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7. Hand and Wrist MCQs

Practice Set 54 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 1061

Topic: 7. Hand and Wrist

A 50-year-old patient undergoes extension block pinning (Ishiguro technique) for a bony mallet finger with volar subluxation.

Which of the following describes the correct pin configuration for this technique?

. A single longitudinal pin crossing the DIP joint only
. One dorsal pin driven into the middle phalanx head to block the fragment, and a second pin to transfix the DIP joint in extension
. Two crossed pins through the distal fragment into the middle phalanx
. A single pin driven transversally through the fracture site
. An intramedullary screw placed through the distal tip of the phalanx

Correct Answer & Explanation

. One dorsal pin driven into the middle phalanx head to block the fragment, and a second pin to transfix the DIP joint in extension

Explanation

The Ishiguro extension block technique utilizes a dorsal pin placed into the head of the middle phalanx to block dorsal migration of the fracture fragment, followed by a second longitudinal or oblique pin across the DIP joint to maintain extension and reduction.

Question 1062

Topic: Nerve & Tendon

What is the most common complication associated with non-operative extension splinting of a mallet finger?

. Infection
. Nail bed deformity
. Dorsal skin maceration and ulceration
. Complex regional pain syndrome
. Tendon rupture

Correct Answer & Explanation

. Dorsal skin maceration and ulceration

Explanation

Dorsal skin maceration, blistering, or necrosis over the DIP joint is the most common complication of mallet finger splinting, often caused by poor splint fit or excessive hyperextension.

Question 1063

Topic: Nerve & Tendon

In the Doyle classification of mallet finger injuries, a Type IVC injury is defined by which of the following characteristics?

. Closed soft tissue injury
. Laceration of the tendon
. Deep abrasion with skin loss
. Fracture involving >50% of the articular surface
. Fracture involving <20% of the articular surface

Correct Answer & Explanation

. Fracture involving >50% of the articular surface

Explanation

According to the Doyle classification, Type IVC is a mallet fracture involving greater than 50% of the articular surface, which typically indicates a high risk of volar subluxation.

Question 1064

Topic: Hand Trauma & Infection

A patient with a diagnosed thumb UCL injury is deemed appropriate for non-operative management. What is the standard conservative protocol?

. Buddy taping to the index finger for 3 weeks
. Thumb spica immobilization for 4 to 6 weeks
. Figure-of-eight splinting for 2 weeks
. Early active range of motion without immobilization
. Nighttime extension splinting only

Correct Answer & Explanation

. Thumb spica immobilization for 4 to 6 weeks

Explanation

Incomplete tears of the UCL (Grades I and II) without a Stener lesion are treated with thumb spica cast or splint immobilization for 4 to 6 weeks to allow ligamentous healing.

Question 1065

Topic: Nerve & Tendon

A 65-year-old woman presents with a painful, stiff DIP joint secondary to an untreated chronic mallet finger sustained 10 years ago. Radiographs show severe osteoarthritis of the DIP joint. What is the most reliable definitive treatment?

. Terminal tendon reconstruction
. Central slip tenotomy
. DIP joint arthrodesis
. DIP joint arthroplasty
. Oblique retinacular ligament reconstruction

Correct Answer & Explanation

. DIP joint arthrodesis

Explanation

In the setting of a chronic mallet finger with end-stage post-traumatic osteoarthritis and pain, DIP joint arthrodesis is the most reliable procedure to eliminate pain and provide a stable pinch.

Question 1066

Topic: Hand Trauma & Infection

When evaluating a patient with a 'Gamekeeper's thumb,' how does the pathophysiology traditionally differ from a 'Skier's thumb'?

. Gamekeeper's thumb involves the radial collateral ligament
. Gamekeeper's thumb is caused by chronic, repetitive valgus stress
. Gamekeeper's thumb exclusively involves bony avulsions
. Gamekeeper's thumb requires operative intervention in all cases
. Gamekeeper's thumb is typically sustained in a flexed MCP position

Correct Answer & Explanation

. Gamekeeper's thumb is caused by chronic, repetitive valgus stress

Explanation

Historically, 'Gamekeeper's thumb' refers to chronic attenuation of the UCL due to repetitive valgus forces (e.g., breaking the necks of game), whereas 'Skier's thumb' refers to an acute traumatic rupture.

