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7. Hand and Wrist MCQs

Practice Set 45 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 881

Topic: 7. Hand and Wrist

A 38-year-old patient with a symptomatic volar wrist ganglion inquires about arthroscopic excision, having heard it offers faster recovery and improved cosmesis for wrist ganglions. Based on the summary of key literature and guidelines, what is the most accurate statement regarding arthroscopic excision for *volar* wrist ganglions?

. Arthroscopic excision is the preferred method for volar ganglions due to superior visualization and lower recurrence rates.
. Arthroscopic techniques for volar ganglions are significantly more technically challenging due to confined space and proximity of vital neurovascular structures.
. Arthroscopic excision is contraindicated for all volar wrist ganglions due to an unacceptably high complication rate.
. Arthroscopic excision offers comparable recurrence rates to open excision for volar ganglions, with a faster return to full activity.
. Arthroscopic excision is primarily used for intraosseous ganglions, not soft tissue volar ganglions.

Correct Answer & Explanation

. Arthroscopic techniques for volar ganglions are significantly more technically challenging due to confined space and proximity of vital neurovascular structures.

Explanation

Correct Answer: BThe case states under 'Arthroscopic Excision': 'However, forvolar wrist ganglions, arthroscopic techniques are significantly more technically challenging. This is primarily due to the anatomically confined operative space, the close proximity of vital neurovascular structures (especially the radial artery), and the inherent difficulty in achieving direct intra-articular visualization and thorough excision of the volar capsule and stalk from within the joint.'Option A is incorrect. The case explicitly states arthroscopic techniques are more challenging for volar ganglions and are not the preferred method.Option C is incorrect. While challenging, it is not stated to be absolutely contraindicated, but rather less common and reserved for experienced surgeons.Option D is incorrect. The literature for arthroscopic excision ofvolarganglions is described as 'less robust and mature' compared to dorsal lesions, implying that comparable recurrence rates and faster recovery are not as well-established or universally achieved as with open techniques for volar lesions.Option E is incorrect. Arthroscopic excision is primarily discussed in the context of soft tissue ganglions (dorsal or volar), not specifically intraosseous ganglions.

Question 882

Topic: 7. Hand and Wrist

During a fasciectomy for Dupuytren's disease, the surgeon dissects a spiral cord causing a severe PIP joint contracture. What is the typical anatomic relationship of the neurovascular bundle to the spiral cord?

. Central, superficial, and proximal
. Central, deep, and distal
. Lateral, deep, and proximal
. Lateral, superficial, and distal
. Medial, deep, and distal

Correct Answer & Explanation

. Central, superficial, and proximal

Explanation

The spiral cord characteristically displaces the neurovascular bundle centrally, superficially, and proximally. This altered anatomy places the digital nerve at an exceptionally high risk for iatrogenic transection during surgical excision.

Question 883

Topic: Nerve & Tendon

A 32-year-old rugby player presents with an inability to actively flex the DIP joint of his right ring finger. Radiographs reveal a small bony avulsion fragment volar to the PIP joint. According to the Leddy-Packer classification, what is the appropriate management timeframe?

. Within 7 to 10 days
. Within 3 to 4 weeks
. Within 2 to 3 months
. Immediate primary arthrodesis
. Observation and early mobilization

Correct Answer & Explanation

. Within 3 to 4 weeks

Explanation

A small bony fragment retracted to the level of the PIP joint indicates a Type II FDP avulsion (Jersey finger). The tendon is held by the intact vincula longus, preserving its blood supply, which safely allows surgical repair to be delayed up to 3 to 4 weeks.

Question 884

Topic: Nerve & Tendon

A 22-year-old baseball batter reports chronic hypothenar hand pain and new-onset weakness in finger abduction and adduction. Sensory examination over the volar small finger is completely normal. Which of the following is the most likely site of neural compression?

. Cubital tunnel
. Guyon's canal Zone 1
. Guyon's canal Zone 2
. Guyon's canal Zone 3
. Carpal tunnel

Correct Answer & Explanation

. Guyon's canal Zone 2

Explanation

Guyon's canal Zone 2 contains only the deep motor branch of the ulnar nerve. Compression here, often from a hook of hamate fracture in bat-and-racquet sports, causes isolated motor weakness of the intrinsic muscles with sparing of sensation.

Question 885

Topic: 7. Hand and Wrist

A 45-year-old carpenter presents with aching pain in the volar forearm and numbness in the thumb, index, and middle fingers. Phalen's and Tinel's signs at the wrist are negative. Sensation is decreased over the thenar eminence. Which of the following structures is most likely compressing the affected nerve?

