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7. Hand and Wrist MCQs

Practice Set 83 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 1641

Topic: Wrist & Carpus

A 40-year-old female sustains a comminuted distal radius fracture with an associated distal radioulnar joint (DRUJ) dislocation. Intraoperatively, following anatomic volar plate fixation of the distal radius, the DRUJ remains grossly unstable in supination. The ulnar styloid is intact on fluoroscopy. What is the most appropriate next step in management?

. Pinning the DRUJ in pronation for 6 weeks
. Open repair of the deep fibers of the triangular fibrocartilage complex (TFCC) to the fovea
. Ulnar shortening osteotomy
. Darrach procedure
. Reconstruction of the distal oblique bundle

Correct Answer & Explanation

. Open repair of the deep fibers of the triangular fibrocartilage complex (TFCC) to the fovea

Explanation

DRUJ instability after anatomic fixation of the distal radius without an ulnar styloid fracture suggests an avulsion of the deep (foveal) fibers of the TFCC, which are the primary stabilizers of the DRUJ. Direct open or arthroscopic repair of the radioulnar ligaments to their foveal footprint is the most appropriate management to restore stability.

Question 1642

Topic: Wrist & Carpus
A 50-year-old male presents with chronic wrist pain and a known history of an untreated scapholunate ligament tear. Radiographs reveal narrowing and sclerosis at the radioscaphoid joint as well as the capitolunate joint. The radiolunate joint is well-preserved. According to the SLAC (Scapholunate Advanced Collapse) classification, which stage is this, and what is an appropriate surgical treatment?
. SLAC I; Scapholunate ligament reconstruction
. SLAC II; Radial styloidectomy
. SLAC III; Proximal row carpectomy or 4-corner fusion
. SLAC IV; Total wrist arthrodesis
. SLAC III; Total wrist arthrodesis

Correct Answer & Explanation

. SLAC III; Proximal row carpectomy or 4-corner fusion

Explanation

This patient has SLAC III arthritis, which involves the radioscaphoid and capitolunate joints while sparing the radiolunate joint. (SLAC I involves only the radial styloid-scaphoid articulation; SLAC II involves the entire radioscaphoid fossa). The standard surgical treatment options for SLAC III are proximal row carpectomy (PRC) or scaphoid excision with 4-corner fusion. Total wrist fusion is typically reserved for SLAC IV (pancarpal, including radiolunate arthritis) or failed salvage.

Question 1643

Topic: Nerve & Tendon

A 45-year-old male presents with progressive hand clumsiness, intrinsic muscle atrophy, and a positive Froment's sign. He reports a childhood elbow fracture that was treated non-operatively. Current elbow radiographs reveal a severe cubitus valgus deformity and a nonunion of the lateral humeral condyle. What is the pathomechanism of his current neurologic deficit?

. Median nerve entrapment at the ligament of Struthers
. Acute radial nerve stretch across the radiocapitellar joint
. Posterior interosseous nerve compression at the arcade of Frohse
. Ulnar nerve traction due to progressive valgus deformity
. Anterior interosseous nerve compression by the lacertus fibrosus

Correct Answer & Explanation

. Ulnar nerve traction due to progressive valgus deformity

Explanation

Nonunion of a pediatric lateral condyle fracture leads to a progressive cubitus valgus deformity over time. This increased carrying angle produces chronic stretching and traction on the ulnar nerve as it passes behind the medial epicondyle, resulting in a 'tardy ulnar nerve palsy.' The symptoms described (intrinsic atrophy, positive Froment's sign) are classic for ulnar neuropathy.

