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 1181
Topic: 7. Hand and Wrist
Flexor tendon injuries in the hand historically carry a poor prognosis when occurring in "Zone II" due to the tight confines of the fibro-osseous sheath. What is the proximal anatomical boundary of Zone II?
Correct Answer & Explanation
. Proximal edge of the A1 pulley
Explanation
Zone II, often called "no man's land," extends proximally from the proximal edge of the A1 pulley to the insertion of the flexor digitorum superficialis (FDS) at the middle phalanx. Both FDS and flexor digitorum profundus (FDP) tendons travel together within this tight sheath.
Question 1182
Topic: 7. Hand and Wrist
A 45-year-old pregnant female at 32 weeks gestation presents with severe, bilateral carpal tunnel syndrome that is unresponsive to nighttime splinting and causes significant sleep deprivation. What is the most appropriate next step in management?
Correct Answer & Explanation
. Corticosteroid injection into the carpal tunnel
Explanation
In a pregnant patient with carpal tunnel syndrome failing conservative management like splinting, a local corticosteroid injection is the most appropriate and safe next step. Surgical release is generally deferred as symptoms typically resolve rapidly after delivery.
Question 1183
Topic: 7. Hand and Wrist
In flexor tendon repair of the hand, which anatomical landmarks define the proximal and distal borders of "Zone II"?
Correct Answer & Explanation
. Distal palmar crease to the insertion of the flexor digitorum superficialis
Explanation
Zone II (historically called "No Man's Land") extends from the distal palmar crease proximally to the insertion of the flexor digitorum superficialis distally. It is notorious for poor clinical outcomes due to both FDS and FDP tendons gliding within the same tight fibro-osseous sheath.
Question 1184
Topic: 7. Hand and Wrist
A 24-year-old man sustains a proximal pole scaphoid fracture. The risk of avascular necrosis is high due to the retrograde blood supply of the scaphoid. Which artery is the primary source of this blood supply?
Correct Answer & Explanation
. Dorsal carpal branch of the radial artery
Explanation
The scaphoid receives its primary blood supply from the dorsal carpal branch of the radial artery, which enters distally and flows proximally (retrograde). This anatomical quirk explains the high rate of nonunion and avascular necrosis in proximal pole fractures.
Question 1185
Topic: 7. Hand and Wrist
A 32-year-old manual laborer presents with dorsal wrist pain. Radiographs reveal sclerosis and fragmentation of the lunate with carpal height collapse and a fixed scaphoid rotation (Lichtman Stage IIIB). What is the most appropriate surgical treatment?
Correct Answer & Explanation
. Proximal row carpectomy
Explanation
Lichtman Stage IIIB Kienbock disease is characterized by lunate collapse and fixed scaphoid rotation leading to carpal collapse. Joint leveling is contraindicated at this stage; salvage procedures like proximal row carpectomy or scaphocapitate fusion are indicated.
Question 1186
Topic: Nerve & Tendon
A 55-year-old heavy laborer presents with elbow stiffness, loss of terminal extension, and painful clicking. Radiographs reveal osteophytes at the olecranon tip, coronoid, and several loose bodies in the olecranon fossa. Which physical exam finding is most typical for this primary osteoarthritis condition?
Correct Answer & Explanation
. Pain at the extreme end-ranges of elbow flexion and extension
Explanation
Primary osteoarthritis of the elbow classically presents with impingement pain at the extreme end-ranges of motion due to osteophyte formation and loose bodies in the fossae, while mid-arc motion typically remains relatively painless.
Question 1187
Topic: Nerve & Tendon
A 50-year-old man complains of lateral elbow pain radiating down the posterior forearm. He has pain with resisted supination and middle finger extension, but Cozen's test is negative. There is no sensory deficit. This clinical presentation most closely mimics lateral epicondylitis but is actually due to entrapment of which nerve?
Correct Answer & Explanation
. Posterior interosseous nerve (PIN) at the Arcade of Frohse
Explanation
Radial tunnel syndrome (entrapment of the posterior interosseous nerve) presents with lateral forearm pain and can mimic lateral epicondylitis. Pain with resisted middle finger extension or resisted supination is characteristic, and unlike PIN palsy, there is typically no motor weakness, only pain.