. Transverse carpal ligament
. Ligament of Struthers
. Bicipital aponeurosis (lacertus fibrosus)
. Arcade of Frohse
. Osborne's ligament

Correct Answer & Explanation

. Bicipital aponeurosis (lacertus fibrosus)

Explanation

This describes Pronator Syndrome, distinguished from carpal tunnel syndrome by proximal forearm pain and numbness over the thenar eminence. The palmar cutaneous branch of the median nerve does not pass through the carpal tunnel, and the median nerve is typically compressed proximally by the bicipital aponeurosis, pronator teres, or FDS arch.

Question 886

Topic: 7. Hand and Wrist
A 28-year-old rugby player felt a "pop" in his ring finger while grabbing an opponent's jersey. He cannot actively flex the distal interphalangeal (DIP) joint, but proximal interphalangeal (PIP) joint flexion is intact. The affected finger rests in extension compared to the other digits. Which zone of flexor tendon injury does this represent?
. Zone I
. Zone II
. Zone III
. Zone IV
. Zone V

Correct Answer & Explanation

. Zone I

Explanation

A "Jersey finger" is an avulsion of the flexor digitorum profundus (FDP) tendon from the base of the distal phalanx. This injury occurs strictly in Zone I, which is distal to the flexor digitorum superficialis (FDS) insertion on the middle phalanx.

Question 887

Topic: Nerve & Tendon

A 55-year-old diabetic female presents with a painful triggering of her right middle finger. She has failed a trial of splinting and one corticosteroid injection given 6 months ago. What is the most appropriate next step in management?

. Repeat corticosteroid injection
. A1 pulley release
. A2 pulley release
. Flexor tenosynovectomy
. FDS slip excision

Correct Answer & Explanation

. A1 pulley release

Explanation

In diabetic patients, trigger finger is much less responsive to corticosteroid injections compared to the general population. Surgical release of the A1 pulley is the definitive and most appropriate next step after a failed initial injection in this demographic.

Question 888

Topic: 7. Hand and Wrist

An infant presents with an absent grasp reflex and a claw hand deformity following a difficult delivery. Shoulder abduction and elbow flexion are fully intact. If a neuroma-in-continuity is identified during surgical exploration, which trunk of the brachial plexus is most likely involved?

. Upper trunk
. Middle trunk
. Lower trunk
. Posterior cord
. Lateral cord

Correct Answer & Explanation

. Lower trunk

Explanation

Klumpke's palsy involves the lower roots (C8-T1) or lower trunk of the brachial plexus. It presents with absent grasp and intrinsic hand muscle paralysis (claw hand deformity), while proximal muscle function (C5-C6) remains intact.

Question 889

Topic: 7. Hand and Wrist

A 32-year-old male presents with severe pain and swelling of his right index finger 2 days after a puncture wound. Examination reveals uniform swelling, a flexed posture, pain on passive extension, and tenderness along the tendon sheath. What is the standard surgical approach for irrigation and debridement?

. Mid-lateral incision over the entire digit
. Zig-zag Bruner incisions over the affected joints only
. Small transverse incisions at the A1 pulley and distal palmar crease
. A1 pulley incision and distal mid-lateral incision for catheter irrigation
. Dorsal longitudinal incision

Correct Answer & Explanation

. Small transverse incisions at the A1 pulley and distal palmar crease

Explanation

The patient exhibits Kanavel's cardinal signs for pyogenic flexor tenosynovitis. Standard minimally invasive treatment involves a proximal incision at the A1 pulley and a distal incision (usually mid-lateral) to flush the tendon sheath with a pediatric feeding tube or catheter.

Question 890

Topic: 7. Hand and Wrist
A 60-year-old mechanic presents with chronic wrist pain. Radiographs reveal scapholunate interval widening, radioscaphoid arthritis, and capitolunate arthritis. The radiolunate joint is completely spared. What stage of SLAC (Scapholunate Advanced Collapse) wrist does this represent, and what is an appropriate surgical option?
. Stage I SLAC; Scaphoid excision and four-corner fusion
. Stage II SLAC; Proximal row carpectomy
. Stage III SLAC; Scaphoid excision and four-corner fusion
. Stage III SLAC; Total wrist arthroplasty
. Stage IV SLAC; Total wrist arthrodesis

Correct Answer & Explanation

. Stage III SLAC; Scaphoid excision and four-corner fusion

Explanation

Stage III SLAC wrist involves arthritis of the radioscaphoid and capitolunate joints, while reliably sparing the radiolunate joint. Scaphoid excision and four-corner fusion is a standard procedure for Stage III, whereas proximal row carpectomy is contraindicated due to the pre-existing capitate arthritis.

