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7. Hand and Wrist MCQs

Practice Set 7 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 121

Topic: Nerve & Tendon

A 40-year-old typist complains of numbness in the small and ring fingers of her right hand, along with weakness in pinch strength. Froment's sign is positive. Which nerve is most likely compressed, and at what anatomical site?

. Median nerve at the carpal tunnel
. Ulnar nerve at the cubital tunnel
. Radial nerve at the spiral groove
. Median nerve at the pronator teres
. Ulnar nerve at Guyon's canal

Correct Answer & Explanation

. Ulnar nerve at the cubital tunnel

Explanation

Numbness in the ulnar digits and weak pinch (a positive Froment's sign due to adductor pollicis weakness) strongly indicate ulnar neuropathy. The cubital tunnel at the elbow is the most common site of ulnar nerve compression.

Question 122

Topic: 7. Hand and Wrist
A 35-year-old manual laborer complains of chronic dorsal wrist pain. Radiographs reveal sclerosis and fragmentation of the lunate bone, and ulnar minus variance. What is the most appropriate initial surgical intervention for stage IIIA Kienböck's disease in this patient?
. Proximal row carpectomy
. Total wrist arthrodesis
. Radial shortening osteotomy
. Lunate excision and silastic replacement
. Ulnar lengthening osteotomy

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

In patients with early-stage Kienböck's disease and ulnar negative variance, a radial shortening osteotomy is indicated. This joint-leveling procedure unloads the radiolunate joint, allowing potential revascularization of the lunate.

Question 123

Topic: 7. Hand and Wrist

A 55-year-old heavy smoker complains of right shoulder pain radiating down the medial aspect of his arm to his little finger. Examination reveals ipsilateral ptosis and miosis, but a normal shoulder exam. What is the most likely diagnosis?

. C8-T1 cervical disc herniation
. Ulnar neuropathy at the cubital tunnel
. Superior sulcus (Pancoast) tumor
. Parsonage-Turner syndrome
. Rotator cuff tear

Correct Answer & Explanation

. Superior sulcus (Pancoast) tumor

Explanation

A Pancoast tumor located in the lung apex can invade the lower brachial plexus (C8, T1) and the cervical sympathetic chain. This causes radicular medial arm/hand pain and Horner's syndrome (ptosis, miosis, anhidrosis).

Question 124

Topic: 7. Hand and Wrist

A 35-year-old woman presents with dactylitis of her hands. Hand radiographs reveal cystic, "lace-like" lucencies in the phalanges with intact but thinned cortices. A chest radiograph demonstrates bilateral hilar lymphadenopathy. What is the most likely diagnosis?

. Rheumatoid arthritis
. Tuberculosis
. Sarcoidosis
. Enchondromatosis
. Gout

Correct Answer & Explanation

. Sarcoidosis

Explanation

Osseous sarcoidosis classically presents with lace-like, cystic bone lesions in the phalanges of the hands or feet. This finding is strongly supported by the presence of bilateral hilar lymphadenopathy on chest imaging.

Question 125

Topic: 7. Hand and Wrist

A 62-year-old heavy smoker presents with symmetric, painful swelling of his wrists and ankles. Clinical examination reveals prominent digital clubbing. Radiographs show solid periosteal new bone formation along the diaphyses of the distal radius and ulna. What is the most important next diagnostic step?

. Rheumatoid factor testing
. Chest X-ray
. Serum uric acid levels
. HLA-B27 testing
. Bone marrow biopsy

Correct Answer & Explanation

. Chest X-ray

Explanation

This patient is exhibiting signs of hypertrophic pulmonary osteoarthropathy (HPOA). Because HPOA is strongly associated with underlying bronchogenic carcinoma, a chest X-ray is the crucial next step.

Question 126

Topic: 7. Hand and Wrist

A 55-year-old woman is treated with a cast for a conservatively managed distal radius fracture. She is highly anxious about developing complex regional pain syndrome (CRPS). Which of the following oral supplements has been shown in some randomized controlled trials to decrease the incidence of CRPS following wrist fractures?

. Vitamin B12
. Vitamin C
. Vitamin D
. Calcium carbonate
. Glucosamine chondroitin

Correct Answer & Explanation

. Vitamin C

Explanation

Several studies, notably by Zollinger et al., have demonstrated that 500 mg of Vitamin C daily for 50 days following a distal radius fracture significantly reduces the risk of developing complex regional pain syndrome (CRPS).