Question 1188
Topic: 7. Hand and Wrist
A 22-year-old male sustains a fracture of the proximal pole of the scaphoid. He is counseled on a high risk of avascular necrosis and nonunion. This risk is primarily due to which anatomic feature?
Correct Answer & Explanation
. Retrograde blood supply via the dorsal carpal branch of the radial artery
Explanation
The scaphoid receives its primary blood supply from the dorsal carpal branch of the radial artery, which enters distally and flows retrograde to the proximal pole. Fractures at the proximal pole disrupt this delicate supply, significantly increasing the risk of avascular necrosis.
Question 1189
Topic: Hand Trauma & Infection
A 35-year-old carpenter presents with a swollen, erythematous index finger 48 hours after a puncture wound. When assessing for Kanavel's cardinal signs of pyogenic flexor tenosynovitis, which of the following is typically the earliest and most sensitive clinical indicator?
Correct Answer & Explanation
. Exquisite pain with passive extension of the digit
Explanation
Kanavel's four cardinal signs indicate pyogenic flexor tenosynovitis. Exquisite pain with passive extension of the involved digit is widely considered the earliest and most sensitive clinical sign of the infection.
Question 1190
Topic: 7. Hand and Wrist
A 35-year-old carpenter suffers a laceration to the volar aspect of his index finger at the level of the proximal phalanx, resulting in an inability to flex the PIP and DIP joints. This injury is classified in which flexor tendon zone?
Correct Answer & Explanation
. Zone II
Explanation
Zone II extends from the distal palmar crease to the insertion of the flexor digitorum superficialis tendon. Lacerations in this area typically involve both the FDS and FDP tendons and were historically known as 'no man's land' due to poor repair outcomes.
Question 1191
Topic: Wrist & Carpus
Which of the following radiographic parameters is the most critical to restore during the operative fixation of an intra-articular distal radius fracture to prevent radiocarpal arthrosis?
Correct Answer & Explanation
. Intra-articular step-off less than 2 mm
Explanation
While restoring extra-articular alignment is important for overall mechanics, correcting an intra-articular step-off or gap to less than 2 mm is the most critical factor for minimizing the risk of post-traumatic radiocarpal arthrosis.
Question 1192
Topic: 7. Hand and Wrist
A candidate is asked to outline the initial investigations for a suspected scaphoid fracture. Which sequence reflects the most appropriate and mark-scoring strategy?
Correct Answer & Explanation
. Wrist X-rays (PA, lateral, oblique, scaphoid views), clinical re-assessment, then consider advanced imaging (CT/MRI) if suspicion remains high despite negative X-rays.
Explanation
Correct Answer: CThe standard and most mark-efficient approach for suspected scaphoid fractures involves initial dedicated scaphoid series X-rays. Due to the high false-negative rate of early X-rays, clinical suspicion warrants immobilization and re-assessment. If suspicion persists or X-rays are negative, advanced imaging like CT (for bony detail) or MRI (for occult fracture/ligament injury) is then indicated. This systematic, stepwise approach demonstrates an understanding of diagnostic pathways and resource utilization, which is highly valued in exams.
Question 1193
Topic: 7. Hand and Wrist
A 40-year-old manual laborer presents with chronic wrist pain. Radiographs reveal a scaphoid nonunion advanced collapse (SNAC) stage II, demonstrating radioscaphoid arthritis but sparing the midcarpal joint. Which of the following is the most appropriate surgical treatment?
Correct Answer & Explanation
. Proximal row carpectomy.
Explanation
In SNAC stage II, arthritis is limited to the radioscaphoid articulation. A proximal row carpectomy (or four-corner fusion) removes the arthritic radioscaphoid joint while preserving midcarpal motion and is the preferred salvage procedure.
Question 1194
Topic: 7. Hand and Wrist
A 28-year-old carpenter sustains a laceration to the volar aspect of his proximal phalanx, resulting in an inability to flex his PIP and DIP joints. This injury is located in 'Zone II' of the flexor tendon system. Why was this area historically referred to as 'no man's land'?
Correct Answer & Explanation
. Both the FDS and FDP tendons are tightly enclosed within a single, narrow fibro-osseous sheath.