Question 891

Topic: Wrist & Carpus
A 65-year-old female presents with severe pain at the base of her thumb. Radiographs show Eaton-Littler Stage III trapeziometacarpal arthritis with significant subluxation and a 40-degree hyperextension deformity of the metacarpophalangeal (MCP) joint. In addition to a trapeziectomy and LRTI, what additional procedure must be performed?
. Thumb CMC arthrodesis
. Thumb MCP joint arthrodesis or volar capsulodesis
. Excision of the scaphoid
. Distal radius osteotomy
. Transfer of the EIP to the EPL

Correct Answer & Explanation

. Thumb MCP joint arthrodesis or volar capsulodesis

Explanation

In thumb CMC arthritis with an associated MCP joint hyperextension deformity of greater than 30 degrees, the MCP joint must be addressed to prevent recurrent CMC subluxation and weakness. This is typically managed with a volar capsulodesis, EPB transfer, or MCP joint arthrodesis.

Question 892

Topic: Nerve & Tendon

A 48-year-old cellist presents with progressive weakness and clumsiness in his left hand. Examination reveals profound atrophy of the first dorsal interosseous muscle, weakness in finger abduction, and a positive Froment's sign. Which nerve and site of compression are most likely responsible?

. Median nerve at the carpal tunnel
. Anterior interosseous nerve at the pronator teres
. Ulnar nerve at the cubital tunnel
. Posterior interosseous nerve at the arcade of Frohse
. Median nerve at the bicipital aponeurosis

Correct Answer & Explanation

. Ulnar nerve at the cubital tunnel

Explanation

Intrinsic wasting (first dorsal interosseous) and a positive Froment's sign (compensatory IP flexion via the median-innervated FPL due to adductor pollicis weakness) indicate an ulnar neuropathy. The cubital tunnel is the most common site of ulnar nerve entrapment.

Question 893

Topic: Hand Trauma & Infection

A 42-year-old carpenter sustains a puncture wound to his index finger. Two days later, he presents with the finger held in slight flexion, symmetric fusiform swelling of the digit, tenderness along the entire flexor tendon sheath, and severe pain with passive extension. Which of the following is the most appropriate immediate management?

. Splinting, oral antibiotics, and follow-up in 48 hours
. Intravenous antibiotics and close observation for 24 hours before considering surgery
. Emergent open irrigation and debridement of the flexor tendon sheath
. Local corticosteroid injection and early active motion
. Amputation of the affected digit

Correct Answer & Explanation

. Emergent open irrigation and debridement of the flexor tendon sheath

Explanation

The patient exhibits all four of Kanavel's cardinal signs of acute pyogenic flexor tenosynovitis. This is a surgical emergency requiring immediate irrigation and debridement of the flexor tendon sheath to prevent tendon necrosis and loss of digit function.

Question 894

Topic: Nerve & Tendon

A 34-year-old basketball player presents 3 weeks after jamming his ring finger. Examination reveals PIP joint flexion and DIP joint hyperextension.

Which of the following anatomic structures is primarily injured in this deformity?

. Terminal extensor tendon
. Flexor digitorum profundus
. Central slip of the extensor tendon
. Volar plate
. Sagittal band

Correct Answer & Explanation

. Central slip of the extensor tendon

Explanation

A Boutonniere deformity is characterized by PIP flexion and DIP hyperextension. It is caused by a rupture or attenuation of the central slip of the extensor tendon, which allows the lateral bands to subluxate volarly.

Question 895

Topic: 7. Hand and Wrist

A 22-year-old male fell on an outstretched hand 6 months ago but did not seek medical attention. He now presents with dorsal radial wrist pain. Radiographs demonstrate a scaphoid nonunion with a radiocarpal angle of 20 degrees and a scapholunate angle of 85 degrees.

What deformity pattern has developed in this patient's wrist?

. Dorsal intercalated segment instability (DISI)
. Volar intercalated segment instability (VISI)
. Ulnar translocation of the carpus
. Madelung deformity
. Dorsal perilunate dislocation

Correct Answer & Explanation

. Dorsal intercalated segment instability (DISI)

Explanation

Scaphoid nonunions commonly progress to a DISI deformity, characterized by an extended lunate (scapholunate angle > 60 degrees) and a collapsed, flexed scaphoid distal fragment. The radiolunate angle is typically >15 degrees extended.