Question 1067

Topic: Nerve & Tendon

During the physical examination of a suspected mallet finger, what clinical finding most accurately distinguishes a terminal tendon rupture from a central slip rupture (boutonniere deformity)?

. Inability to actively extend the PIP joint
. Inability to actively extend the DIP joint with the PIP joint stabilized in extension
. Hyperextension of the DIP joint
. Flexion of the MCP joint
. Volar subluxation of the PIP joint

Correct Answer & Explanation

. Inability to actively extend the DIP joint with the PIP joint stabilized in extension

Explanation

A mallet finger presents with an inability to actively extend the DIP joint. Stabilizing the PIP joint in extension isolates the terminal tendon function, confirming the diagnosis and ruling out central slip involvement (which presents with a PIP extension lag).

Question 1068

Topic: 7. Hand and Wrist

A 28-year-old male skier presents after falling with his thumb caught in a ski pole strap. Examination reveals point tenderness over the ulnar aspect of the thumb metacarpophalangeal (MCP) joint and a palpable mass. A Stener lesion is suspected. Which of the following describes the anatomic basis of a Stener lesion?

. Avulsion of the proper UCL with interposition of the abductor pollicis brevis
. Avulsion of the distal UCL displacing superficial to the adductor pollicis aponeurosis
. Avulsion of the proximal UCL displacing deep to the adductor pollicis aponeurosis
. Rupture of the accessory UCL with interposition of the volar plate
. Entrapment of the extensor pollicis brevis between the UCL and proximal phalanx

Correct Answer & Explanation

. Avulsion of the distal UCL displacing superficial to the adductor pollicis aponeurosis

Explanation

A Stener lesion occurs when the distal end of the completely ruptured ulnar collateral ligament (UCL) displaces superficial and proximal to the adductor pollicis aponeurosis. This interposition prevents the ligament from healing to its anatomic insertion, rendering conservative management ineffective and necessitating surgical repair.

Question 1069

Topic: Hand Trauma & Infection

In the evaluation of a suspected Skier's thumb, valgus stress testing is performed to assess the integrity of the ulnar collateral ligament (UCL) complex. Which of the following statements regarding the biomechanical function of the thumb MCP joint ligaments is correct?

. The proper UCL is the primary stabilizer to valgus stress in full extension.
. The accessory UCL is the primary stabilizer to valgus stress in 30 degrees of flexion.
. The proper UCL is most taut in 30 degrees of MCP flexion.
. The volar plate provides primary resistance to valgus stress in full flexion.
. The adductor pollicis provides dynamic stability against varus stress.

Correct Answer & Explanation

. The proper UCL is most taut in 30 degrees of MCP flexion.

Explanation

The proper UCL is the primary restraint to valgus stress when the thumb MCP joint is in 30 degrees of flexion, as it is most taut in this position. The accessory UCL and volar plate become the primary restraints when the MCP joint is in full extension.

Question 1070

Topic: Nerve & Tendon

A 32-year-old woman presents 5 weeks after sustaining a closed soft-tissue mallet finger injury to her small finger. She has not received any prior treatment and currently has a 45-degree extensor lag. Which of the following is the most appropriate initial management?

. Surgical repair of the terminal tendon using a micro-bone anchor
. Arthrodesis of the distal interphalangeal (DIP) joint
. Continuous DIP joint extension splinting for 8 weeks
. Nighttime only DIP extension splinting for 6 weeks
. Surgical tenodermodesis

Correct Answer & Explanation

. Continuous DIP joint extension splinting for 8 weeks

Explanation

Delayed presentation of a soft-tissue mallet finger (up to 3 months post-injury) can still be successfully treated with conservative management. The protocol remains strict continuous DIP joint extension splinting for a full 8 weeks.

Question 1071

Topic: Hand Trauma & Infection

A 25-year-old female presents after a skiing accident with pain and swelling at the ulnar base of her right thumb. On examination, valgus stress testing reveals 40 degrees of laxity with the metacarpophalangeal (MCP) joint in 30 degrees of flexion, compared to 10 degrees on the contralateral thumb. There is no palpable end-point. MRI confirms a complete ligament rupture. During surgical repair, the torn proximal stump of the ligament is most likely to be found superficial to which of the following structures?

