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 141
Topic: 7. Hand and Wrist
A 25-year-old male falls on an outstretched hand and sustains a non-displaced fracture of the proximal pole of the scaphoid. He is at a high risk for avascular necrosis and nonunion. What is the primary anatomical reason for this complication?
Correct Answer & Explanation
. Retrograde blood supply from branches of the radial artery
Explanation
The scaphoid relies on a retrograde blood supply, primarily from the dorsal carpal branch of the radial artery which enters at the distal pole. Fractures at the proximal pole effectively sever its blood supply, leading to high rates of avascular necrosis.
Question 142
Topic: 7. Hand and Wrist
A 22-year-old falls onto an outstretched hand and presents with tenderness in the anatomical snuffbox. Initial radiographs of the wrist are negative for fractures. What is the most appropriate management?
Correct Answer & Explanation
. Thumb spica splint and repeat imaging in 10-14 days
Explanation
Occult scaphoid fractures may not be visible on initial radiographs. Immobilization in a thumb spica splint with repeat radiographs in 10-14 days (or obtaining an immediate MRI) is standard of care to prevent nonunion.
Question 143
Topic: 7. Hand and Wrist
Six weeks after conservative cast management of a minimally displaced distal radius fracture, a 60-year-old patient suddenly loses the ability to actively extend the interphalangeal joint of the thumb. Which complication has most likely occurred?
Correct Answer & Explanation
. Extensor pollicis longus tendon rupture
Explanation
Extensor pollicis longus (EPL) tendon rupture is a well-recognized complication after nondisplaced or minimally displaced distal radius fractures. It occurs due to mechanical attrition over Lister's tubercle or local ischemia from hematoma.
Question 144
Topic: 7. Hand and Wrist
A 28-year-old Afro-Caribbean nurse develops painful nodules on the shins of her legs. She has a low-grade fever and has lost 5 kg in weight over the past 2 months. Her chest X-ray shows bilateral hilar lymphadenopathy. The most likely outcome of this patientโs illness is?
Correct Answer & Explanation
. Complete remission without any specific treatment
Explanation
Correct Answer: B- Complete remission without any specific treatment Explanation Complete remission without any specific treatment This lady has acute sarcoidosis. Spontaneous remission occurs in nearly two-thirds of patients with acute sarcoidosis. Complete initial remission but soon interrupted by increasingly frequent relapses Complete initial remission but soon interrupted by increasingly frequent relapses is incorrect. Stage 1 sarcoidosis (ie bilateral hilar lymphadenopathy on chest radiograph) is not usually associated with frequent relapses. At 5 years following initial diagnosis, 95% of patients previously diagnosed with stage 1 sarcoidosis will be asymptomatic. Complete remission after appropriate course of steroid and cytotoxic drugs Complete remission after appropriate course of steroid and cytotoxic drugs is incorrect. Spontaneous remission of acute sarcoidosis occurs in nearly two-thirds of patients. Diffuse reticulonodular changes in the lung and progressive shortness of breath Diffuse reticulonodular changes in the lung and progressive shortness of breath is incorrect. Acute sarcoidosis is characterised by erythema nodosum with X-ray findings of bilateral hilar adenopathy, often accompanied by joint symptoms, including arthritis at the ankles, knees, wrists or elbows. Diffuse reticulonodular changes in the lung and progressive shortness of breath would be expected in chronic sarcoidosis, which affects 10โ30% of patients. Generalised lymphadenopathy and progressive wasting in 5โ10 years Generalised lymphadenopathy and progressive wasting in 5โ10 years is incorrect. These are not features of sarcoidosis.
Question 145
Topic: 7. Hand and Wrist
A 24-year-old carpenter sustains a laceration to the volar aspect of his index finger, exactly at the level of the proximal interphalangeal (PIP) joint. Both the flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) are severed. This injury occurs in which flexor tendon zone?
Correct Answer & Explanation
. Zone II
Explanation
Zone II extends from the proximal A1 pulley to the insertion of the FDS at the middle phalanx (often called "no man's land"). Lacerations here frequently involve both the FDS and FDP tendons and historically have poorer surgical outcomes due to adhesions.
Question 146
Topic: 7. Hand and Wrist
During an open carpal tunnel release, the surgeon must avoid injury to the recurrent motor branch of the median nerve. According to the most common anatomical variant (extraligamentous configuration), how does this branch typically course in relation to the transverse carpal ligament?
Correct Answer & Explanation
. It arises distal to the ligament and courses retrogradely
Explanation
In the majority of individuals (46-90%), the recurrent motor branch of the median nerve is extraligamentous, arising distal to the transverse carpal ligament and curving back retrogradely to supply the thenar muscles. The transligamentous variant occurs in about 20% of people.
