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7. Hand and Wrist MCQs

Practice Set 80 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 1581

Topic: 7. Hand and Wrist

Which of the following radiographic findings indicates that the injury to the great toe shown in Figures 60a and 60b should be reducible by closed manipulation?

. The sesamoids are separated
. The sesamoid is fractured
. The proximal phx is on the neck of the metatarsal
. The dislocation is dorsal and centered
. The proximal phalanx is hyperextended

Correct Answer & Explanation

. The sesamoids are separated

Explanation

In the case of first MP joint dislocation, though rare, there is a complete disruption of the intersesamoid ligament, at separation of the sesamoid seen or x-ray (Type II). This dislocation can be readily reduced. A Type I lesion/dislocation yields no disruption of the sesamoid mass though a dislocation is present. This type I lesion are usually irreducible if attempted closed.

Question 1582

Topic: Nerve & Tendon

A 40-year-old male undergoes a single-incision anterior approach for repair of a distal biceps tendon rupture. Postoperatively, he complains of numbness and tingling along the radial border of his forearm. Which of the following is the most likely etiology of this complication?

. Injury to the posterior interosseous nerve (PIN)
. Injury to the superficial radial nerve
. Retraction injury to the lateral antebrachial cutaneous nerve (LABCN)
. Compression of the median nerve at the lacertus fibrosus
. Ulnar nerve transposition during the procedure

Correct Answer & Explanation

. Injury to the posterior interosseous nerve (PIN)

Explanation

The most common complication following a single-incision anterior repair of a distal biceps tendon rupture is a neurapraxia of the lateral antebrachial cutaneous nerve (LABCN), which occurs in approximately 10-25% of cases. The LABCN courses superficially in the lateral aspect of the antecubital fossa and is highly susceptible to traction or direct injury from retractors during this approach. Injury to the PIN is less common but is a severe complication associated with poor retractor placement or failure to keep the forearm in supination during the approach.

Question 1583

Topic: Wrist & Carpus

A 45-year-old man falls from a height and sustains a comminuted radial head fracture. During surgery, the radial head is deemed unsalvageable and excised. Postoperatively, the patient develops progressive wrist pain and ulnar-sided prominence.

What is the primary pathomechanical cause of this complication?

. Undiagnosed scaphoid fracture
. Disruption of the triangular fibrocartilage complex (TFCC) alone
. Unrecognized interosseous membrane (IOM) disruption
. Radial nerve palsy
. Proximal radioulnar joint instability

Correct Answer & Explanation

. Unrecognized interosseous membrane (IOM) disruption

Explanation

The clinical presentation is classic for an Essex-Lopresti injury, which consists of a radial head fracture, disruption of the interosseous membrane (IOM), and injury to the distal radioulnar joint (DRUJ). Excision of the radial head in the presence of an IOM injury leads to proximal migration of the radius, causing ulnar impaction syndrome and DRUJ instability. The primary stabilizer against proximal radial migration is the radial head, and the secondary stabilizer is the central band of the IOM.

Question 1584

Topic: Nerve & Tendon

Which of the following intraoperative techniques is most strongly recommended to minimize the risk of postoperative ulnar neuropathy during a total elbow arthroplasty for a patient with rheumatoid arthritis?

. In situ decompression of the ulnar nerve without mobilization
. Routine anterior subcutaneous transposition of the ulnar nerve
. Routine anterior submuscular transposition of the ulnar nerve
. Medial epicondylectomy
. Leaving the nerve in the cubital tunnel and protecting it with a retractor

Correct Answer & Explanation

. Routine anterior subcutaneous transposition of the ulnar nerve

Explanation

Postoperative ulnar neuropathy is a common complication after total elbow arthroplasty (TEA). Most high-volume elbow surgeons recommend routine identification, mobilization, and anterior subcutaneous transposition of the ulnar nerve during TEA to move it away from the surgical field, reduce tension during flexion, and prevent impingement by the implants or cement. In situ decompression or leaving it in the tunnel risks injury during the extensive capsular release and component preparation.