. Abductor pollicis brevis aponeurosis
. Adductor pollicis aponeurosis
. Flexor pollicis brevis tendon
. Extensor pollicis longus tendon
. First dorsal interosseous fascia

Correct Answer & Explanation

. Adductor pollicis aponeurosis

Explanation

This describes a Stener lesion, which occurs in 80% of complete proper UCL tears. The adductor pollicis aponeurosis becomes interposed between the torn UCL and its insertion, preventing spontaneous healing and necessitating surgical repair.

Question 1072

Topic: 7. Hand and Wrist

A 35-year-old male sustains a bony mallet finger to his dominant right long finger while playing baseball. Radiographs demonstrate a dorsal avulsion fracture of the distal phalanx involving 40% of the articular surface. Which of the following radiographic findings serves as an absolute indication for surgical intervention rather than non-operative splinting?

. Fracture fragment involving greater than 20% of the articular surface
. Volar subluxation of the distal phalanx relative to the middle phalanx
. A 2 mm fracture gap
. Presence of a dorsal cortical osteophyte
. A concomitant non-displaced tuft fracture

Correct Answer & Explanation

. Volar subluxation of the distal phalanx relative to the middle phalanx

Explanation

Volar subluxation of the distal phalanx indicates joint incongruity and instability, serving as an absolute indication for surgical management (typically extension block pinning). Fragment size alone is controversial, but subluxation is a universally accepted surgical indication.

Question 1073

Topic: Nerve & Tendon

A 45-year-old female presents with a 6-month history of a symptomatic chronic soft-tissue mallet finger of her left index finger. She has developed a swan neck deformity with a 35-degree extensor lag at the DIP joint and PIP joint hyperextension. Both joints remain fully passively correctable, and there is no radiographic evidence of osteoarthritis. Which of the following surgical interventions is most appropriate?

. DIP joint arthrodesis
. Terminal extensor tendon imbrication
. Fowler central slip tenotomy
. PIP joint volar plate arthroplasty
. Extensor indicis proprius (EIP) transfer

Correct Answer & Explanation

. Fowler central slip tenotomy

Explanation

In a chronic mallet finger with a flexible swan neck deformity, a Fowler central slip tenotomy allows the lateral bands to shift volarly, correcting PIP hyperextension while redirecting extensor force to the terminal tendon to correct the DIP lag.

Question 1074

Topic: Nerve & Tendon

A 50-year-old male presents to your clinic 5 weeks after sustaining a closed soft-tissue mallet injury to his right small finger. He has not sought prior medical attention and currently has a 40-degree extensor lag at the DIP joint. Radiographs are negative for fractures. What is the recommended initial management for this delayed presentation?

. Surgical repair of the terminal extensor tendon using a suture anchor
. DIP joint arthrodesis
. Continuous DIP joint extension splinting for 8 weeks
. Dynamic extension splinting for 4 weeks
. Observation and reassurance as the injury is now chronic

Correct Answer & Explanation

. Continuous DIP joint extension splinting for 8 weeks

Explanation

Soft-tissue mallet fingers presenting delayed (up to 12 weeks post-injury) still demonstrate excellent outcomes with strict, continuous DIP extension splinting for 8 weeks. Surgery is generally reserved for failed conservative management or specific bony mallets.

Question 1075

Topic: 7. Hand and Wrist

During the surgical approach for repairing a completely ruptured ulnar collateral ligament of the thumb with an associated Stener lesion, an incision is made over the ulnar aspect of the thumb MCP joint. Which of the following neurologic structures is at greatest risk of iatrogenic injury during this approach?

. Palmar cutaneous branch of the median nerve
. Terminal branches of the superficial radial nerve
. Proper palmar digital nerve of the thumb
. Dorsal sensory branch of the ulnar nerve
. Recurrent motor branch of the median nerve

Correct Answer & Explanation

. Terminal branches of the superficial radial nerve

Explanation

Terminal sensory branches of the superficial radial nerve course directly over the dorsal-ulnar aspect of the thumb MCP joint. They must be carefully identified and protected during a surgical approach for a skier's thumb to prevent painful neuroma formation.

