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7. Hand and Wrist MCQs

Practice Set 76 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 1501

Topic: Nerve & Tendon
Figures 1 and 2 show the intraoperative photographs obtained during surgical treatment for de Quervain tendonitis. For orientation purposes, dorsal is at the top. Figure 1 is obtained just after the initial first extensor compartment release, and Figure 2 shows the floor of the first extensor compartment. If the structure marked by the black dot is not addressed, the most common postoperative problem would be:
. persistent pain.
. tendon subluxation.
. altered sensation.
. tendon rupture.

Correct Answer & Explanation

. persistent pain.

Explanation

The black dot identifies an accessory compartment of the extensor pollicis brevis (EPB) tendon. The incidence of accessory EPB compartment in patients undergoing surgical treatment for de Quervain syndrome ranges from 46% to 60%. Failure to release this compartment at the time of initial surgery can cause persistent postoperative pain. The patient would not experience altered sensation if this compartment were not released. Altered sensation would most commonly occur following injury to the dorsal radial sensory nerve branch during surgery. EPB tendon subluxation also would not occur should the accessory compartment not be released. For EPB tendon subluxation to occur, its own compartment would need to be released first. Finally, EPB tendon rupture would be an extremely uncommon complication of failure to release the accessory compartment.

Question 1502

Topic: 7. Hand and Wrist
The lateral arm flap is based on what arterial supply?
. Posterior radial collateral
. Anterior radial collateral
. Brachial
. Subscapular
. Circumflex scapular

Correct Answer & Explanation

. Posterior radial collateral

Explanation

The lateral arm flap is based on the posterior radial collateral artery, a branch of the profunda brachial artery.

Question 1503

Topic: 7. Hand and Wrist

Which of the following structures is predominantly composed of Type 1 collagen? Review Topic

. Epithelial Basement Membrane
. L4 disc nucleus pulposus
. Anterior cruciate ligament
. Medial femoral condyle articular cartilage
. Dupuytren's contracture tissue

Correct Answer & Explanation

. Epithelial Basement Membrane

Explanation

The most common fiber type in the Anterior cruciate ligament is Type 1 collagen.Type 1 collagen accounts for more than 90% of the total collagen content in the body. Type 1 collagen is found in bone, ligament, tendon, meniscus, annulus of intervertebral discs, skin, healed cartilage, scar tissue, and nerves.Duthon et al present a review of the ACL and its histologic and mechanical properties. The ACL has a mean length of 32 mm and a width of 7-12 mm. They state that the ACL has a microstructure of collagen bundles of multiple types (mostly type I) and a matrix made of a network of proteins, glycoproteins, elastic systems, and glycosaminoglycans with multiple functional interactions.Incorrect1: Epithelial2: L4 discBasementMembrane is made up of Typenucleus pulposus is composed of mostly Type4 collagen.2 collagen4: Medial femoral condyle articular cartilage is comprised mostly of Type 2 collagen. 5: Dupuytren's contracture tissue is mostly Type 3 collagen.

Question 1504

Topic: Wrist & Carpus
A 26-year-old man falls off a motorcycle and injures his left wrist. There are no open wounds and the neurovascular examination is normal. Radiographs are shown in Figures 10a and 10b. Definitive management should consist of
. closed reduction and casting.
. external fixation and percutaneous pinning of the distal radius.
. open reduction and internal fixation of the distal radius.
. open reduction and internal fixation of the distal radius and open repair of the ulnar styloid.
. nonbridging external fixation of the distal radius.

Correct Answer & Explanation

. open reduction and internal fixation of the distal radius.

Explanation

DISCUSSION: The patient has a high-energy injury with resultant comminution of the distal radius metaphysis. Cast immobilization is likely to lead to radial shortening and angulation due to the comminution. Similarly, while external fixation and pinning has been successful in the past, some loss of radial length and volar angulation is typically noted. Present plate fixation devices for the distal radius employing locking screw technology have a superior ability to resist radial shortening and dorsal angulation. Fixation of the ulnar styloid is warranted when there is distal radioulnar joint instability or significant displacement of the styloid. This is more likely to occur with a fracture at the base of the styloid. In this instance, the distal radioulnar joint does not appear to be disrupted. REFERENCES: May MM, Lawton JN, Blazar PE: Ulnar styloid fractures associated with distal radius fractures: Incidence and implications for distal radioulnar joint instability. J Hand Surg Am 2002;27:965-971. Nana AD, Joshi A, Lichtman DM: Plating of the distal radius. J Am Acad Orthop Surg 2005;13:159-171.

