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7. Hand and Wrist MCQs

Practice Set 81 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 1601

Topic: 7. Hand and Wrist
A 24-year-old manual laborer with Kienbock's disease presents with chronic dorsal wrist pain. Radiographs reveal lunate sclerosis and collapse, fixed volar rotation of the scaphoid (ring sign), and a decreased carpal height ratio. The radioscaphoid and midcarpal joints do not show signs of arthritis. He has 3 mm of ulnar negative variance. What Lichtman stage does this represent, and what is the preferred surgical treatment?
. Stage II; Radial shortening osteotomy
. Stage IIIA; Radial shortening osteotomy
. Stage IIIB; Scaphocapitate or scaphotrapeziotrapezoid (STT) arthrodesis
. Stage IV; Proximal row carpectomy
. Stage IIIB; Ulnar lengthening osteotomy

Correct Answer & Explanation

. Stage IIIB; Scaphocapitate or scaphotrapeziotrapezoid (STT) arthrodesis

Explanation

The patient has Lichtman Stage IIIB Kienbock's disease, defined by lunate collapse with fixed scaphoid rotation and decreased carpal height, but without generalized carpal arthritis (which would be Stage IV). While joint-leveling procedures (like radial shortening osteotomy) are ideal for Stages II and IIIA (where carpal height is maintained), they are less effective in Stage IIIB. Limited intercarpal arthrodesis (such as STT or scaphocapitate fusion) is preferred to unload the lunate and stabilize the carpus in Stage IIIB.

Question 1602

Topic: 7. Hand and Wrist

During the surgical repair of a Zone II flexor tendon laceration in the hand, preservation or reconstruction of specific components of the flexor sheath is critical to prevent bowstringing and maintain digital kinematics. Which two annular pulleys are biomechanically the most important to preserve?

. A1 and A3
. A2 and A4
. A1 and A5
. A3 and A5
. A2 and A3

Correct Answer & Explanation

. A2 and A4

Explanation

The flexor tendon sheath consists of five annular (A1-A5) and three cruciform (C1-C3) pulleys. The A2 pulley (located over the proximal phalanx) and the A4 pulley (located over the middle phalanx) are the most critical biomechanically. Disruption of these pulleys leads to significant bowstringing of the flexor tendons, loss of mechanical advantage, and a substantial decrease in active interphalangeal joint flexion.

Question 1603

Topic: 7. Hand and Wrist

A patient presents with acute wrist pain and swelling following a high-energy motorcycle collision. Lateral radiographs demonstrate a 'spilled teacup' sign, with the lunate displaced volarly and the capitate aligned with the distal radius. This injury mechanism most commonly occurs due to terminal disruption of ligaments in which of the following anatomic zones?

. Space of Poirier
. Guyon's canal
. Space of Parona
. Carpal tunnel
. Quadrangular space

Correct Answer & Explanation

. Space of Poirier

Explanation

The patient has a Stage IV perilunate dislocation (lunate dislocation). The terminal event in Mayfield's progressive perilunate instability involves failure of the dorsal radiocarpal ligaments and volar extrusion of the lunate through the Space of Poirier, an area of inherent weakness between the capitate and lunate.

Question 1604

Topic: 7. Hand and Wrist

In a patient with a known Martin-Gruber anastomosis, a high complete transection of the ulnar nerve just proximal to the elbow would most likely result in which of the following unexpected clinical findings?

. Complete loss of all intrinsic hand muscle function
. Preservation of normal sensation in the small finger
. Unexpected preservation of function in the first dorsal interosseous and adductor pollicis
. Loss of flexor pollicis longus function
. Complete claw hand deformity involving all four fingers

Correct Answer & Explanation

. Unexpected preservation of function in the first dorsal interosseous and adductor pollicis

Explanation

A Martin-Gruber anastomosis is a crossing of motor nerve fibers from the median to the ulnar nerve in the forearm. In a high ulnar nerve injury, these median nerve fibers bypass the lesion and unexpectedly preserve motor function in ulnar-innervated intrinsic hand muscles, such as the first dorsal interosseous.

Question 1605

Topic: Wrist & Carpus

A 45-year-old female undergoes volar locked plating for a comminuted distal radius fracture. Postoperatively, she develops a spontaneous rupture of the flexor pollicis longus (FPL) tendon. Which of the following technical errors during surgery is the most significant risk factor for this complication?