Question 1585

Topic: Nerve & Tendon

During a single-incision anterior approach for distal biceps tendon repair, which nerve is at greatest risk of iatrogenic injury if retractors are placed too vigorously on the lateral aspect of the wound?

. Median nerve
. Ulnar nerve
. Posterior interosseous nerve (PIN)
. Superficial radial nerve
. Lateral antebrachial cutaneous nerve (LABC)

Correct Answer & Explanation

. Posterior interosseous nerve (PIN)

Explanation

The posterior interosseous nerve (PIN) is at significant risk with excessive lateral retraction during the single-incision anterior approach as it wraps around the radial neck. The LABC is also at risk but is typically injured more superficially during the initial exposure.

Question 1586

Topic: Nerve & Tendon

A 45-year-old bodybuilder feels a sudden 'pop' in his antecubital fossa while lifting weights and presents with weakness in supination. A distal biceps tendon rupture is diagnosed, and surgical repair via a single-incision anterior approach is planned. What is the most common iatrogenic nerve injury associated with this specific surgical approach?

. Posterior interosseous nerve
. Lateral antebrachial cutaneous nerve
. Superficial radial nerve
. Median nerve
. Ulnar nerve

Correct Answer & Explanation

. Posterior interosseous nerve

Explanation

The lateral antebrachial cutaneous nerve (LABCN) is the most commonly injured nerve during the single-incision anterior approach for distal biceps tendon repair. It is at risk during superficial dissection laterally. The posterior interosseous nerve (PIN) is more commonly at risk during the two-incision technique, particularly if retractors are placed aggressively around the radial neck or if the arm is not fully pronated during the posterolateral dissection.

Question 1587

Topic: Nerve & Tendon

A 35-year-old male presents with severe elbow stiffness 6 months following operative fixation of an elbow fracture-dislocation. Radiographs show mature heterotopic ossification (HO) bridging the medial humerus and ulna. He requests surgical intervention to improve his motion. Which of the following is true regarding surgical excision of HO in this setting?

. Surgery should be delayed until 18 months post-injury to prevent recurrence.
. Prophylaxis with local radiation or oral indomethacin is contraindicated postoperatively.
. The ulnar nerve is at low risk and does not routinely require exposure or transposition.
. A normal serum alkaline phosphatase level and mature trabecular pattern on radiographs indicate the HO is safe to excise.
. Continuous passive motion (CPM) machines postoperatively have been shown to drastically increase HO recurrence.

Correct Answer & Explanation

. A normal serum alkaline phosphatase level and mature trabecular pattern on radiographs indicate the HO is safe to excise.

Explanation

Surgical excision of heterotopic ossification (HO) around the elbow should be performed when the bone is mature to decrease the risk of recurrence. Clinical signs of maturity include normalization of alkaline phosphatase levels and a sharply defined, mature trabecular pattern on radiographs, typically occurring 6 to 9 months post-injury. Postoperative prophylaxis (radiation or indomethacin) is commonly used to prevent recurrence. The ulnar nerve is at high risk and must be carefully identified and often transposed.

Question 1588

Topic: Wrist & Carpus
A 42-year-old male sustains a high-energy fall onto an outstretched hand. He is diagnosed with a comminuted, unsalvageable radial head fracture, an interosseous membrane tear, and distal radioulnar joint (DRUJ) disruption. What is the most appropriate surgical management strategy?
. Radial head resection and casting in supination
. Radial head replacement, followed by assessment of DRUJ stability, and pinning of the DRUJ if unstable
. Radial head resection and immediate DRUJ pinning
. Open reduction internal fixation of the radial head and Darrach procedure
. Radial head replacement and immediate Sauvé-Kapandji procedure

Correct Answer & Explanation

. Radial head replacement, followed by assessment of DRUJ stability, and pinning of the DRUJ if unstable

Explanation

This is an Essex-Lopresti injury. The interosseous membrane (IOM) and DRUJ are disrupted, leading to longitudinal radioulnar dissociation. Radial head resection alone is contraindicated, as it will lead to proximal migration of the radius, ulnar positive variance, and chronic wrist pain. The correct management is radial head replacement to restore the primary stabilizer against proximal radial migration, followed by assessment of the DRUJ. If the DRUJ is unstable, it should be pinned (typically in supination) or the TFCC repaired.