Question 1644

Topic: 7. Hand and Wrist
A 30-year-old manual laborer presents with dorsal wrist pain and decreased grip strength. Radiographs show sclerosis and collapse of the lunate, with proximal migration of the capitate and fixed scaphoid rotation. The patient has ulnar neutral variance. MRI confirms Kienböck's disease. According to the Lichtman classification, this represents Stage IIIB. Which of the following is the most appropriate surgical intervention?
. Radial shortening osteotomy
. Proximal row carpectomy or STT fusion
. Vascularized bone grafting from the distal radius
. Lunate excision and silicone replacement
. Radial wedge osteotomy

Correct Answer & Explanation

. Proximal row carpectomy or STT fusion

Explanation

Lichtman Stage IIIB Kienböck's disease is characterized by lunate collapse with fixed scaphoid rotation and carpal height loss (carpal collapse). Because carpal kinematics are significantly altered, joint-leveling procedures (like radial shortening) or revascularization are no longer effective. Salvage procedures such as proximal row carpectomy (PRC), scaphoid-trapezium-trapezoid (STT) fusion, or scaphocapitate fusion are indicated for Stage IIIB.

Question 1645

Topic: 7. Hand and Wrist

A 25-year-old male sustains a trans-scaphoid perilunate dislocation. During emergent open reduction and internal fixation, the surgeon notes that the lunate is completely extruded and entirely devoid of any capsular or ligamentous soft-tissue attachments. Despite this finding, what is the accepted standard of care regarding the lunate?

. Excision of the lunate and immediate proximal row carpectomy
. Primary total wrist arthrodesis
. Reduction and stabilization of the lunate with pin or screw fixation
. Replacement of the lunate with a silicone spacer
. Lunate excision and scaphocapitate fusion

Correct Answer & Explanation

. Reduction and stabilization of the lunate with pin or screw fixation

Explanation

Even when the lunate is completely extruded and devoid of soft-tissue attachments, the standard of care is immediate reduction and stabilization (with K-wires or screws) combined with ligamentous repair. While the risk of avascular necrosis (AVN) is high, the lunate often revascularizes or functions reasonably well without significant collapse. Primary salvage procedures (PRC or fusion) are not indicated in the acute setting.

Question 1646

Topic: 7. Hand and Wrist

A 35-year-old competitive rower presents with dorsal forearm pain and swelling, approximately 4-5 cm proximal to the radiocarpal joint. Examination reveals crepitus and swelling with active wrist flexion and extension. He is diagnosed with intersection syndrome, caused by friction between the muscle bellies of the first extensor compartment and the tendons of the second extensor compartment. Which tendons constitute the second extensor compartment?

. Abductor pollicis longus and extensor pollicis brevis
. Extensor carpi radialis longus and extensor carpi radialis brevis
. Extensor pollicis longus
. Extensor digitorum communis and extensor indicis proprius
. Extensor carpi ulnaris

Correct Answer & Explanation

. Extensor carpi radialis longus and extensor carpi radialis brevis

Explanation

Intersection syndrome is characterized by tenosynovitis at the crossing point where the muscle bellies of the first extensor compartment (abductor pollicis longus and extensor pollicis brevis) cross over the tendons of the second extensor compartment (extensor carpi radialis longus and extensor carpi radialis brevis). It typically occurs 4-5 cm proximal to the wrist joint.

Question 1647

Topic: 7. Hand and Wrist
A 45-year-old manual laborer presents with advanced scaphoid nonunion advanced collapse (SNAC). Radiographs reveal arthritis involving the radioscaphoid and capitolunate joints, with absolute preservation of the radiolunate joint. Which of the following surgical options is most appropriate?
. Radial styloidectomy
. Proximal row carpectomy (PRC)
. Scaphoid excision and four-corner arthrodesis
. Total wrist arthrodesis
. Scaphoid ORIF with vascularized bone graft

Correct Answer & Explanation

. Scaphoid excision and four-corner arthrodesis

Explanation

This patient has Stage III SNAC wrist characterized by capitolunate arthritis. PRC is contraindicated when the capitate articular surface is degenerate; therefore, scaphoid excision and four-corner arthrodesis is the preferred motion-preserving procedure.