. Placement of the volar plate distal to the watershed line (Soong Grade 2)
. Failure to repair the pronator quadratus muscle
. Use of locking screws rather than non-locking screws
. Over-penetration of dorsal cortical screws
. Placement of the plate proximal to the watershed line (Soong Grade 0)

Correct Answer & Explanation

. Placement of the volar plate distal to the watershed line (Soong Grade 2)

Explanation

FPL tendon rupture is a known complication of volar plating of the distal radius. Placement of the plate distal to the watershed line (Soong Grade 2) causes the plate to sit proud, creating mechanical attrition on the FPL tendon.

Question 1606

Topic: 7. Hand and Wrist

When performing a primary flexor tendon repair in Zone II of the hand, which of the following factors has been shown to be the primary determinant of the repair's resistance to gap formation and overall tensile strength?

. The caliber of the suture used for the epitendinous repair
. The timing of the initial surgical repair within the first 14 days
. The number of suture strands crossing the repair site
. The specific type of core knot tied (e.g., Kessler vs. Tajima)
. The length of the tendon core purchase

Correct Answer & Explanation

. The number of suture strands crossing the repair site

Explanation

Biomechanical studies demonstrate that the initial strength of a flexor tendon repair and its resistance to gap formation are directly proportional to the number of core suture strands crossing the repair site (e.g., 4-strand vs 2-strand).

Question 1607

Topic: Wrist & Carpus

Following volar locking plate fixation of a distal radius fracture, a patient develops attrition and rupture of the flexor pollicis longus (FPL) tendon. Which radiographic parameter on the postoperative lateral view is most highly predictive of this complication?

. Prominence of the plate volar to the critical line of Soong (Soong Grade 2)
. Dorsal screw penetration into the radiocarpal joint
. Plate placement proximal to the pronator quadratus footprint
. Use of non-locking cortical screws in the distal row
. Radial translation of the distal plate border

Correct Answer & Explanation

. Prominence of the plate volar to the critical line of Soong (Soong Grade 2)

Explanation

Plate prominence volar to the watershed line, classified as Soong Grade 2, significantly increases the risk of flexor tendon irritation. This mechanical conflict most commonly leads to rupture of the flexor pollicis longus (FPL).

Question 1608

Topic: Nerve & Tendon

During a routine carpal tunnel release, the surgeon notes an anomalous neural connection between the median and ulnar nerves in the forearm, known as the Martin-Gruber anastomosis. What is the typical directional flow of these crossing fibers?

. Ulnar to median nerve in the distal forearm
. Median to ulnar nerve in the proximal forearm
. Median to ulnar nerve in the deep palm
. Ulnar to median nerve in the deep palm
. Radial to median nerve in the distal forearm

Correct Answer & Explanation

. Median to ulnar nerve in the proximal forearm

Explanation

The Martin-Gruber anastomosis is a common anatomical variant in the forearm where motor nerve fibers cross from the median nerve (or anterior interosseous nerve) to the ulnar nerve. It typically innervates intrinsic hand muscles.

Question 1609

Topic: 7. Hand and Wrist
A 50-year-old laborer presents with scapholunate advanced collapse (SLAC) Stage III, demonstrating arthritic changes in the radioscaphoid and capitolunate joints. The radiolunate joint is spared. Which of the following is the most appropriate surgical treatment?
. Proximal row carpectomy
. Scaphoid excision and four-corner arthrodesis
. Isolated radioscaphoid arthrodesis
. Total wrist arthroplasty
. Scapholunate ligament reconstruction with capsulodesis

Correct Answer & Explanation

. Scaphoid excision and four-corner arthrodesis

Explanation

SLAC Stage III involves arthritic changes extending to the capitolunate joint. Proximal row carpectomy is contraindicated due to capitate arthritis, making scaphoid excision with four-corner fusion the preferred and durable treatment.

Question 1610

Topic: Wrist & Carpus

A 60-year-old female presents with a sudden inability to flex her thumb interphalangeal joint 6 months following volar locked plating of a distal radius fracture. Which of the following plate positions is the most likely biomechanical cause of this complication?