Question 1505

Topic: 7. Hand and Wrist
  • A patient reports persistent pain in the wrist 6 months after undergoing open reduction and internal fixation of a Galleazi fracture. Radiographs of the wrist in a neutral position are normal. Which of the following studies would best evaluate the reduction of the distal radioulnar joint?
. Arthrogram of the wrist
. MRI scan of both wrists
. CT scan of both wrists in the same position
. Radiographs of the wrist in supination and pronation
. Radiographs of the opposite wrist in the same position

Correct Answer & Explanation

. Arthrogram of the wrist

Explanation

If late instability is suspected after the associated fractures have healed, comparison scans in pronation (to detect volar subluxation) neutral (dorsal subluxation and diastasis of the DRUJ) and supination (to confirm the degree of reduction) If early a single axial CT in any position can aid in diagnosis. As described by Mino, a line drawn on both the dorsal and volar radial ulnar borders will place an adequately reduced ulna between them

Question 1506

Topic: 7. Hand and Wrist
A 30-year-old woman sustains a transverse amputation of the distal phalanx of the index finger, leaving exposed bone. What is the most appropriate management of the soft-tissue defect?
. Dressing changes and healing by secondary intention
. Split-thickness skin grafting
. V-Y advancement flap
. Moberg (volar advancement flap)
. First dorsal metacarpal artery-island pedicled flap

Correct Answer & Explanation

. V-Y advancement flap

Explanation

DISCUSSION: V-Y advancement flaps are ideal for fingertip amputations that are transverse or dorsal oblique in nature. Healing by secondary intention is contraindicated with exposed bone. Shortening of exposed bone to allow primary skin closure is a possible alternative, as long as significant shortening of the index finger is avoided. A Moberg flap is useful only for distal amputations of the thumb. The first dorsal metacarpal artery-island pedicled flap uses tissue from the dorsum of the proximal index finger, and is typically used to resurface defects of the thumb. REFERENCES: Fassler PR: Fingertip injuries: Evaluation and treatment. J Am Acad Orthop Surg 1996;4:84-92. Atasoy E, Ioakimidis E, Kasdan ML, et al: Reconstruction of the amputated fingertip with a triangular volar flap: A new surgical procedure. J Bone Joint Surg Am 1970;52:921-926.

Question 1507

Topic: 7. Hand and Wrist
A 69-year-old man sustains a traumatic amputation to the distal phalanx of his little finger while working with power tools. Radiographs are shown in Figures 27a and 27b. The patient was instructed how to perform wet-to-dry dressing changes in the emergency department. Clinical pictures taken in the office are shown in Figures 27c through 27e. What is the most appropriate management of this soft-tissue wound?
. Continue wet-to-dry dressing changes until the wound heals by secondary intention.
. Perform a volar advancement flap (ie, Moberg flap).
. Perform a V-Y advancement flap.
. Perform a thenar flap.
. Perform a cross-finger flap to the ring finger.

Correct Answer & Explanation

. Continue wet-to-dry dressing changes until the wound heals by secondary intention.

Explanation

The clinical photographs and radiographs reveal a distal phalangeal amputation with soft-tissue coverage over nonexposed bone. This is an ideal circumstance to allow healing by secondary intention with wet-to-dry dressing changes. There are few complications and the aesthetics surpass that of any soft-tissue reconstruction procedure. Volar advancement flaps (Moberg flaps) are limited to small defects about the thumb. A thenar flap will provide good coverage; however, the results are not comparable to simple dressing changes. A V-Y flap is useful when there is more tissue loss dorsally.