Question 896

Topic: 7. Hand and Wrist

A 45-year-old boxer presents with pain and swelling over the third metacarpophalangeal (MCP) joint after a punch. When he attempts to extend his fingers from a fist, the middle finger lags, and the extensor tendon snaps into the valley between the third and fourth metacarpal heads. Which of the following is the most likely diagnosis?

. Extensor digitorum communis rupture
. Radial sagittal band rupture
. Ulnar sagittal band rupture
. Metacarpal neck fracture
. Trigger finger

Correct Answer & Explanation

. Radial sagittal band rupture

Explanation

Sagittal band ruptures (boxer's knuckle) typically occur on the radial side of the middle finger MCP joint, leading to ulnar subluxation of the extensor tendon during flexion. The patient exhibits characteristic extensor lag and snapping upon extension.

Question 897

Topic: 7. Hand and Wrist

A 38-year-old right-hand dominant carpenter sustains a severe crush injury to his left dorsal hand, resulting in a 6x8 cm soft tissue defect with exposed extensor tendons and metacarpal bone. Local tissue options are insufficient. Preoperative assessment reveals a positive Allen's test on the left hand, confirming adequate ulnar collateral circulation. The surgeon plans a reverse radial forearm flap (RRFF) for coverage. Which of the following statements accurately describes the primary vascular supply mechanism for this flap?

. The flap relies on direct antegrade flow from the radial artery through its entire course.
. The flap is perfused by retrograde flow through the radial artery, primarily via collateral circulation from the ulnar artery around the elbow.
. The flap's vascularity is solely dependent on musculocutaneous perforators from the brachioradialis muscle.
. The primary arterial supply is from the anterior interosseous artery, anastomosing with the radial artery distally.
. The flap is a random pattern flap, deriving its blood supply from the subdermal plexus only.

Correct Answer & Explanation

. The flap is perfused by retrograde flow through the radial artery, primarily via collateral circulation from the ulnar artery around the elbow.

Explanation

Correct Answer: BThe reverse radial forearm flap (RRFF) is an axial pattern flap based on the radial artery. Its unique characteristic is that it relies onretrograde flow through the radial artery. After the proximal radial artery is ligated and divided during harvest, the blood supply to the flap is maintained by collateral circulation from the u ulnar artery, primarily through the palmar and dorsal carpal arches around the wrist, which then perfuses the radial artery in a reverse direction. This retrograde flow then supplies the fasciocutaneous perforators within the flap.Option A is incorrectbecause the flap is distally based, meaning the proximal radial artery is ligated, and flow is reversed, not antegrade through its entire course.Option C is incorrectbecause while fasciocutaneous perforators are crucial, the primary vascular pedicle is the radial artery itself, which carries the main blood supply, not solely musculocutaneous perforators from a specific muscle.Option D is incorrectas the anterior interosseous artery is not the primary arterial supply for the radial forearm flap; the radial artery is the main pedicle.Option E is incorrectbecause the RRFF is an axial pattern flap, meaning it has a defined, named vascular pedicle (the radial artery), unlike a random pattern flap which relies on the less predictable subdermal plexus.

Question 898

Topic: 7. Hand and Wrist

A 55-year-old diabetic patient presents with a chronic non-healing ulcer over the dorsal aspect of his right wrist, exposing the extensor retinaculum. He has a history of peripheral vascular disease. Prior to considering a reverse radial forearm flap, the most critical preoperative assessment to perform is:

. A detailed neurological examination of the right hand and forearm.
. Measurement of the defect size and creation of a sterile template.
. A thorough Allen's test on the right hand to assess ulnar artery collateral circulation.
. Assessment of the patient's nutritional status and HbA1c levels.
. Doppler ultrasound mapping of the superficial radial nerve course.

Correct Answer & Explanation

. A thorough Allen's test on the right hand to assess ulnar artery collateral circulation.

Explanation

Correct Answer: CThe most critical preoperative assessment for a reverse radial forearm flap (RRFF) is a thoroughAllen's test. The entire principle of the RRFF relies on retrograde flow from the ulnar artery via the palmar and dorsal carpal arches to perfuse the radial artery after its proximal ligation. If the ulnar artery's collateral circulation is compromised (a negative Allen's test), harvesting the radial artery would risk significant ischemia to the entire hand, making it an absolute contraindication. Given the patient's history of diabetes and peripheral vascular disease, this assessment is even more paramount.Option A is incorrect, while a neurological exam is important for overall assessment, it is not the most critical step specifically for determining the safety of radial artery harvest.Option B is incorrect, defect measurement is essential for flap planning but does not address the absolute contraindication related to hand vascularity.Option D is incorrect, nutritional status and HbA1c are important for overall healing, especially in a diabetic patient, but they do not supersede the immediate safety concern of hand vascularity.Option E is incorrect, Doppler mapping of the superficial radial nerve is relevant if a sensate flap is desired, but it is not the most critical step for flap viability or hand safety.