Explanation
Zone II is located from the A1 pulley to the FDS insertion. It is called 'no man's land' because both the flexor digitorum superficialis (FDS) and profundus (FDP) tendons run together in a tight fibro-osseous sheath, making surgical repair prone to debilitating adhesions.
Question 1195
Topic: 7. Hand and Wrist
A 50-year-old active female complains of second MTP joint pain. Non-weight-bearing radiographs are normal. An MRI is ordered to evaluate for a plantar plate tear.
At which anatomic location does the plantar plate most commonly tear?
Correct Answer & Explanation
. Distal insertion at the base of the proximal phalanx
Explanation
The plantar plate most commonly tears or attenuates at its distal insertion on the plantar base of the proximal phalanx. MRI typically shows discontinuity, high T2 signal, or a gap at this insertion site.
Question 1196
Topic: 7. Hand and Wrist
A 45-year-old woman presents with pain at the plantar aspect of her second metatarsophalangeal (MTP) joint. She notes that her second toe has recently started to deviate medially. Which of the following physical examination maneuvers is most specific for diagnosing the suspected pathology?
Correct Answer & Explanation
. Dorsal drawer test of the MTP joint
Explanation
The patient has symptoms and signs of plantar plate insufficiency (MTP joint instability), which commonly leads to a crossover toe deformity. The dorsal drawer test evaluates the integrity of the plantar plate; a positive test exhibits dorsal translation of the proximal phalanx on the metatarsal head.
Question 1197
Topic: 7. Hand and Wrist
The plantar plate is a critical static stabilizer of the lesser metatarsophalangeal (MTP) joints, functioning to resist dorsal translation of the proximal phalanx. What is the primary distal bony attachment of the plantar plate?
Correct Answer & Explanation
. Base of the proximal phalanx
Explanation
The plantar plate is a fibrocartilaginous structure that firmly attaches distally to the plantar base of the proximal phalanx, providing critical sagittal plane stability to the MTP joint.
Question 1198
Topic: 7. Hand and Wrist
A 10-year-old boy with a congenital LLD is being evaluated for potential epiphysiodesis. The surgeon emphasizes the importance of accurate growth prediction to time the intervention correctly. For predicting LLD at skeletal maturity, which of the following is considered the most crucial and accurate determinant of remaining growth potential, according to the principles outlined in the case?
Correct Answer & Explanation
. Skeletal age, determined by comparing a left hand and wrist radiograph to the standardized Greulich and Pyle atlas
Explanation
Correct Answer: DThe case explicitly states that 'A crucial takeaway from their decades of observation was the absolute superiority ofskeletal ageover chronological age for assessing remaining growth potential. Skeletal age is determined by comparing a left hand and wrist radiograph to the standardized Greulich and Pyle atlas.' This highlights skeletal age as the cornerstone of accurate prediction.While chronological age (A) is a factor, it is less accurate than skeletal age. Height percentile (B), parental height (C), and weight-for-age percentile (E) are general growth indicators but do not directly measure the remaining growth potential of the physes with the same precision as skeletal age.
Question 1199
Topic: Nerve & Tendon
During the utility posterior approach for a terrible triad repair, the ulnar nerve is a critical structure to manage. What is the specific management strategy for the ulnar nerve described in the operative sequence?
Correct Answer & Explanation
. C) Identification, decompression, and protection in situ
Explanation
Correct Answer: CThe case details the ulnar nerve management: "The ulnar nerve would be identified, decompressed, and protected in situ." This approach aims to prevent iatrogenic injury to the nerve during the procedure while avoiding unnecessary transposition unless indicated by preoperative symptoms or significant intraoperative tension.
Question 1200
Topic: 7. Hand and Wrist
A 28-year-old female sustains a Bado Type I Monteggia fracture-dislocation. On examination, she is unable to actively extend her thumb and MCP joints but has intact wrist extension with radial deviation. Which of the following is the most appropriate management for this neurologic deficit?
Correct Answer & Explanation
. Observation with delayed exploration if no recovery in 3 to 6 months
Explanation
The patient has a posterior interosseous nerve (PIN) palsy, which is the most common neurologic complication in Bado Type I and III Monteggia fractures. It is typically a neurapraxia that resolves spontaneously, making 3 to 6 months of observation the standard of care.
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