. Placement dorsal to the Lister tubercle
. Placement proximal to the pronator quadratus insertion
. Placement distal to the watershed line
. Placement with excessive radial inclination
. Placement extending into the distal radioulnar joint space

Correct Answer & Explanation

. Placement distal to the watershed line

Explanation

Flexor pollicis longus (FPL) rupture is a known complication of volar distal radius plating. It is most frequently caused by placement of the plate distal to the watershed line, leading to mechanical attrition of the tendon against the prominent plate edge.

Question 1611

Topic: 7. Hand and Wrist

A 62-year-old female presents with severe basilar thumb pain. Radiographs demonstrate advanced pantrapezial arthritis involving the trapeziometacarpal and scaphotrapezialtrapezoid (STT) joints (Eaton-Littler Stage IV). Which of the following procedures is most appropriate?

. Trapeziometacarpal joint arthrodesis
. Volar ligament reconstruction without trapeziectomy
. Trapeziometacarpal hemiarthroplasty
. Ligament reconstruction and tendon interposition (LRTI) with complete trapeziectomy
. Metacarpal extension osteotomy

Correct Answer & Explanation

. Ligament reconstruction and tendon interposition (LRTI) with complete trapeziectomy

Explanation

In the presence of STT arthritis (Stage IV), joint-sparing or isolated trapeziometacarpal procedures (like arthrodesis or hemiarthroplasty) are contraindicated because they do not address the STT pathology. Complete trapeziectomy with or without LRTI is the treatment of choice.

Question 1612

Topic: Nerve & Tendon

A patient with severe cubital tunnel syndrome demonstrates a positive Froment sign when attempting to pinch a piece of paper. This sign is caused by compensatory hyperflexion of the thumb interphalangeal joint driven by a muscle innervated by which nerve?

. Recurrent motor branch of the median nerve
. Anterior interosseous nerve
. Deep branch of the ulnar nerve
. Posterior interosseous nerve
. Superficial branch of the radial nerve

Correct Answer & Explanation

. Anterior interosseous nerve

Explanation

Froment sign occurs due to weakness of the ulnar-innervated adductor pollicis. The patient compensates by utilizing the flexor pollicis longus (FPL) to pinch, resulting in thumb IP joint hyperflexion. The FPL is innervated by the anterior interosseous nerve.

Question 1613

Topic: Wrist & Carpus
According to Mayfield's progressive stages of perilunate instability, a Stage III injury is characterized by the disruption of which of the following structures, leading to a complete perilunate dislocation?
. Scapholunate interosseous ligament
. Radioscaphocapitate ligament
. Lunotriquetral interosseous ligament
. Dorsal radiocarpal ligament
. Volar radiolunate ligament

Correct Answer & Explanation

. Lunotriquetral interosseous ligament

Explanation

Mayfield staging describes the progressive ligamentous disruption around the lunate. Stage I is scapholunate, Stage II involves the space of Poirier (capitolunate), Stage III is lunotriquetral disruption (resulting in perilunate dislocation), and Stage IV is lunate dislocation.

Question 1614

Topic: Hand Trauma & Infection

Among Kanavel's four cardinal signs of flexor tenosynovitis, which is generally considered the most reliable, earliest, and most sensitive indicator of the condition?

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

Correct Answer & Explanation

. Pain with passive extension of the digit

Explanation

Pain with passive extension is considered the earliest and most sensitive of Kanavel's signs for pyogenic flexor tenosynovitis. The other signs include fusiform swelling, flexed resting posture, and tenderness along the sheath.

Question 1615

Topic: 7. Hand and Wrist
A 45-year-old construction worker presents with severe wrist pain. Radiographs reveal scapholunate advanced collapse (SLAC) Stage III, with degenerative changes in the radioscaphoid and capitolunate joints. The radiolunate joint is preserved. Which surgical option is most appropriate?
. Proximal row carpectomy
. Scaphoid excision and four-corner fusion
. Scapholunate ligament reconstruction
. Total wrist arthroplasty
. Radioscapholunate arthrodesis

Correct Answer & Explanation

. Scaphoid excision and four-corner fusion

Explanation

SLAC Stage III involves the radioscaphoid and capitolunate joints. A proximal row carpectomy is contraindicated due to capitate head arthritis; therefore, scaphoid excision with four-corner fusion is the most appropriate motion-preserving procedure.