Question 127

Topic: Nerve & Tendon
A 28-year-old rugby player is unable to flex the distal interphalangeal (DIP) joint of his right ring finger after aggressively grabbing an opponent's jersey. Radiographs reveal a bony avulsion fragment retracted to the level of the A2 pulley. According to the Leddy and Packer classification, what type of injury is this?
. Type I
. Type II
. Type III
. Type IV
. Type V

Correct Answer & Explanation

. Type II

Explanation

A Leddy and Packer Type II jersey finger involves retraction of the flexor digitorum profundus (FDP) tendon to the level of the PIP joint or A2 pulley. A small avulsion fracture often catches at the chiasm of the FDS, preserving some regional blood supply.

Question 128

Topic: Hand Trauma & Infection

A 35-year-old construction worker presents with a swollen, painful index finger after a minor puncture wound. Which of the following is NOT one of Kanavel's cardinal signs of flexor tendon sheath infection?

. Pain on passive extension of the digit
. Fusiform swelling of the digit
. Flexed resting posture of the digit
. Erythema extending proximal to the wrist crease
. Tenderness along the course of the flexor tendon sheath

Correct Answer & Explanation

. Erythema extending proximal to the wrist crease

Explanation

Kanavel's four signs of suppurative flexor tenosynovitis are fusiform swelling, flexed posture, tenderness along the tendon sheath, and severe pain on passive extension. Erythema extending proximal to the wrist is not a specific Kanavel sign.

Question 129

Topic: Wrist & Carpus

A 65-year-old female undergoes volar locked plating for a comminuted distal radius fracture. Postoperatively, she develops an inability to actively flex the interphalangeal joint of her thumb. Which tendon is most likely injured?

. Extensor pollicis longus (EPL)
. Flexor pollicis longus (FPL)
. Flexor carpi radialis (FCR)
. Abductor pollicis longus (APL)
. Extensor pollicis brevis (EPB)

Correct Answer & Explanation

. Flexor pollicis longus (FPL)

Explanation

The flexor pollicis longus (FPL) tendon is at risk of attrition and rupture from prominent hardware on the volar aspect of the distal radius. Loss of active interphalangeal joint flexion confirms FPL injury.

Question 130

Topic: 7. Hand and Wrist

A 25-year-old rugby player presents 2 days after aggressively grabbing an opponent's jersey. He felt a "pop" in his right ring finger and cannot actively flex the distal interphalangeal (DIP) joint. Physical examination reveals tenderness in the palm and absence of the profundus cascade. Radiographs show no fracture. What is the most likely location of the retracted tendon end?

. At the level of the proximal phalanx (Zone 2)
. At the level of the A4 pulley
. In the palm at the origin of the lumbricals
. At the level of the A1 pulley
. In the distal forearm

Correct Answer & Explanation

. In the palm at the origin of the lumbricals

Explanation

This is a Type I flexor digitorum profundus (FDP) avulsion (Jersey finger), where the tendon tears entirely from the bone and retracts into the palm at the lumbrical origin. It requires prompt surgical repair within 7-10 days before tendon contracture occurs.

Question 131

Topic: 7. Hand and Wrist

A 29-year-old man is admitted feeling a little more tired than usual. He has no history of previous respiratory disease and works as a builder. On examination he is 184 cm in height, with a blood pressure of 142/80 mmHg, and his pulse is 80 bpm. His oxygen saturation is 95% on air. Breath sounds appear normal bilaterally on auscultation and his respiratory rate is 16/min. The chest X-ray shows a 1-cm rim of air on the right-hand side of the chest. Which of the following is the most appropriate management?

. Admit and observe
. Aspiration
. Discharge
. Large-size chest drain
. Small-size chest drain

Correct Answer & Explanation

. Discharge

Explanation

Correct Answer: C- Discharge Explanation Discharge We are not given any indication that this man is in distress because his saturation is 95% and his respiratory rate is 16/min. With only a 1-cm rim of air, British Thoracic Society (BTS) guidelines therefore would suggest that he can be safely discharged, with instructions to return if he has significant pleuritic chest pain or feels more short of breath. Admit and observe Admit and observe is incorrect. We are not given any indication that this man is in distress because his saturation is 95% and his respiratory rate is 16/min. With only a 1-cm rim of air, British Thoracic Society (BTS) guidelines therefore would suggest that he can be safely discharged, with instructions to return if he has significant pleuritic chest pain or feels more short of breath. Aspiration Aspiration is incorrect. Significant shortness of breath or a rim of air of 2 cm or greater necessitates air aspiration as long as there is no history of previous chest pathology. Large-size chest drain Large-size chest drain is incorrect. Large-size chest drains are not recommended as first-line intervention in a atraumatic pneumothorax. Small-size chest drain Small-size chest drain is incorrect. If there is a history or evidence of previous chest disease, a small- bore chest drain is recommended if there is s ignificant shortness of breath or a rim of air of 2 cm or greater.