Question 1508

Topic: 7. Hand and Wrist
A 25-year-old man shot himself at the base of the right index finger while cleaning his handgun. Examination reveals that the finger is cool and cyanotic. A clinical photograph and radiograph are shown in Figures 44a and 44b. What is the recommended treatment?
. Open reduction and internal fixation and arterial reconstruction
. Crossed pinning with Kirschner wires
. Open (Guillotine) finger amputation
. Index ray amputation
. Application of an external fixator

Correct Answer & Explanation

. Index ray amputation

Explanation

DISCUSSION: The gunshot wound has caused injury to multiple systems: bone, vascular, skin, and tendon; therefore, the treatment of choice is amputation. An immediate ray amputation allows for a more rapid return to activities and less time off work. REFERENCES: Peimer CA, Wheeler DR, Barrett A, et al: Hand function following single ray amputation. J Hand Surg Am 1999;24:1245-1248. Neumeister MW, Brown RE: Mutilating hand injuries: Principles and management. Hand Clin 2003;19:1-15.

Question 1509

Topic: 7. Hand and Wrist
What is the most appropriate surgical treatment for a stage III symptomatic scapholunate advanced collapsed (SLAC) wrist?
. Radioscapholunate arthrodesis
. Scaphotrapeziotrapezoid arthrodesis
. Scaphocapitate arthrodesis
. Proximal row carpectomy
. Scaphoid excision and capitate-lunate-triquetrum-hamate arthrodesis

Correct Answer & Explanation

. Scaphoid excision and capitate-lunate-triquetrum-hamate arthrodesis

Explanation

DISCUSSION: SLAC is the end result of chronic scapholunate instability. The arthritis follows a predictable pattern. Stage I disease involves cartilage loss between the waist of the scaphoid and the radial styloid. In stage II, the arthritis progresses to include the proximal pole of the scaphoid and the scaphoid fossa of the radius. Finally, stage III goes on to include arthritis of the capitolunate joint. The only treatment option that addresses all of the sites of arthritis is the scaphoid excision and four corner fusion. REFERENCES: Ashmead DT IV, Watson HK, Damon C, et al: Scapholunate advanced collapse wrist salvage. J Hand Surg Am 1994;19:741-750. Sauerbier M, Trankle M, Linsner G, et al: Midcarpal arthrodesis with complete scaphoid excision and interposition bone graft in the treatment of advanced carpal collapse (SNAC/SLAC wrist): Operative technique and outcome assessment. J Hand Surg Br 2000;25:341-345.

Question 1510

Topic: Nerve & Tendon

An 8-year-old boy sustains a 100% displaced extension-type supracondylar humerus fracture. Examination reveals no sensory deficit. Capillary refill is approximately 1 second. The patient is unable to flex the index distal interphalangeal joint and the thumb interphalangeal joint. The remainder of the motor examination is normal. Which of the following best explains these physical findings? Review Topic

. Volkmann ischemic contracture
. Radial nerve palsy
. Ulnar nerve palsy
. Median nerve palsy
. Anterior interosseous nerve palsy

Correct Answer & Explanation

. Volkmann ischemic contracture

Explanation

Preoperative nerve deficit is common in children with displaced extension-type supracondylar humerus fractures (approximately 20%). Commonly injured nerves include the anterior interosseous nerve (a branch of the median nerve), the median nerve, and the radial nerve. The physical examination findings are most consistent with an anterior interosseous nerve palsy. The ulnar nerve is the most likely nerve to be injured in flexion-type supracondylar humerus fractures.

Question 1511

Topic: 7. Hand and Wrist

-Figures a and b are the T2-weighted MRI scans of a 37-year-old left-hand-dominant man with a 3-month history of neck pain radiating down the back of his left arm and into his left hand. He also noted difficulty with buttoning his shirt. Examination reveals full strength and sensation in all extremities. He has radiating pain in all extremities with neck extension and flexion. He also has hyperactive reflexes and difficulty with tandem gait. What is the most appropriate treatment?

. Physical therapy
. Transforaminal epidural injections
. Anterior discectomy and fusion at C6-7
. Nonsteroidal anti-inflammatory medications
. Posterior decompression and fusion from C3-T1