Question 1589

Topic: Nerve & Tendon

A 24-year-old weightlifter complains of a snapping sensation and medial elbow pain during triceps extensions. Examination reveals a snapping structure over the medial epicondyle during elbow flexion. Ultrasound demonstrates ulnar nerve subluxation as well as an additional snapping muscular structure. What is the most likely diagnosis?

. Snapping triceps syndrome
. Subluxation of the flexor carpi ulnaris
. Medial collateral ligament insufficiency
. Anconeus epitrochlearis
. Cubital tunnel syndrome with isolated nerve subluxation

Correct Answer & Explanation

. Snapping triceps syndrome

Explanation

Snapping triceps syndrome involves the subluxation of the medial head of the triceps over the medial epicondyle during active elbow flexion. It is frequently associated with concurrent ulnar nerve subluxation and can cause ulnar neuritis.

Question 1590

Topic: Nerve & Tendon
What are the two terminal branches of the lateral cord of the brachial plexus?
. Musculocutaneous and median
. Musculocutaneous and axillary
. Median and axillary
. Ulnar and median
. Ulnar and medial pectoral

Correct Answer & Explanation

. Musculocutaneous and median

Explanation

The lateral cord divides into the musculocutaneous and median nerves. The posterior cord terminates into the axillary and radial nerves. The medial cord divides into the ulnar and median nerves.

Question 1591

Topic: 7. Hand and Wrist
In the injury shown in Figures 1 and 2, what ligament remains intact?
. Short radiolunate
. Scapholunate
. Radioscaphocapitate
. Dorsal radiocarpal

Correct Answer & Explanation

. Short radiolunate

Explanation

Perilunate dislocations result from high-energy injuries to the extended wrist. The injury shown is a lunate dislocation. Two classification systems have been described, the Mayfield system and the Herzberg system. Mayfield described the four stages of progressive ligamentous instability following injury. In stage I, the radioscaphocapitate and scapholunate ligaments fail. Stage II involves dislocation of the lunocapitate joint, usually a dorsal dislocation of the capitate. In stage III, the lunotriquetral ligament fails. In stage IV, the dorsal radiocarpal ligament is torn, and the lunate dislocates volarly. The short radiolunate ligament is the only ligament that remains intact, resulting in rotation of the lunate volarly. Herzberg and associates further classified perilunate dislocations as stage I injuries and lunate dislocations as stage II injuries. Lunate dislocations were further classified into stage IIA, in which the lunate exhibits rotation less than 90°, and stage IIB, in which the lunate exhibits rotation greater than 90°. The radiographs represent a Mayfield stage IV, Herzberg stage IIA injury.

Question 1592

Topic: 7. Hand and Wrist
Figure 1 is the clinical photograph of a 65-year-old right-hand dominant man who has finger contracture and stiffness. He experiences minimal pain but has severe functional limitations and elects for treatment with injectable collagenase Clostridium histolyticum. What types of collagen will be affected by this injection?
. Types I and II
. Types II and III
. Types I and III
. Types III and IV

Correct Answer & Explanation

. Types I and III

Explanation

Type II collagen is the predominant type found in articular cartilage. Type IV collagen is the predominant type found in the basement membranes of neurovascular structures. Collagenase Clostridium histolyticum injection targets type I and type III collagen.