Question 1616

Topic: Nerve & Tendon

A 40-year-old avid cyclist presents with hand weakness. Examination shows isolated profound weakness of the adductor pollicis and dorsal interossei muscles of the right hand. Sensation in the small finger is completely normal, and the hypothenar muscles demonstrate normal bulk and strength. An ulnar nerve compression is most likely localized to which zone of Guyon's canal?

. Zone 1
. Zone 2
. Zone 3
. Zone 4
. Proximal to the canal

Correct Answer & Explanation

. Zone 2

Explanation

Zone 2 of Guyon's canal contains the deep motor branch of the ulnar nerve. Compression here (especially distal to the hypothenar motor branches) produces isolated motor weakness of the interossei and adductor pollicis without sensory loss.

Question 1617

Topic: 7. Hand and Wrist

During a routine physical examination of a 60-year-old man with progressive gait unsteadiness and hand clumsiness, the examiner aggressively flicks the distal phalanx of the middle finger, causing reflex flexion of the thumb and index finger. This positive Hoffmann sign is indicative of compression or injury to which of the following?

. Spinothalamic tract
. Dorsal columns
. Corticospinal tract
. Rubrospinal tract
. Vestibulospinal tract

Correct Answer & Explanation

. Corticospinal tract

Explanation

A positive Hoffmann sign represents an upper motor neuron lesion (hyperreflexia), classically seen in cervical myelopathy. It indicates compression or dysfunction of the descending corticospinal tract.

Question 1618

Topic: Nerve & Tendon

A 48-year-old carpenter presents with progressive numbness in his small and ring fingers, accompanied by intrinsic hand muscle weakness. Clinical evaluation suggests ulnar nerve entrapment at the elbow. Which of the following structures is the most common site of compression for this condition?

. Arcade of Struthers
. Osborne's ligament
. Medial intermuscular septum
. Guyon's canal
. Lacertus fibrosus

Correct Answer & Explanation

. Osborne's ligament

Explanation

Osborne's ligament (the cubital tunnel retinaculum), which spans from the medial epicondyle to the olecranon, is the most common anatomic site of ulnar nerve compression at the elbow. The Arcade of Struthers is a more proximal, less common site of ulnar nerve entrapment.

Question 1619

Topic: 7. Hand and Wrist
Figures 1 and 2 are the radiographs of a 36-year-old right-hand-dominant man who has had persistent wrist pain for 6 months after a motor vehicle collision. The initial treatment was splint immobilization. What is the best next step?
. Therapy/rehabilitation
. Open reduction and internal fixation (ORIF)
. Proximal row carpectomy
. Wrist arthrodesis

Correct Answer & Explanation

. Wrist arthrodesis

Explanation

This patient has a chronic untreated volar lunate dislocation. Lunate dislocations are usually the result of a high-energy injury. Recommended treatment for an acute lunate dislocation is ORIF with repair of injured structures (ligament and bone). If the patient has paresthesias in a median nerve distribution, carpal tunnel release is recommended in the same setting as ORIF. Six months after injury, the prognosis for successful ORIF is poor and proximal row carpectomy is recommended. Among perilunate/lunate dislocations, 25% are initially missed. If a patient arrives for treatment and there is evidence of radiocarpal and midcarpal arthrosis, wrist arthrodesis is recommended.

Question 1620

Topic: 7. Hand and Wrist
A 72-year-old woman with diabetes mellitus has right hand numbness. Provocative test findings are consistent with carpal tunnel syndrome, and electrodiagnostic study (EDS) findings show prolonged median motor and sensory distal latencies with low-amplitude thenar compound muscle action potential. Poor prognosis is most associated with which factor?
. Diabetes
. Older age
. Female gender
. Severity of EDS findings

Correct Answer & Explanation

. Severity of EDS findings

Explanation

EXPLANATION: Although carpal tunnel syndrome remains a clinical diagnosis, EDS findings have become important tools. Moderate disease is defined as abnormal median sensory distal latency and prolonged median motor distal latency. Severe disease is defined as prolonged median motor and sensory distal latencies with either absent sensory nerve action potential or mixed nerve action potential or low-amplitude or absent thenar compound muscle action potential. Although female gender and diabetes are considered risk factors, there is little association with postsurgical outcome. Severe disease as confirmed by EDS is the factor most strongly associated with poor recovery after surgery.

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