Question 1076

Topic: 7. Hand and Wrist

A patient with a soft-tissue mallet finger has been undergoing continuous extension splinting. At the 4-week mark, the patient admits to removing the splint to wash his hands, during which the DIP joint fell into full flexion. What is the most appropriate next step in management?

. Add 2 weeks to the total splinting duration
. Immediately proceed with surgical pinning of the DIP joint
. Restart the 6-to-8 week continuous splinting protocol from day zero
. Discontinue splinting and begin range of motion exercises
. Transition to nighttime-only splinting for 4 weeks

Correct Answer & Explanation

. Restart the 6-to-8 week continuous splinting protocol from day zero

Explanation

Any flexion of the DIP joint during the acute splinting phase disrupts the fragile healing tissue of the terminal extensor tendon. The continuous 6-to-8 week splinting protocol must be restarted entirely from day zero.

Question 1077

Topic: 7. Hand and Wrist

A 32-year-old mechanic sustains a closed soft-tissue mallet finger. He is compliant with 8 weeks of continuous extension splinting, followed by a weaning protocol. At his final follow-up, he notes a firm, painless bump over the dorsal aspect of the DIP joint but has full active extension. What is the most likely etiology of this dorsal prominence?

. Osteophyte formation secondary to post-traumatic arthritis
. Dorsal subluxation of the distal phalanx
. Fibrous tissue hyperplasia at the healing tendon site
. A missed bony avulsion fracture
. Epidermal inclusion cyst from splint friction

Correct Answer & Explanation

. Fibrous tissue hyperplasia at the healing tendon site

Explanation

A prominent dorsal bump after non-operative treatment of a mallet finger is common and typically represents fibrous tissue/scar hyperplasia at the tendon healing site. It is usually painless and tends to slowly remodel over several months.

Question 1078

Topic: 7. Hand and Wrist

A 28-year-old male presents with a thumb injury.

Assuming the radiograph demonstrates a bony mallet finger with a large dorsal fragment (45% of the articular surface) and volar subluxation of the distal phalanx, what is the most widely accepted surgical technique for this specific pattern?

. Open reduction and internal fixation with a mini-fragment plate
. Closed reduction and extension block pinning
. Excision of the fragment and advancement of the terminal tendon
. Primary DIP joint arthrodesis
. Percutaneous headless compression screw fixation

Correct Answer & Explanation

. Closed reduction and extension block pinning

Explanation

Bony mallet fingers with volar subluxation require surgical stabilization. Extension block pinning (Ishiguro technique) is the most widely utilized and effective technique, avoiding the high complication rates of open reduction at the DIP joint.

Question 1079

Topic: 7. Hand and Wrist

A 22-year-old skier presents after a fall with a painful thumb. Radiographs demonstrate a 3 mm displaced avulsion fracture of the ulnar base of the thumb proximal phalanx. The MCP joint is subluxated radially. What is the most appropriate management?

. Thumb spica cast for 6 weeks
. Closed reduction and percutaneous pinning of the MCP joint
. Open reduction and internal fixation of the avulsion fragment
. Excision of the fragment and primary repair of the UCL to bone
. Observation and early active range of motion

Correct Answer & Explanation

. Open reduction and internal fixation of the avulsion fragment

Explanation

Bony avulsions of the UCL insertion (bony Skier's thumb) that are significantly displaced (>2 mm) or associated with joint subluxation should be treated with Open Reduction and Internal Fixation (ORIF) to restore joint congruity and stability.

Question 1080

Topic: Nerve & Tendon

A 62-year-old male presents with a chronic mallet finger of his right index finger sustained 5 years ago. He complains of significant pain, difficulty with pinch grip, and a 45-degree extensor lag. Radiographs reveal complete loss of joint space, subchondral sclerosis, and osteophytes at the DIP joint. What is the definitive treatment of choice?

. Terminal extensor tendon reconstruction with a palmaris longus graft
. Spiral oblique retinacular ligament (SORL) reconstruction
. Fowler central slip tenotomy
. Silicone arthroplasty of the DIP joint
. DIP joint arthrodesis

Correct Answer & Explanation

. DIP joint arthrodesis

Explanation

In the setting of a chronic, painful mallet finger with advanced osteoarthritic changes of the DIP joint, soft tissue reconstructions will fail and remain painful. DIP joint arthrodesis provides stable, pain-free pinch mechanics.

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