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7. Hand and Wrist MCQs

Practice Set 57 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 1121

Topic: 7. Hand and Wrist

When comparing full-thickness skin grafts (FTSG) to split-thickness skin grafts (STSG) for hand reconstruction, which of the following statements accurately describes their contraction profiles?

. FTSG undergoes more primary contraction and more secondary contraction.
. FTSG undergoes more primary contraction and less secondary contraction.
. STSG undergoes more primary contraction and more secondary contraction.
. STSG undergoes less primary contraction and less secondary contraction.
. Both grafts undergo equal rates of secondary contraction.

Correct Answer & Explanation

. FTSG undergoes more primary contraction and less secondary contraction.

Explanation

Full-thickness skin grafts contain more elastin, leading to greater primary contraction immediately upon harvest. However, because they contain the entire dermis, they resist secondary contraction much better than STSGs, making them the preferred choice for palmar and flexor surface defects.

Question 1122

Topic: Nerve & Tendon

A 55-year-old patient with poorly controlled type 2 diabetes mellitus presents with a locked trigger ring finger. How does the patient's diabetic status affect the expected outcome of a local corticosteroid injection compared to a non-diabetic patient?

. Higher success rate with a single injection
. Lower success rate and higher likelihood of requiring surgery
. Increased risk of spontaneous tendon rupture
. Decreased risk of subcutaneous fat atrophy
. Absolute contraindication to corticosteroid use

Correct Answer & Explanation

. Lower success rate and higher likelihood of requiring surgery

Explanation

Diabetic patients have a significantly lower success rate (often <50%) with corticosteroid injections for trigger finger compared to non-diabetics (who have up to 80-90% success). Diabetics frequently require multiple injections or proceed to surgical release.

Question 1123

Topic: 7. Hand and Wrist

A 45-year-old woman is 4 weeks status post open carpal tunnel release. She complains of persistent, deep-seated aching pain in the thenar and hypothenar eminences. She has full nerve recovery and normal wound healing. What is the most appropriate management?

. Surgical re-exploration for incomplete release
. Corticosteroid injection into the carpal tunnel
. Reassurance, stretching, and supportive care
. Rigid wrist splinting for an additional 4 weeks
. MRI of the wrist to rule out a neuroma

Correct Answer & Explanation

. Reassurance, stretching, and supportive care

Explanation

The patient is experiencing "pillar pain," a common postoperative complication after carpal tunnel release. It is typically self-limiting, resolving within 3 to 6 months with supportive care, reassurance, and desensitization therapy.

Question 1124

Topic: 7. Hand and Wrist

During evaluation for suspected carpal tunnel syndrome, the examiner notes decreased two-point discrimination over the volar aspect of the index and middle fingers, but perfectly preserved sensation over the thenar eminence. What anatomical rationale explains the preserved thenar sensation?

. The palmar cutaneous branch of the median nerve arises proximal to the transverse carpal ligament.
. The recurrent motor branch supplies sensation to the thenar eminence.
. The ulnar nerve supplies sensory innervation to the thenar eminence.
. The musculocutaneous nerve provides overlapping sensory innervation.
. The radial sensory nerve supplies the entire volar thenar area.

Correct Answer & Explanation

. The palmar cutaneous branch of the median nerve arises proximal to the transverse carpal ligament.

Explanation

The palmar cutaneous branch of the median nerve typically branches off approximately 5 cm proximal to the transverse carpal ligament and travels superficial to it. Therefore, it is spared from compression within the carpal tunnel, preserving sensation over the thenar eminence.

Question 1125

Topic: Nerve & Tendon

During an open surgical release of the A1 pulley for a trigger thumb, which nerve is at greatest risk of iatrogenic injury due to its oblique anatomical course crossing the flexor pollicis longus sheath?