Question 147
Topic: 7. Hand and Wrist
A 30-year-old carpenter lacerates his index finger flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS) tendons at the level of the proximal phalanx. This injury occurs in which flexor tendon zone, historically known as "no man's land"?
Correct Answer & Explanation
. Zone II
Explanation
Zone II extends from the proximal A1 pulley to the insertion of the FDS at the middle phalanx. It was historically called "no man's land" due to poor surgical outcomes secondary to adhesions between the FDP and FDS tendons within the tight fibro-osseous sheath.
Question 148
Topic: Nerve & Tendon
A 40-year-old secretary complains of numbness in her ring and small fingers, and weakness with pinch. Examination shows a positive Froment's sign. Which muscle is compensating for the weakened adductor pollicis during this test?
Correct Answer & Explanation
. Flexor pollicis longus
Explanation
Froment's sign indicates ulnar nerve palsy leading to weakness of the adductor pollicis. The patient compensates by using the flexor pollicis longus (innervated by the anterior interosseous nerve) to hyperflex the thumb interphalangeal joint during key pinch.
Question 149
Topic: 7. Hand and Wrist
A 25-year-old male falls onto an outstretched hand and complains of radial-sided wrist pain. On examination, he has distinct tenderness in the anatomic snuffbox. Initial AP, lateral, and scaphoid-view radiographs demonstrate no visible fracture. What is the most appropriate management plan?
Correct Answer & Explanation
. Apply a thumb spica splint and repeat radiographs in 10-14 days
Explanation
Occult scaphoid fractures can initially be invisible on plain radiographs. Standard practice for clinical snuffbox tenderness with negative x-rays is immobilization in a thumb spica splint with follow-up imaging (repeat x-rays in 10-14 days or prompt MRI).
Question 150
Topic: 7. Hand and Wrist
An orthopedic surgeon is performing an open carpal tunnel release. If the longitudinal incision is erroneously extended too far distally beyond Kaplan's cardinal line, which of the following vascular structures is at the highest immediate risk of iatrogenic transection?
Correct Answer & Explanation
. Superficial palmar arch
Explanation
The superficial palmar arch lies just distal to the transverse carpal ligament, roughly corresponding to the level of Kaplan's cardinal line. Extending a carpal tunnel release too far distally places this arterial arch at significant risk of transection.
Question 151
Topic: Nerve & Tendon
A 30-year-old carpenter sustains a deep laceration to the volar aspect of his index finger precisely at the level of the A1 pulley, resulting in loss of active flexion. This injury corresponds to which flexor tendon zone?
Correct Answer & Explanation
. Zone II
Explanation
Zone II of the flexor tendon system, historically known as "no man's land", extends from the level of the A1 pulley to the insertion of the flexor digitorum superficialis. Injuries here are notoriously difficult to treat due to the tight fibro-osseous tunnel.
Question 152
Topic: 7. Hand and Wrist
A 35-year-old woman presents with a 6-week history of malaise, with a dry cough, sweats, and a stitch-like, right-sided chest pain. Apparently, she had a heavy cold and cough at the beginning of the episode that improved initially. A past history of rheumatoid arthritis for which she takes weekly methotrexate is noted. On examination, her BP is 125/80 mmHg, pulse is 75 bpm and regular. There are diminished breath sounds on the right-hand side of the chest and it is dull to percussion. There is no evidence of active synovitis. Investigations: Hb 12.1 g/dl, WCC 11.2 ร 10^9/l, PLT 303 ร 10^9/l, ESR 72 mm/h, Na+ 137 mmol/l, K+ 4.3 mmol/l, Creatinine 110 ฮผmol/l. CXR: Right-sided pleural effusion. Effusion pH 7.08, Effusion LDH 1556 U/l, Effusion Glucose 2.0 mmol/l, Effusion Protein 45 g/l. Which of the following is the most likely diagnosis?
Correct Answer & Explanation
. Empyema
Explanation
Correct Answer: Empyema. The pH, LDH, and glucose all fit the criteria for diagnosis of empyema (rather than parapneumonic effusion) as defined in BTS guidelines. In all likelihood, the empyema developed as a result of an acute pneumonia some 6 weeks earlier. Inflammatory pleural effusion is incorrect; the raised white count and ESR support the presence of continuing infection as no evidence is given of a flare of her rheumatoid arthritis. Mesothelioma is incorrect; there is no history of asbestos exposure to support a diagnosis of mesothelioma. Parapneumonic effusion is incorrect; the pH, LDH, and glucose fit the criteria for empyema. Tuberculous effusion is incorrect; with respect to tuberculosis, we would expect a history of symptoms of greater than 6 weeks.