Correct Answer & Explanation

. Physical therapy

Explanation

Question 1512

Topic: Nerve & Tendon
A 17-year-old boy with left spastic hemiplegia secondary to cerebral palsy is being evaluated for persistent swan neck deformities of the affected hand. Splinting has been tried with some improvement, but the patient does not want to wear the splints any more. On physical examination, he demonstrates full extension of the metacarpophalangeal (MCP) joints, 30° of hyperextension of the proximal interphalangeal (PIP) joints, and flexion of the distal interphalangeal (DIP) joints when he attempts to actively extend his digits. He is able to initiate flexion at the PIP joints with his MCP joints held in neutral extension. He has equal PIP flexion when the MCP joints are extended and flexed. What is the most appropriate surgical treatment to address his swan neck deformity?
. Central slip tenotomy
. Terminal tendon release
. Dorsal rerouting of the lateral bands
. Intrinsic lengthening

Correct Answer & Explanation

. Central slip tenotomy

Explanation

EXPLANATION: This patient demonstrates full extension of the MCP joints when he actively extends his fingers, indicative of overpull of the extrinsic finger extensors. This clinical scenario can be corrected by a central slip tenotomy. A terminal tendon release is used to address a Boutonnière deformity. The patient does not demonstrate intrinsic tightness (equal PIP flexion while the MCP flexed and extended), therefore his swan neck would be unlikely to respond to intrinsic lengthening. Dorsal rerouting of the lateral bands is performed for a Boutonnière deformity. A central slip tenotomy would balance the extension forces between the PIP and DIP joints.

Question 1513

Topic: 7. Hand and Wrist
A 40-year-old right-handed professional football player reports persistent right wrist pain after falling during a game 5 days ago. A radiograph is shown in Figure 21. Management should consist of
. immobilization in a short arm thumb spica cast.
. immobilization in a long arm thumb spica cast.
. arthroscopic repair and percutaneous pinning.
. open repair and percutaneous pinning.
. dorsal capsulodesis.

Correct Answer & Explanation

. open repair and percutaneous pinning.

Explanation

DISCUSSION: The radiograph reveals an increased distance between the scaphoid and the lunate, which is indicative of scapholunate dissociation. A ring sign is also present, which represents the distal pole of the scaphoid viewed end on in a palmarly flexed position. In the acute setting, the scapholunate can be repaired. Open repair and percutaneous pinning is the treatment of choice. Dorsal capsulodesis is performed in the chronic setting if such an injury is initially missed.

Question 1514

Topic: 7. Hand and Wrist

A 24-year-old man with weakness and atrophy of the thumb for 12 months has very slight numbness on the radial side of his thumb that is constant and not progressing. He has no other hand or finger numbness.His 2-point static sensory examination is unremarkable in all digits and there is marked atrophy of the thenar muscles. His carpal tunnel provocative tests are negative. He has no symptoms on the opposite hand and otherwise is in excellent health. Which next step will most likely reveal the diagnosis?

. An MRI scan
. Muscle biopsy
. Carpal tunnel diagnostic injection
. Electrodiagnostic testing
. Carpal tunnel view radiograph

Correct Answer & Explanation

. An MRI scan

Explanation

Question 1515

Topic: 7. Hand and Wrist
  • Figure 24 shows the AP radiograph of a 22-year-old woman who has pain with activity and crepitus at he second metatarsophalangeal joint. Despite nonsurgical treatment, the pain has become progressively worse over the past year. Treatment should include

. silicone implant joint replacement
. metatarsophalangeal joint arthrodesis
. metatarsophalangeal joint debridement
. resection of the metatarsal head
. resection of the base of the proximal phalanx

Correct Answer & Explanation

. metatarsophalangeal joint debridement

Explanation

The use of NSAIDs along with soft metatarsal insoles may alleviate the stress on MTP joint. Occasionally, an intraarticular injection may alleviate symptoms. Failed conservative treatment should be followed by synovectomy of the MTP joint. When the proximal phalanx is hyperextended, a flexor tendon transfer may also be used to produce some plantar flexion. Early synovectomy may prevent the development of subluxation, dislocation, or hammer-toe development. The other treatment options given are much more invasive and are typically salvage procedures.

Question 1516

Topic: 7. Hand and Wrist
Nerve conduction velocity is slowed by
. increased skin temperature.
. increased perineural blood flow.
. external compression.
. hand dominance.

Correct Answer & Explanation

. external compression.

Explanation

A number of factors affect nerve conduction velocity; for example, increased body temperature increases nerve conduction velocity. Nerve conduction velocity is slowed by advancing age, compression, decreased blood flow, and fibrosis (from large imprecise sutures used for nerve repair). There is no association between hand dominance and nerve conduction velocity.