Question 132

Topic: 7. Hand and Wrist
A 28-year-old carpenter sustains a laceration to the volar aspect of his index finger, severing both the FDS and FDP tendons. The injury is located between the distal palmar crease and the proximal interphalangeal joint. In which flexor tendon zone is this injury?
. Zone I
. Zone II
. Zone III
. Zone IV
. Zone V

Correct Answer & Explanation

. Zone II

Explanation

Zone II extends from the A1 pulley (distal palmar crease) to the FDS insertion (mid-middle phalanx). It contains both the FDS and FDP within a tight fibro-osseous sheath.

Question 133

Topic: 7. Hand and Wrist

A 45-year-old woman presents with symmetrical polyarthritis of her wrists and metacarpophalangeal joints. Serological testing reveals high titers of a highly specific autoantibody. This antibody targets which of the following?

. Double-stranded DNA
. Fc portion of IgG
. Cyclic citrullinated peptides
. Nuclear ribonucleoproteins
. Centromeres

Correct Answer & Explanation

. Cyclic citrullinated peptides

Explanation

Anti-cyclic citrullinated peptide (anti-CCP) antibodies are highly specific (up to 95%) for rheumatoid arthritis. They play a critical role in the pathogenesis and early diagnosis of the disease.

Question 134

Topic: 7. Hand and Wrist

A 30-year-old man sustains a severe laceration to his volar wrist, completely transecting the median nerve. Over the next few weeks, the distal nerve segment undergoes a specific physiological process. What is this process called?

. Chromatolysis
. Wallerian degeneration
. Neuropraxia
. Retrograde amnesia
. Axonotmesis

Correct Answer & Explanation

. Wallerian degeneration

Explanation

Following a complete nerve transection, the axon distal to the injury undergoes Wallerian degeneration. This involves the breakdown and clearance of the axon and myelin sheath by Schwann cells and macrophages.

Question 135

Topic: 7. Hand and Wrist

A 30-year-old male sustains a non-displaced scaphoid waist fracture. Which of the following arteries provides the primary blood supply to the proximal pole, increasing its risk for avascular necrosis?

. Superficial palmar arch
. Deep palmar arch
. Dorsal carpal branch of the radial artery
. Volar carpal branch of the radial artery
. Ulnar artery

Correct Answer & Explanation

. Dorsal carpal branch of the radial artery

Explanation

The primary blood supply to the scaphoid comes from the dorsal carpal branch of the radial artery, which enters distally and flows retrograde. This retrograde blood supply puts proximal pole fractures at high risk for avascular necrosis.

Question 136

Topic: 7. Hand and Wrist

A 55-year-old man presents with progressive inability to extend his ring and small fingers. Examination shows palpable cords and nodules in the palmar fascia. Pathogenesis of this condition is primarily mediated by which of the following cell types?

. Chondrocytes
. Osteoblasts
. Myofibroblasts
. Schwann cells
. Synoviocytes

Correct Answer & Explanation

. Myofibroblasts

Explanation

Dupuytren's contracture is characterized by fibroproliferative disease of the palmar fascia. The myofibroblast is the primary effector cell responsible for the excessive collagen production and tissue contraction seen in this disease.

Question 137

Topic: 7. Hand and Wrist

A 25-year-old male presents with chronic wrist pain years after an unrecognized fall onto an outstretched hand. X-rays show a scaphoid nonunion with advanced radioscaphoid arthritis and early scaphocapitate arthritis, but a preserved radiolunate joint (SNAC stage II). What is the most appropriate surgical management?