Question 1593

Topic: 7. Hand and Wrist
Based on the findings seen in the posteroanterior radiograph of the wrist shown in Figure 17, which of the following structures is torn?
. Distal radioulnar ligament
. Radioscapholunate ligament
. Radioscaphocapitate ligament
. Scapholunate interosseous ligament
. Triangular fibrocartilage

Correct Answer & Explanation

. Scapholunate interosseous ligament

Explanation

The radiograph shows widening between the scaphoid and lunate. The normal variance is up to 5 mm. Although several ligaments may be torn, the scapholunate interosseous ligament must be torn for this widening to occur.

Question 1594

Topic: 7. Hand and Wrist
A 65-year-old woman has severe pain and numbness in her hand. She notes frequent awakenings at nighttime and difficulty with fine tasks. She also has a history of cervical radiculopathy and notes intermittent pain in her upper arm and periscapular region. An examination reveals a positive Tinel sign over the midforearm and carpal tunnel. Electrodiagnostic testing shows a median nerve sensory distal latency of 3.8 ms (normal latency is 3.5 ms). Which intervention or test would best predict if carpal tunnel release would be successful in relieving this patient's symptoms?
. Trigger point injections with lidocaine
. Carpal tunnel corticosteroid injection
. Ultrasound of the wrist
. Carpal tunnel view radiograph

Correct Answer & Explanation

. Carpal tunnel corticosteroid injection

Explanation

This patient demonstrates several upper extremity issues including possible carpal tunnel syndrome, cervical radiculopathy, and pronator syndrome. The electrodiagnostic testing is equivocal, and a corticosteroid carpal tunnel injection should be performed prior to surgical intervention to assess its effectiveness in eliminating the patient's symptoms. Positive response (meaning improvement in symptoms) after corticosteroid injection at the carpal tunnel correlates well with symptom relief following surgery. Trigger-point injections are not indicated for carpal tunnel syndrome. Ultrasound and carpal tunnel view radiograph can provide diagnostic information but would not be helpful in determining treatment in this specific case.

Question 1595

Topic: Hand Trauma & Infection

A 35-year-old carpenter presents with a swollen, painful index finger 3 days after a puncture wound. The physician suspects acute pyogenic flexor tenosynovitis. According to Kanavel's cardinal signs, which of the following is typically the earliest and most sensitive clinical finding?

. Fusiform swelling of the entire digit
. Flexed resting posture of the digit
. Exquisite tenderness along the flexor tendon sheath
. Severe pain with passive extension of the digit
. Erythema tracking up the forearm

Correct Answer & Explanation

. Fusiform swelling of the entire digit

Explanation

Kanavel's four classic signs of acute pyogenic flexor tenosynovitis are: 1) flexed resting posture of the digit, 2) fusiform (sausage-like) swelling, 3) exquisite tenderness along the course of the flexor tendon sheath, and 4) severe pain elicited by passive extension. Pain with passive extension is typically the earliest, most reliable, and most sensitive clinical sign of infection within the tendon sheath.

Question 1596

Topic: Hand Trauma & Infection

A 28-year-old carpenter presents with a swollen, painful index finger 3 days after a splinter injury. On examination, the finger is held in slight flexion. Which of Kanavel's four cardinal signs is considered the earliest and most sensitive indicator of pyogenic flexor tenosynovitis?

. Fusiform swelling of the digit
. Flexed resting posture of the digit
. Pain with passive extension of the digit
. Tenderness along the flexor tendon sheath
. Erythema extending to the palm

Correct Answer & Explanation

. Pain with passive extension of the digit

Explanation

Pain out of proportion with passive extension is classically described as the earliest and most sensitive of Kanavel's four signs for pyogenic flexor tenosynovitis.

Question 1597

Topic: Wrist & Carpus

A 50-year-old female undergoes open reduction and internal fixation of a distal radius fracture with a volar locking plate. Six months postoperatively, she presents with an inability to actively flex the interphalangeal joint of her thumb. Which of the following technical errors during the index procedure is most likely responsible for this complication?