. Recurrent motor branch of the median nerve
. Radial digital nerve of the thumb
. Ulnar digital nerve of the thumb
. Palmar cutaneous branch of the median nerve
. Superficial branch of the radial nerve

Correct Answer & Explanation

. Radial digital nerve of the thumb

Explanation

The radial digital nerve of the thumb has an oblique course that brings it very close to the proximal edge of the A1 pulley. It is highly susceptible to injury during trigger thumb release if careful blunt dissection is not employed.

Question 1126

Topic: 7. Hand and Wrist

A patient presents with a dorsal hand avulsion injury. The wound bed consists exclusively of exposed metacarpal bone completely devoid of periosteum. Which of the following is the most appropriate definitive coverage option?

. Split-thickness skin graft
. Full-thickness skin graft
. Cultured epidermal autograft
. Regional flap or free tissue transfer
. Secondary intention healing with negative pressure wound therapy

Correct Answer & Explanation

. Regional flap or free tissue transfer

Explanation

Skin grafts require a vascularized wound bed to survive. Bare bone without periosteum, bare tendon without paratenon, and bare cartilage cannot support a skin graft, necessitating flap coverage to provide a new blood supply.

Question 1127

Topic: 7. Hand and Wrist

Which of the following systemic conditions is most strongly associated with severe bilateral carpal tunnel syndrome secondary to amyloid deposition in the transverse carpal ligament and tenosynovium?

. Hypothyroidism
. Diabetes mellitus
. Rheumatoid arthritis
. End-stage renal disease on chronic hemodialysis
. Acromegaly

Correct Answer & Explanation

. End-stage renal disease on chronic hemodialysis

Explanation

Patients with end-stage renal disease on long-term hemodialysis are prone to beta-2-microglobulin amyloidosis. This amyloid material commonly deposits in the transverse carpal ligament and flexor tenosynovium, leading to severe and often bilateral carpal tunnel syndrome.

Question 1128

Topic: 7. Hand and Wrist

A 72-year-old female presents with chronic carpal tunnel syndrome. She demonstrates profound thenar atrophy and an inability to oppose her thumb to her small finger. EMG shows severe denervation. Following a carpal tunnel release, what concomitant procedure is most appropriate to restore opposition?

. Opponensplasty using the extensor indicis proprius
. Tendon transfer using the flexor digitorum profundus
. Tenodesis of the flexor pollicis longus
. Z-plasty of the first web space
. Arthrodesis of the thumb carpometacarpal joint

Correct Answer & Explanation

. Opponensplasty using the extensor indicis proprius

Explanation

In advanced carpal tunnel syndrome with irreversible thenar atrophy and complete loss of opposition, an opponensplasty is indicated. The extensor indicis proprius (EIP) or flexor digitorum superficialis (FDS) of the ring finger are commonly used for this tendon transfer.

Question 1129

Topic: 7. Hand and Wrist

A surgeon decides to mesh a split-thickness skin graft 1.5:1 for a large dorsal hand defect. Aside from expanding the surface area of the graft, what is the primary biological advantage of meshing in this setting?

. Decreases secondary contraction
. Allows egress of fluid to prevent hematoma and seroma
. Increases the primary contraction
. Promotes faster inosculation from the wound bed
. Thickens the dermis over time

Correct Answer & Explanation

. Allows egress of fluid to prevent hematoma and seroma

Explanation

Meshing a split-thickness skin graft allows for the egress of serum and blood. This prevents the accumulation of fluid (hematoma or seroma) beneath the graft, which is the most common cause of graft failure.

Question 1130

Topic: 7. Hand and Wrist

The A1 pulley of the digital flexor tendon sheath primarily originates from which of the following anatomical structures?

. Metacarpal shaft
. Volar plate of the metacarpophalangeal joint
. Shaft of the proximal phalanx
. Volar plate of the proximal interphalangeal joint
. Deep transverse metacarpal ligament

Correct Answer & Explanation

. Volar plate of the metacarpophalangeal joint

Explanation

The A1 pulley is located at the level of the metacarpophalangeal (MCP) joint and originates from the volar plate of the MCP joint, as well as the adjacent base of the proximal phalanx.