Question 1648

Topic: Wrist & Carpus
In a progressive perilunate instability pattern (Mayfield classification), which ligamentous disruption occurs immediately after the scapholunate ligament fails?
. Lunotriquetral ligament
. Volar radiolunate ligament
. Capitolunate articulation
. Dorsal radiocarpal ligament
. Triangular fibrocartilage complex (TFCC)

Correct Answer & Explanation

. Capitolunate articulation

Explanation

According to Mayfield's stages of perilunate instability, the injury progresses sequentially around the lunate: scapholunate (Stage I), capitolunate (Stage II), lunotriquetral (Stage III), and finally volar dislocation of the lunate (Stage IV).

Question 1649

Topic: 7. Hand and Wrist
A 45-year-old male laborer presents with chronic right wrist pain. Radiographs reveal advanced narrowing and sclerosis of the radioscaphoid and capitolunate joints, with a completely preserved radiolunate joint. What is the most appropriate motion-preserving surgical intervention?
. Proximal row carpectomy (PRC)
. Scaphoid excision and four-corner fusion
. Total wrist arthroplasty
. Total wrist fusion
. Radial styloidectomy

Correct Answer & Explanation

. Scaphoid excision and four-corner fusion

Explanation

This patient has Stage III Scapholunate Advanced Collapse (SLAC) wrist, characterized by capitolunate involvement with a preserved radiolunate joint. Scaphoid excision and four-corner fusion is the procedure of choice, as proximal row carpectomy is contraindicated when the capitate articular surface is degenerate.

Question 1650

Topic: 7. Hand and Wrist

According to Mayfield's stages of progressive perilunate instability, what is the sequential anatomic progression of ligamentous disruption that ultimately results in a volar lunate dislocation (Stage IV)?

. Scapholunate, lunocapitate, lunotriquetral, dorsal radiocarpal
. Lunotriquetral, lunocapitate, scapholunate, dorsal radiocarpal
. Dorsal radiocarpal, scapholunate, lunotriquetral, volar radiocarpal
. Scapholunate, lunotriquetral, lunocapitate, dorsal intercarpal
. Volar radiocarpal, scapholunate, lunocapitate, dorsal radiocarpal

Correct Answer & Explanation

. Scapholunate, lunotriquetral, lunocapitate, dorsal intercarpal

Explanation

Mayfield described a progressive sequence of injury starting radially and progressing ulnarward: 1) Scapholunate, 2) Lunocapitate (Space of Poirier), 3) Lunotriquetral, and 4) Dorsal radiocarpal ligament, which allows the lunate to dislocate completely into the carpal tunnel.

Question 1651

Topic: 7. Hand and Wrist
A 30-year-old manual laborer presents with progressive wrist pain. Radiographs reveal ulnar minus variance and lunate sclerosis with early fragmentation, but no signs of carpal collapse or radiocarpal arthritis (Lichtman Stage IIIa). What is the preferred surgical intervention?
. Proximal row carpectomy
. Total wrist fusion
. Radial shortening osteotomy
. Lunate excision with silastic replacement
. Scaphotrapeziotrapezoid (STT) fusion

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

In Kienböck's disease with ulnar negative variance and no carpal collapse or advanced arthritis (Lichtman Stage I, II, or IIIa), joint-leveling procedures such as a radial shortening osteotomy are indicated to decompress the lunate and halt disease progression.

Question 1652

Topic: Nerve & Tendon

When performing a single-incision anterior approach for the repair of a distal biceps tendon rupture, excessive traction on the lateral soft-tissue retractors most commonly places which of the following nerves at risk of injury?

. Lateral antebrachial cutaneous nerve
. Posterior interosseous nerve
. Median nerve
. Ulnar nerve
. Anterior interosseous nerve

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve

Explanation

The lateral antebrachial cutaneous nerve (LABC) is the most commonly injured nerve in a single-incision distal biceps repair due to lateral retraction. The posterior interosseous nerve (PIN) is more at risk during the deep, distal part of the exposure or during a two-incision approach if dissection violates the supinator.

Question 1653

Topic: Wrist & Carpus

What is the most common tendon rupture associated with the placement of a volar locking plate for a distal radius fracture if the plate is positioned distal to the watershed line?