Question 153
Topic: 7. Hand and Wrist
A 32-year-old manual laborer presents with chronic dorsal wrist pain. Radiographs reveal sclerosis of the lunate without collapse. MRI confirms avascular necrosis of the lunate. Ulnar variance is negative 3 mm. What is the most appropriate surgical intervention?
Correct Answer & Explanation
. Radial shortening osteotomy
Explanation
In Lichtman Stage II (sclerosis without collapse) or Stage IIIa with ulnar minus variance, joint-leveling procedures such as a radial shortening osteotomy are indicated. This offloads the lunate and halts disease progression.
Question 154
Topic: 7. Hand and Wrist
A 22-year-old rugby player sustains a flexor digitorum profundus (FDP) avulsion from the distal phalanx. The tendon has retracted into the palm (Leddy-Packer Type I). Within what timeframe must surgical repair ideally be performed to prevent irreversible tendon necrosis and severe myostatic contracture?
Correct Answer & Explanation
. 7 to 10 days
Explanation
Leddy-Packer Type I FDP avulsions retract into the palm, completely disrupting the vincular blood supply. Early surgical repair within 7 to 10 days is critical before the tendon undergoes necrosis or severe contracture.
Question 155
Topic: Wrist & Carpus
Six weeks following a minimally displaced Colles' fracture treated in a short arm cast, a 65-year-old woman presents unable to actively extend the interphalangeal joint of her thumb. She recalls a sudden painless pop the previous day. What is the most appropriate surgical treatment?
Correct Answer & Explanation
. Extensor indicis proprius (EIP) to extensor pollicis longus (EPL) tendon transfer
Explanation
Delayed rupture of the EPL following a distal radius fracture leaves degenerated and retracted tendon ends, rendering direct repair impossible. An EIP to EPL tendon transfer is the gold standard treatment for restoration of function.
Question 156
Topic: 7. Hand and Wrist
A 45-year-old manual laborer presents with chronic wrist pain and is diagnosed with Scaphoid Nonunion Advanced Collapse (SNAC) Stage II. Radiographs show arthritis limited to the radioscaphoid joint, with preservation of the midcarpal articulation. Which of the following is the most appropriate surgical intervention?
Correct Answer & Explanation
. Proximal row carpectomy (PRC)
Explanation
SNAC Stage II is characterized by radioscaphoid arthritis, making scaphoid reconstruction alone inadequate due to the pre-existing joint damage. Proximal row carpectomy or scaphoid excision with a four-corner fusion are highly effective salvage procedures when the radiolunate and midcarpal joints are completely spared.
Question 157
Topic: 7. Hand and Wrist
A 28-year-old carpenter amputates his index finger at the level of the proximal phalanx base. Replantation is attempted. What is the standard correct sequence of structural repair in digit replantation?
The standard sequence for digit replantation is: Bone (osteosynthesis), Extensor tendons, Flexor tendons, Arteries, Nerves, and finally Veins. This sequence establishes skeletal stability before vascular repair and ensures the volar structures are repaired before closing.
Question 158
Topic: 7. Hand and Wrist
A 55-year-old woman is evaluated for right hand numbness and tingling. Physical exam reveals a positive Phalen's test and atrophy of the abductor pollicis brevis. Carpal tunnel release is planned. Which anatomical structure forms the ulnar border of the carpal tunnel?
Correct Answer & Explanation
. Pisiform and hook of hamate
Explanation
The carpal tunnel is bordered ulnarly by the pisiform and the hook of the hamate. The radial border consists of the scaphoid tubercle and the ridge of the trapezium.
Question 159
Topic: Nerve & Tendon
A 45-year-old cyclist presents with numbness and tingling in his small and ring fingers. He has weakness of finger abduction but normal sensation over the dorso-ulnar aspect of his hand. Where is the most likely site of nerve compression?
Correct Answer & Explanation
. Guyon's canal (Zone 1)
Explanation
Normal dorso-ulnar sensation indicates the compression is distal to the dorsal ulnar cutaneous nerve branch (sparing the cubital tunnel). Involvement of both volar sensation (ring/small fingers) and intrinsic motor function localizes the lesion to Zone 1 of Guyon's canal.
Question 160
Topic: 7. Hand and Wrist
A 30-year-old carpenter sustains a laceration to the volar aspect of his index finger at the level of the proximal phalanx. Both the FDS and FDP tendons are completely severed. This injury is classified as occurring in which flexor tendon zone?
Correct Answer & Explanation
. Zone II
Explanation
Zone II ('no man's land') extends from the A1 pulley (distal palmar crease) to the FDS insertion at the middle phalanx. Injuries here involve both the FDS and FDP within the tight fibro-osseous sheath, complicating surgical repair.
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