Question 1131

Topic: 7. Hand and Wrist

Comparing endoscopic carpal tunnel release (ECTR) to open carpal tunnel release (OCTR), high-level evidence demonstrates which of the following outcomes for ECTR?

. Lower risk of transient iatrogenic nerve injury
. Faster return to work and less early scar pain
. Higher long-term grip strength at 1 year postoperatively
. Complete elimination of postoperative pillar pain
. Lower rate of long-term symptom recurrence

Correct Answer & Explanation

. Faster return to work and less early scar pain

Explanation

Endoscopic carpal tunnel release (ECTR) is associated with a faster return to work and less early scar pain compared to open techniques. However, long-term outcomes for symptom relief and grip strength are equivalent, and ECTR carries a slightly higher risk of transient median nerve neuropraxia.

Question 1132

Topic: Hand Trauma & Infection



A 50-year-old male received a corticosteroid injection for a trigger middle finger 5 days ago. He now presents with severe throbbing pain, diffuse fusiform swelling of the digit, a semiflexed posture, and excruciating pain with passive extension. Which anatomical structure is the primary conduit for the proximal spread of this suspected infection?

. Lumbrical canal
. Cleland's ligament
. Parona's space
. Flexor tendon sheath
. Grayson's ligament

Correct Answer & Explanation

. Flexor tendon sheath

Explanation

The patient exhibits Kanavel's cardinal signs of infectious pyogenic flexor tenosynovitis. The infection propagates longitudinally through the flexor tendon sheath, which in the middle finger can eventually rupture into the midpalmar space.

Question 1133

Topic: Nerve & Tendon

During an open surgical release of the A1 pulley for a trigger thumb, which neurovascular structure is at the greatest risk of iatrogenic injury due to its anatomical course?

. Radial digital nerve of the thumb
. Ulnar digital nerve of the thumb
. Recurrent motor branch of the median nerve
. Radial artery
. Superficial branch of the radial nerve

Correct Answer & Explanation

. Radial digital nerve of the thumb

Explanation

The radial digital nerve of the thumb obliquely crosses the flexor sheath near the metacarpophalangeal flexion crease. It is highly susceptible to injury if the incision is too deep or radial during an A1 pulley release.

Question 1134

Topic: 7. Hand and Wrist

Which of the following electrodiagnostic findings is typically the earliest and most sensitive indicator of carpal tunnel syndrome?

. Increased insertional activity in the abductor pollicis brevis
. Prolonged distal motor latency
. Prolonged sensory peak latency
. Decreased motor compound muscle action potential amplitude
. Fibrillation potentials in the thenar muscles

Correct Answer & Explanation

. Prolonged sensory peak latency

Explanation

Sensory nerve fibers are typically affected before motor fibers in compressive neuropathies like carpal tunnel syndrome. A prolonged sensory peak latency is the most sensitive and earliest electromyographic/nerve conduction study finding.

Question 1135

Topic: 7. Hand and Wrist

When comparing full-thickness skin grafts (FTSG) to split-thickness skin grafts (STSG) for reconstructing a volar hand defect, which of the following statements regarding graft contraction is true?

. FTSG exhibits greater primary contraction and greater secondary contraction.
. FTSG exhibits greater primary contraction and less secondary contraction.
. FTSG exhibits less primary contraction and less secondary contraction.
. STSG exhibits greater primary contraction and greater secondary contraction.
. STSG exhibits greater primary contraction and less secondary contraction.

Correct Answer & Explanation

. FTSG exhibits greater primary contraction and less secondary contraction.

Explanation

Primary contraction occurs immediately after harvest due to elastin fibers, which are more abundant in the thicker dermis of FTSG. Secondary contraction occurs during healing and is mediated by myofibroblasts, which is more severe in STSG.

