalk or accessory loculations.
Explanation
Correct Answer: CThe case explicitly states under 'Complications & Management' that for recurrence, it is 'Higher risk if the stalk and a sufficient cuff of adjacent capsule are not fully excised.' In the 'Summary of Key Literature / Guidelines,' it reiterates, 'Incomplete excision of the capsular stalk or failure to remove all accessory loculations is widely considered the predominant cause of recurrence.'Option A, inadequate post-operative immobilization, is not cited as the most common reason for recurrence. While immobilization is part of post-op care, its primary role is comfort and initial healing, not preventing recurrence from an incompletely excised stalk.Option B, failure to identify and protect the radial artery, is a severe intraoperative complication but not the cause of ganglion recurrence.Option D, CRPS, is a rare but severe complication of surgery, not a cause of ganglion recurrence.Option E, excessive early post-operative wrist mobilization, can contribute to pain or stiffness but is not identified as the primary cause of ganglion recurrence.
Question 879
Topic: 7. Hand and Wrist
During a volar wrist ganglion excision, despite meticulous technique, the radial artery is inadvertently lacerated. The pre-operative Allen's test was positive, indicating a dominant radial artery supply to the hand. What is the most appropriate immediate management strategy for this complication?
Correct Answer & Explanation
. Perform primary repair of the laceration or interpositional vein grafting by a surgeon experienced in microsurgery.
Explanation
Correct Answer: CThe case states under 'Complications & Management' for Radial Artery Injury: 'Potentially leads to hand ischemia in cases of dominant radial artery supply (identified by a positive Allen's test).' For 'Salvage Strategies / Management,' it advises: 'Immediate Intraoperative: Primary repair if small laceration. Transection/Thrombosis: Microvascular repair or interpositional vein grafting by a surgeon experienced in microsurgery if there is a significant risk of hand ischemia (positive Allen's test).' A positive Allen's test signifies a critical need for repair to prevent ischemia.Option A is incorrect. Ligation of the radial artery with a positive Allen's test would likely lead to severe hand ischemia and potential tissue loss.Option B is incorrect. Direct pressure might temporarily control bleeding but does not address the laceration, and observation alone is insufficient given the risk of ischemia with a positive Allen's test.Option D is incorrect. While post-operative anticoagulation may be necessary after repair, it is not the immediate intraoperative management for an acute laceration.Option E is incorrect. Delayed repair after packing the wound would increase the risk of ischemia and is not appropriate for an acute arterial injury, especially with a positive Allen's test.
Question 880
Topic: 7. Hand and Wrist
A patient has undergone successful open surgical excision of a volar wrist ganglion. The surgeon is planning the post-operative rehabilitation protocol for the immediate period (Day 0-7). Which of the following is a key component of this immediate post-operative phase?
Correct Answer & Explanation
. Strict elevation of the hand and immediate, gentle active range of motion (AROM) for the fingers.
Explanation
Correct Answer: CThe case outlines the 'Immediate Post-Operative Period (Day 0-7)' as follows: 'Elevation: Strict elevation of the hand above heart level... is crucial to minimize post-operative swelling and edema.' And 'Finger ROM: Encourage immediate, gentle active range of motion (AROM) exercises for the fingers and thumb. This helps prevent stiffness in the digits, maintains tendon gliding, and promotes lymphatic drainage.'Option A, progressive strengthening exercises, is part of the intermediate rehabilitation phase (Weeks 3-6), not the immediate post-operative period.Option B, suture removal and scar massage, typically occurs in the early rehabilitation phase (Weeks 1-3), after the initial 7-10 days.Option D, aggressive passive range of motion, is generally avoided in the immediate post-operative period to protect healing tissues and prevent pain. Gentle PROM might be initiated later in the early or intermediate phase, often with a therapist.Option E, dynamic splinting, is an advanced rehabilitation technique for persistent stiffness and is not part of the immediate post-operative protocol.
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