. Placement of the plate dorsal to the extensor pollicis longus tendon
. Placement of the plate distal to the watershed line
. Use of excessively long screws penetrating the dorsal cortex
. Failure to release the brachioradialis insertion
. Inadequate reduction of the dorsal tilt

Correct Answer & Explanation

. Placement of the plate distal to the watershed line

Explanation

The patient has sustained an iatrogenic rupture of the flexor pollicis longus (FPL) tendon. This is a well-documented complication of volar locked plating for distal radius fractures. It most commonly occurs when the plate is positioned too far distally, extending past the 'watershed line' (the bony ridge at the distal margin of the pronator fossa). This prominent distal hardware creates mechanical friction against the FPL tendon, ultimately leading to fraying and rupture.

Question 1598

Topic: Wrist & Carpus

Six weeks after closed reduction and cast immobilization for a non-displaced distal radius fracture, a 55-year-old female presents with a sudden inability to actively extend her thumb interphalangeal joint. What is the preferred surgical management?

. Primary end-to-end repair of the extensor pollicis longus (EPL) tendon
. Extensor indicis proprius (EIP) to EPL tendon transfer
. Free tendon graft reconstruction of the EPL using palmaris longus
. Extensor carpi radialis longus (ECRL) to EPL tendon transfer
. First dorsal compartment release

Correct Answer & Explanation

. Extensor indicis proprius (EIP) to EPL tendon transfer

Explanation

Delayed spontaneous rupture of the extensor pollicis longus (EPL) tendon is a known complication of non-displaced distal radius fractures. Because the tendon ends are typically frayed and retracted, primary repair is usually impossible, making an EIP to EPL tendon transfer the gold standard treatment.

Question 1599

Topic: 7. Hand and Wrist
A 35-year-old male presents with chronic wrist pain. Radiographs reveal a scaphoid nonunion with advanced collapse (SNAC). Imaging demonstrates arthritic changes in the radioscaphoid and midcarpal joints, specifically involving the capitate head. The lunate fossa of the distal radius remains completely spared. Which of the following is the most appropriate surgical treatment?
. Proximal row carpectomy
. Scaphoid excision and four-corner arthrodesis
. Scaphoid excision and capitolunate arthrodesis
. Total wrist arthroplasty
. Radial styloidectomy and scaphoid open reduction internal fixation

Correct Answer & Explanation

. Scaphoid excision and four-corner arthrodesis

Explanation

This patient has a SNAC stage III wrist, defined by radioscaphoid and midcarpal (capitolunate) arthritis with sparing of the radiolunate joint. Proximal row carpectomy (PRC) is contraindicated because the capitate head is degenerated, which would articulate with the lunate fossa postoperatively, leading to continued pain and failure. Scaphoid excision with four-corner (capitate-hamate-lunate-triquetrum) arthrodesis is the gold standard for SNAC III, as it preserves motion at the spared radiolunate joint.

Question 1600

Topic: Wrist & Carpus

A 65-year-old woman presents with the inability to extend her thumb interphalangeal joint. Six weeks prior, she sustained a non-displaced distal radius fracture treated with cast immobilization. Examination confirms rupture of the Extensor Pollicis Longus (EPL) tendon. Which of the following is the most appropriate and reliable surgical treatment?

. Primary end-to-end repair of the EPL
. Extensor Indicis Proprius (EIP) to EPL tendon transfer
. Extensor Carpi Radialis Longus (ECRL) to EPL tendon transfer
. Thumb interphalangeal joint arthrodesis
. Tendon grafting using palmaris longus

Correct Answer & Explanation

. Extensor Indicis Proprius (EIP) to EPL tendon transfer

Explanation

Delayed EPL rupture is a known complication of both operatively and non-operatively treated distal radius fractures, often secondary to ischemic changes or mechanical attrition at the Lister tubercle. Because the tendon ends are typically retracted and degenerated, primary end-to-end repair is rarely feasible. An Extensor Indicis Proprius (EIP) to EPL transfer is the gold standard, providing appropriate excursion, tension, and a reliable functional outcome without significant donor site morbidity.

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