Question 1136

Topic: 7. Hand and Wrist

To avoid injury to the palmar cutaneous branch of the median nerve during an open carpal tunnel release, the longitudinal surgical incision should be placed in line with the radial border of the ring finger and specifically:

. Ulnar to the palmaris longus tendon axis.
. Radial to the palmaris longus tendon axis.
. Directly over the flexor carpi radialis tendon.
. Proximal to the distal wrist crease in the midline.
. Transversely across the distal wrist crease.

Correct Answer & Explanation

. Ulnar to the palmaris longus tendon axis.

Explanation

The palmar cutaneous branch of the median nerve typically travels between the palmaris longus and the flexor carpi radialis. Placing the incision ulnar to the palmaris longus tendon axis keeps the dissection away from this nerve.

Question 1137

Topic: Nerve & Tendon

Which of the following describes the primary histological finding in the A1 pulley of a patient with chronic trigger finger?

. Acute inflammatory infiltrates with neutrophils
. Extensive eosinophilic granulomas
. Fibrocartilaginous metaplasia with chondrocyte proliferation
. Myxoid degeneration of the flexor tendon
. Granulomatous inflammation with multinucleated giant cells

Correct Answer & Explanation

. Fibrocartilaginous metaplasia with chondrocyte proliferation

Explanation

Trigger finger is primarily a degenerative rather than inflammatory condition. Histology demonstrates fibrocartilaginous metaplasia and hypertrophy of the A1 pulley with local chondrocyte proliferation.

Question 1138

Topic: 7. Hand and Wrist

Which of the following clinical findings is the strongest predictor of failure for non-operative management (e.g., splinting, corticosteroid injection) in a patient with carpal tunnel syndrome?

. Intermittent night pain
. Positive Phalen's test at 45 seconds
. Symptoms present for 3 months
. Constant paresthesias with 2-point discrimination > 6 mm
. Positive Tinel's sign at the wrist

Correct Answer & Explanation

. Constant paresthesias with 2-point discrimination > 6 mm

Explanation

Constant paresthesias and an abnormal 2-point discrimination (> 6 mm) indicate severe axonal damage. These findings portend a poor response to conservative therapy and typically necessitate surgical release.

Question 1139

Topic: Nerve & Tendon
A 55-year-old patient with poorly controlled type 2 diabetes mellitus presents with a grade III trigger ring finger. Regarding the use of corticosteroid injections for this condition, the patient should be counseled that:
. The injection is contraindicated due to the risk of severe hyperglycemia.
. The success rate of a single injection is equivalent to that in non-diabetic patients.
. They have a significantly lower rate of symptom resolution compared to non-diabetics.
. The injection carries a 50% risk of flexor tendon rupture.
. Surgical release should always be the first-line treatment in diabetic patients.

Correct Answer & Explanation

. They have a significantly lower rate of symptom resolution compared to non-diabetics.

Explanation

Diabetic patients generally have a much lower success rate (often around 50% or less) with corticosteroid injections for trigger fingers compared to non-diabetics. Multiple injections are less likely to succeed, and surgical release is more frequently required.

Question 1140

Topic: 7. Hand and Wrist

A patient sustains a degloving injury to the dorsal hand, resulting in exposed extensor tendons completely devoid of paratenon. Why is a split-thickness skin graft contraindicated for immediate coverage of this specific defect?

. High risk of hyperpigmentation
. Inability to establish plasmatic imbibition and angiogenesis on an avascular bed
. Excessive secondary contraction leading to an extension contracture
. Risk of generating an inclusion cyst
. High risk of squamous cell carcinoma development

Correct Answer & Explanation

. Inability to establish plasmatic imbibition and angiogenesis on an avascular bed

Explanation

Skin grafts require a vascularized wound bed for survival. A tendon devoid of paratenon is avascular, preventing the critical early phases of plasmatic imbibition and subsequent angiogenesis necessary for graft take.

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