. Extensor pollicis longus
. Flexor pollicis longus
. Flexor digitorum profundus to the index finger
. Extensor digitorum communis
. Flexor carpi radialis

Correct Answer & Explanation

. Flexor pollicis longus

Explanation

Placement of a volar plate distal to the watershed line on the distal radius causes prominent hardware to impinge on the flexor tendons, most commonly leading to attritional rupture of the flexor pollicis longus (FPL) tendon.

Question 1654

Topic: 7. Hand and Wrist

A 47-year-old man who is right-hand dominant reports lateral-sided elbow pain after playing golf. His symptoms developed gradually and without trauma, and he has pain with gripping and repetitive movements with the hand and wrist. Examination reveals his shoulder and wrist to be normal, and the elbow has no effusion and normal range of movement. He is tender near the lateral epicondyle, and symptoms are exacerbated with resisted wrist extension. Radiographs are shown in Figures 104a and 104b. What is the next most appropriate step in management? Review Topic

. Subtendinous epicondylar corticosteroid injection
. Corticosteroid injection into the radial tunnel
. MRI of the elbow
. Percutaneous extensor carpi radialis brevis tenotomy
. Physical therapy for an eccentric conditioning and strengthening program

Correct Answer & Explanation

. Physical therapy for an eccentric conditioning and strengthening program

Explanation

The patient has lateral epicondylitis of relatively short duration. At this early stage of disease, nonsurgical management is indicated. An eccentric physical therapeutic exercise program has been shown to have a beneficial effect on tendon biology; therefore, it would be the most appropriate initial management. While the diagnosis of lateral epicondylitis may be confused with radial tunnel syndrome, the clinical examination and history are most suggestive of the former. Corticosteroid injection has been shown to help with symptoms in short-term follow-up, but does little to affect the natural progression of the condition; it is more appropriate as a second line of treatment. MRI may be beneficial in patients with refractory disease and/or when the diagnosis is in question. Percutaneous surgical treatment is indicated only when nonsurgical measures fail to provide relief.

Question 1655

Topic: Nerve & Tendon

A 21-year-old collegiate baseball pitcher is undergoing ulnar collateral ligament (UCL) reconstruction. Which of the following technical steps regarding the ulnar nerve is currently recommended for routine primary UCL reconstructions to minimize postoperative neuropathy?

. Routine subcutaneous ulnar nerve transposition
. Routine submuscular ulnar nerve transposition
. In situ decompression without transposition unless subluxation is present
. Intramuscular transposition
. Anterior transposition superficial to the flexor pronator mass in all cases

Correct Answer & Explanation

. In situ decompression without transposition unless subluxation is present

Explanation

Current evidence suggests avoiding routine ulnar nerve transposition during primary UCL reconstruction unless there are preoperative ulnar nerve symptoms or intraoperative nerve subluxation. In situ handling decreases the risk of iatrogenic neuropathy.

Question 1656

Topic: Nerve & Tendon

An avid cyclist presents with a 3-month history of right hand weakness. Examination reveals marked atrophy of the dorsal interossei and a positive Froment sign. Sensation is completely intact over the volar and dorsal aspects of the small finger and the ulnar half of the ring finger. Hypothenar muscle bulk is normal. Where is the most likely site of ulnar nerve compression?

. Cubital tunnel
. Zone 1 of Guyon's canal
. Zone 2 of Guyon's canal
. Zone 3 of Guyon's canal
. Arcade of Struthers

Correct Answer & Explanation

. Zone 2 of Guyon's canal

Explanation

The ulnar nerve bifurcates within Guyon's canal. Zone 1 is proximal to the bifurcation (contains both motor and sensory fibers). Zone 2 contains the deep motor branch only. Zone 3 contains the superficial sensory branch only. Sparing of sensation and hypothenar muscles (which are innervated proximally in the canal or just before the deep branch dives) but severe intrinsic weakness points precisely to a deep motor branch compression in Zone 2, commonly seen in cyclists (handlebar palsy).

Question 1657

Topic: Nerve & Tendon

Which of the following physical examination findings is highly specific for distinguishing true neurogenic thoracic outlet syndrome (TOS) from a severe compressive ulnar neuropathy at the elbow (cubital tunnel syndrome)?