Question 1517

Topic: 7. Hand and Wrist
When performing a radioscapholunate (RSL) fusion for posttraumatic radiocarpal arthritis, excision of the distal pole of the scaphoid will cause a decrease in
. the nonunion rate.
. wrist extension.
. carpal height.
. avascular necrosis.

Correct Answer & Explanation

. the nonunion rate.

Explanation

EXPLANATION: RSL arthrodesis is a motion-sparing option for posttraumatic radioscaphoid or radiolunate arthritis when the midcarpal joint is preserved. Preserving the midcarpal joint allows the dart-thrower motion to remain. Mühldorfer-Fodor and associates reported that the rates of nonunion for RSL fusion were reduced by excision of the distal pole of the scaphoid. Multiple studies have shown increased radial and ulnar deviation with excision of the distal pole of the scaphoid; excision of the triquetrum further increases the radial-ulnar arc of motion. Bain and associates and Pervaiz and associates reported increased wrist flexion-extension arcs with distal scaphoid and triquetrum excisions in cadaveric models; other authors have reported no difference.

Question 1518

Topic: 7. Hand and Wrist
A 25-year-old man reports wrist pain following a motorcycle accident. Examination reveals minimal swelling, slightly limited active range of motion, and point tenderness in the snuff box region. AP and oblique radiographs are shown in Figures 40a and 40b. Management should consist of
. closed reduction and a short arm cast for 10 weeks.
. closed reduction and a long arm cast for 10 weeks.
. open reduction and internal fixation.
. limited intercarpal fusion.
. proximal row carpectomy.

Correct Answer & Explanation

. open reduction and internal fixation.

Explanation

DISCUSSION: The radiographs reveal a scaphoid fracture with displacement and comminution and an unstable fracture pattern. Treatment should consist of open reduction and internal fixation. In displaced scaphoid fractures and fractures with unstable fracture patterns, closed reduction is ineffective and is likely to lead to nonunion. Limited intercarpal fusion and proximal row carpectomy are used to correct a variety of traumatic and posttraumatic problems of the wrist.

Question 1519

Topic: 7. Hand and Wrist
Figure 1 is the radiograph of an 18-year-old right-hand-dominant man who has pain and stiffness 3 months after sustaining an injury to his dominant ring finger while playing basketball. An examination reveals significant proximal interphalangeal (PIP) joint swelling with active and passive PIP joint motion of 15/40 degrees of flexion. What is the best next step?
. Supervised hand therapy
. Hemi-hamate autograft
. Dynamic external fixation
. Open reduction and internal fixation (ORIF)

Correct Answer & Explanation

. Hemi-hamate autograft

Explanation

EXPLANATION: This patient has a subacute PIP joint dorsal fracture dislocation with involvement of 50% to 60% of the palmar articular surface of the base of P2. A "V sign" (Figure 2) is evident, indicating dorsal subluxation of the joint. In some cases, an ORIF is possible, but substantial comminution often precludes proper restoration of the critical volar buttress. Therapy is not the answer because the joint is dorsally subluxated and must be corrected. Dynamic external fixation on its own would not result in a reduced joint. The hemi-hamate autograft has proven useful in this type of scenario and serves to restore the volar buttress of P2 using an osteochondral autograft harvested from the distal articular aspect of the hamate at its articulation with the fourth/fifth metacarpal bases.

Question 1520

Topic: 7. Hand and Wrist
Figures 12a through 12c show the radiographs of a 28-year-old professional baseball player who has ulnar-sided wrist pain and numbness and tingling in the fourth and fifth digits for the past 6 weeks. Management should consist of
. cast immobilization.
. bone stimulation and splinting.
. ulnar nerve exploration.
. open reduction and internal fixation.
. excision of the fragment.

Correct Answer & Explanation

. excision of the fragment.

Explanation

DISCUSSION: Hook of the hamate fractures typically occur as a result of direct force from swinging a bat, golf club, or racket. Pain is localized to the hypothenar eminence. The injury is best seen on a carpal tunnel view. CT will confirm the diagnosis. Chronic cases can be associated with neuropathy of the ulnar nerve. Excision of the hook through the fracture site usually yields satisfactory results, allowing the athlete to return to competition.

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