Question 899

Topic: 7. Hand and Wrist

A 28-year-old male presents with a complex soft tissue defect on the dorsal aspect of his left hand following a motorcycle accident, exposing the extensor tendons and metacarpal heads. A reverse radial forearm flap is planned. The image below shows the intraoperative marking for the flap. Based on the principles of RRFF harvest, what is the primary reason for maintaining the distal margin of the skin paddle at least 2-3 cm proximal to the radial styloid?

. To ensure adequate length for primary closure of the donor site.
. To preserve distal perforators that contribute to the blood supply of the hand and minimize donor site morbidity.
. To avoid injury to the superficial radial nerve, which becomes superficial at the wrist.
. To facilitate easier dissection of the radial artery from the flexor carpi radialis tendon.
. To prevent venous congestion by ensuring sufficient length for the venae comitantes.

Correct Answer & Explanation

. To preserve distal perforators that contribute to the blood supply of the hand and minimize donor site morbidity.

Explanation

Correct Answer: BAs stated in the case, the distal margin of the flap should be at least 2-3 cm proximal to the radial styloid. This is done primarily topreserve the distal perforatorsthat contribute to the blood supply of the hand, ensuring adequate circulation to the hand itself after radial artery harvest. Additionally, it helps to minimize donor site morbidity and aesthetic concerns at the wrist, as the scar is less conspicuous away from the joint line.Option A is incorrect; while donor site closure is a consideration, the primary reason for the distal margin placement is vascular preservation, not solely to facilitate primary closure (which often requires a skin graft for wider flaps anyway).Option C is incorrect; the superficial radial nerve (SRN) does become superficial distally, but its preservation or inclusion is a separate consideration. The 2-3 cm margin is specifically for arterial perforator preservation to the hand.Option D is incorrect; the ease of dissection of the radial artery from the flexor carpi radialis tendon is not the primary determinant for the distal margin of the skin paddle.Option E is incorrect; while venous drainage is critical, the specific 2-3 cm margin is more directly related to preserving distal arterial perforators for hand viability rather than solely preventing venous congestion.

Question 900

Topic: 7. Hand and Wrist

A 42-year-old patient undergoes a reverse radial forearm flap for coverage of a complex wrist defect. During the postoperative period, the patient complains of persistent pain and numbness over the dorsum of the thumb and index finger of the donor hand. Which of the following is the most likely cause of this donor site complication?

. Radial artery insufficiency due to inadequate ulnar collateral circulation.
. Partial flap necrosis at the distal margin of the transferred flap.
. Injury or entrapment of the superficial radial nerve in the donor site scar.
. Infection at the recipient site requiring antibiotic treatment.
. Functional deficit of the flexor carpi radialis tendon due to excessive dissection.

Correct Answer & Explanation

. Injury or entrapment of the superficial radial nerve in the donor site scar.

Explanation

Correct Answer: CThe symptoms of persistent pain and numbness over the dorsum of the thumb and index finger of the donor hand are classic for injury or entrapment of thesuperficial radial nerve (SRN). The SRN provides sensory innervation to this specific area. If the SRN was not intentionally harvested with the flap for sensate reconstruction, it can be inadvertently damaged during dissection, entrapped in the donor site scar, or develop a painful neuroma, leading to these symptoms. If it was harvested for a sensate flap, this sensory deficit would be an expected, discussed outcome.Option A is incorrect; radial artery insufficiency would manifest as signs of hand ischemia (pallor, coldness, absent pulses), not primarily as pain and numbness in the SRN distribution, especially if a positive Allen's test was confirmed pre-operatively.Option B is incorrect; partial flap necrosis is a complication of the transferred flap at the recipient site, not a donor site complication causing pain and numbness in the donor hand.Option D is incorrect; infection at the recipient site would cause local signs of inflammation (redness, swelling, warmth, pain) at the recipient site, not specific sensory deficits in the donor hand.Option E is incorrect; while functional deficits can occur, they typically involve grip strength or wrist flexion and are not directly associated with specific sensory complaints in the SRN distribution.

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