. A positive Tinel's sign at the medial epicondyle
. Numbness strictly isolated to the small finger
. Atrophy of the abductor pollicis brevis (APB) muscle
. A positive Froment's sign
. Clawing of the ring and small fingers

Correct Answer & Explanation

. Atrophy of the abductor pollicis brevis (APB) muscle

Explanation

True neurogenic thoracic outlet syndrome typically affects the lower trunk of the brachial plexus (C8-T1). Because T1 fibers contribute to the median nerve to innervate the thenar intrinsics, severe lower trunk TOS presents with atrophy of both the hypothenar muscles AND the thenar muscles (specifically the APB), creating the classic 'Gilliatt-Sumner hand'. Cubital tunnel syndrome only affects ulnar-innervated intrinsic muscles, sparing the median-innervated APB.

Question 1658

Topic: 7. Hand and Wrist
In the predictable progression of Scapholunate Advanced Collapse (SLAC) wrist arthritis, which specific radiocarpal or midcarpal articulation is characteristically spared, allowing for surgical salvage via proximal row carpectomy (PRC) in earlier stages?
. Radioscaphoid joint
. Radiolunate joint
. Capitolunate joint
. Scaphotrapezial joint
. Lunotriquetral joint

Correct Answer & Explanation

. Radiolunate joint

Explanation

SLAC wrist arthritis follows a very predictable sequence: Stage I involves the radial styloid and distal scaphoid; Stage II involves the entire radioscaphoid articulation; Stage III involves the capitolunate joint. The radiolunate joint is universally spared because the lunate maintains a congruous, spherical articulation with the lunate fossa of the radius, lacking abnormal shear forces. This sparing allows for a proximal row carpectomy (which creates a new articulation between the capitate and the lunate fossa) provided the capitate head is not severely arthritic.

Question 1659

Topic: Wrist & Carpus

A patient is diagnosed with a peripheral, foveal avulsion of the Triangular Fibrocartilage Complex (TFCC), classified as a Palmer 1B lesion. To restore stability to the distal radioulnar joint (DRUJ), which specific anatomical structures within the TFCC must be anatomically repaired to the fovea?

. The central articular disc
. The extensor carpi ulnaris (ECU) subsheath
. The deep (ligamentum subcruentum) fibers of the dorsal and volar radioulnar ligaments
. The ulnolunate and ulnotriquetral ligaments
. The meniscal homologue

Correct Answer & Explanation

. The deep (ligamentum subcruentum) fibers of the dorsal and volar radioulnar ligaments

Explanation

The primary stabilizers of the Distal Radioulnar Joint (DRUJ) are the dorsal and volar radioulnar ligaments. The deep fibers of these ligaments converge and attach to the fovea at the base of the ulnar styloid. An anatomic repair of a Palmer 1B foveal avulsion must reattach these deep fibers to the fovea to appropriately restore DRUJ mechanics and stability.

Question 1660

Topic: Nerve & Tendon

In the classic Oberlin transfer used to restore elbow flexion following an upper trunk (C5-C6) brachial plexus avulsion injury, which specific nerve fascicles are transferred to the motor branch of the biceps?

. Sensory fascicles of the median nerve
. Motor fascicles of the ulnar nerve innervating the flexor carpi ulnaris (FCU)
. Motor fascicles of the radial nerve innervating the triceps
. The entire medial pectoral nerve
. The thoracodorsal nerve

Correct Answer & Explanation

. Motor fascicles of the ulnar nerve innervating the flexor carpi ulnaris (FCU)

Explanation

The classic Oberlin transfer is a nerve transfer used for C5-C6 root avulsions to restore elbow flexion. It involves transferring expendable motor fascicles from the intact ulnar nerve (specifically those innervating the flexor carpi ulnaris) directly to the motor branch of the musculocutaneous nerve that innervates the biceps. A double nerve transfer (Somsak) also includes transferring median nerve fascicles (FCR/FDS) to the brachialis branch.

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