. Scaphoid ORIF with vascularized bone graft
. Proximal row carpectomy
. Total wrist arthrodesis
. Radial styloidectomy alone
. Distal radioulnar joint arthroplasty

Correct Answer & Explanation

. Proximal row carpectomy

Explanation

SNAC stage II involves arthritis between the scaphoid and the radial styloid, as well as the scaphocapitate joint, while sparing the radiolunate joint. Because the radiolunate articulation is intact, a proximal row carpectomy or a four-corner fusion are the standard salvage procedures.

Question 138

Topic: Nerve & Tendon
A 25-year-old chef sustains a knife laceration over the volar proximal phalanx of his index finger. He is unable to flex the proximal interphalangeal (PIP) or distal interphalangeal (DIP) joints. This injury corresponds to which flexor tendon zone?
. Zone I
. Zone II
. Zone III
. Zone IV
. Zone V

Correct Answer & Explanation

. Zone II

Explanation

Flexor tendon Zone II, historically called "no man's land", extends from the proximal aspect of the A1 pulley to the insertion of the flexor digitorum superficialis tendon.

Question 139

Topic: 7. Hand and Wrist

People with coal-worker’s pneumoconiosis are predisposed to developing which of the following diseases?

. Carcinoma of the lung
. Left-sided heart failure
. Progressive massive fibrosis
. Silicosis
. Tuberculosis

Correct Answer & Explanation

. Progressive massive fibrosis

Explanation

Correct Answer: C- Progressive massive fibrosis Explanation Progressive massive fibrosis Simple coal-worker’s pneumoconiosis causes no symptoms or physical signs, nor any importantphysiological abnormality. The danger associated with simple pneumoconiosis is that it predisposes to progressive massive fibrosis, a risk directly related to the degree of simple pneumoconiosis seen on the X-ray. Progressive massive fibrosis can occur during the coal- worker’s working life or it can appear clinically for the first time after (sometimes many years after) dust exposure ceases, even when there is no apparent simple pneumoconiosis on the X-ray. Progressive massive fibrosis usually causes a mixture of restriction of lung volumes and (due to associated emphysema) airflow obstruction. Ultimately, it can lead to cor pulmonale and death. However, the rate of progression is variable. In general, the earlier that progressive massive fibrosis develops in a person’s life, the more rapidly it is progressive. A patient with progressive massive fibrosis might complain of shortness of breath and symptoms of cor pulmonale. An unusual, but pathognomonic symptom is melanoptysis – the expectoration of the black contents of a cavitated lesion. Haemoptysis and finger clubbing suggest lung cancer and should not be attributed to pneumoconiosis. Abnormal signs in the chest, if present, relate to the presence of bullae, although sometimes lobar collapse can occur. Coal-worker’s pneumoconiosis is not associated with an increased risk of tuberculosis or of lung cancer, although obviously these diseases can be seen in coal miners and should be suspected if an unusual progression of radiological changes occurs. The association between pneumoconiosis and emphysema has been controversial, but there is now clear evidence of a parallel association between dust exposure and two effects – pneumoconiosis and airflow obstruction. The more dust that a miner has been exposed to, the greater are his risks of pneumoconiosis on the one hand, and productive cough, reduction in forced expiratory volume in 1 s (FEV1), and the presence of centri-acinar emphysema on the other. Of course, the latter risks are also related to cigarette smoking, and the effect of dust exposure is additive. Carcinoma of the lung Carcinoma of the lung is incorrect. Coal worker’s pneumoconiosis is not associated with an increased risk of lung cancer. Left-sided heart failure Left-sided heart failure is incorrect. Coal worker’s pneumoconiosis is not associated with an increased risk of heart failure. Silicosis Silicosis is incorrect. Coal worker’s pneumoconiosis is not associated with an increased risk of silicosis. Tuberculosis Tuberculosis is incorrect. Coal worker’s pneumoconiosis is not associated with an increased risk of tuberculosis.

Question 140

Topic: 7. Hand and Wrist

During the repair of a complete Zone II flexor tendon laceration in the hand, the surgeon must preserve certain structures to prevent bowstringing of the tendon. Which of the following pulley combinations is most critical to preserve or reconstruct?

. A1 and A3
. A2 and A4
. A1 and A5
. C1 and C2
. A3 and C3

Correct Answer & Explanation

. A2 and A4

Explanation

The A2 and A4 pulleys are the most critical biomechanical pulleys in the finger flexor tendon sheath. Preserving or reconstructing them is essential to prevent bowstringing and maintain mechanical efficiency during finger flexion.

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