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7. Hand and Wrist MCQs

Practice Set 84 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 1661

Topic: 7. Hand and Wrist

A 60-year-old patient with severe, chronic carpal tunnel syndrome presents with profound atrophy of the thenar eminence and an inability to palmar abduct the thumb, though thumb interphalangeal joint flexion is strong. To restore thumb palmar abduction with a transfer that requires minimal motor re-education, which of the following is the most commonly indicated procedure?

. Extensor indicis proprius (EIP) transfer (Burkhalter)
. Flexor digitorum superficialis (FDS) of the ring finger transfer (modified Royle-Thompson)
. Abductor digiti minimi (ADM) transfer (Huber)
. Palmaris longus prolonged with palmar aponeurosis transfer (Camitz)
. Brachioradialis transfer

Correct Answer & Explanation

. Palmaris longus prolonged with palmar aponeurosis transfer (Camitz)

Explanation

The Camitz transfer utilizes the palmaris longus tendon, lengthened with a strip of the palmar aponeurosis, and routes it to the abductor pollicis brevis (APB) insertion. It is highly favored in cases of severe chronic carpal tunnel syndrome because it specifically restores palmar abduction (essential for a wide grasp). Furthermore, because the palmaris longus is a wrist flexor, it acts synergistically with finger flexion, meaning the patient requires almost no postoperative motor re-education to use it effectively.

Question 1662

Topic: 7. Hand and Wrist
A 55-year-old man presents with chronic wrist pain and stiffness. Radiographs demonstrate advanced joint space narrowing at the radioscaphoid and capitolunate articulations. The radiolunate joint space is completely preserved. He has failed conservative management. Which of the following surgical interventions is most appropriate?
. Proximal row carpectomy
. Four-corner fusion with scaphoid excision
. Scaphoid excision alone
. Radial styloidectomy
. Total wrist arthroplasty

Correct Answer & Explanation

. Four-corner fusion with scaphoid excision

Explanation

The clinical and radiographic presentation describes a Stage III Scapholunate Advanced Collapse (SLAC) wrist, characterized by radioscaphoid and capitolunate arthritis with a preserved radiolunate joint. Proximal row carpectomy is contraindicated because the capitate head is arthritic and would articulate poorly with the lunate fossa. Four-corner fusion (capitate, hamate, lunate, triquetrum) with scaphoid excision effectively treats the arthritic joints while preserving the healthy radiolunate joint, maintaining functional, albeit reduced, wrist motion.

Question 1663

Topic: Nerve & Tendon

When performing an autogenous cable nerve graft to bridge a 4-cm defect in the median nerve, standard surgical technique involves reversing the orientation of the harvested nerve graft. What is the primary biological rationale for this step?

. To prevent axonal escape into the terminal branches of the graft
. To align the blood vessels to allow retrograde flow
. To match the fascicular cross-sectional area of the proximal stump
. To inhibit Wallerian degeneration within the graft
. To accelerate Schwann cell migration from the distal stump

Correct Answer & Explanation

. To prevent axonal escape into the terminal branches of the graft

Explanation

Autogenous nerve grafts (such as the sural nerve) have multiple branching points. If the graft is placed in its original prograde orientation, regenerating axons from the proximal stump can track down these branches and escape into the surrounding soft tissue, leading to a loss of axons reaching the distal stump and potential neuroma formation. Reversing the graft ensures that any branches point proximally, preventing axonal escape and funneling all regenerating axons directly toward the distal nerve stump.

Question 1664

Topic: 7. Hand and Wrist

A 32-year-old snowboarder sustains a high-energy fall onto an outstretched hand and presents with a volar Barton's fracture of the distal radius. The carpus is subluxated volarly along with the marginal fracture fragment. Which of the following ligamentous structures remains attached to the volar marginal fragment and acts as the primary deforming force tethering the carpus to it?

. Volar radiocarpal ligaments
. Dorsal radiocarpal ligaments
. Triangular fibrocartilage complex (TFCC)
. Scapholunate interosseous ligament
. Transverse carpal ligament

Correct Answer & Explanation

. Volar radiocarpal ligaments

Explanation

A volar Barton's fracture is a shear fracture of the volar margin of the distal radius. The volar radiocarpal ligaments (which include the radioscaphocapitate, long radiolunate, and short radiolunate ligaments) originate on the volar rim of the distal radius. When this rim fractures, these strong stout ligaments remain attached to the fragment, causing the carpus to follow the fragment volarly and proximally due to the pull of the extrinsic flexor tendons.

Question 1665

Topic: 7. Hand and Wrist
A 28-year-old manual laborer is diagnosed with Stage IIIA Kienböck's disease. Radiographs show lunate sclerosis and fragmentation with lunate collapse, but no fixed scaphoid rotation or carpal collapse. His ulnar variance is minus 3 mm. Which of the following is the most appropriate surgical treatment?
. Proximal row carpectomy
. Radial shortening osteotomy
. Scaphocapitate arthrodesis
. Total wrist arthroplasty
. Immobilization and NSAIDs

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

In Kienböck's disease (avascular necrosis of the lunate), Stage IIIA indicates lunate collapse but normal carpal alignment (no fixed scaphoid rotation or carpal height loss). In a patient with negative ulnar variance, joint leveling procedures such as a radial shortening osteotomy or ulnar lengthening are the gold standard. These procedures decompress the radiolunate joint, reducing forces across the lunate and frequently resulting in pain relief and prevention of further collapse. Salvage procedures (PRC or limited fusions) are reserved for later stages (IIIB or IV).

Question 1666

Topic: 7. Hand and Wrist

A 25-year-old professional golfer complains of painful snapping on the ulnar side of his wrist during the downswing. Examination reveals subluxation of the extensor carpi ulnaris (ECU) tendon over the ulnar styloid during forearm supination, ulnar deviation, and wrist flexion. This pathology is primarily due to a tear or attenuation of which of the following structures?

. Extensor retinaculum
. ECU subsheath
. Triangular fibrocartilage complex
. Dorsal radioulnar ligament
. Volar ulnocarpal ligament

Correct Answer & Explanation

. ECU subsheath

Explanation

The extensor carpi ulnaris (ECU) tendon is stabilized in the sixth dorsal compartment by a distinct fascial structure known as the ECU subsheath. This subsheath firmly attaches the tendon to the ulnar groove. The extensor retinaculum lies superficial to the ECU subsheath but does not primarily prevent ECU subluxation. A tear of the ECU subsheath allows the tendon to snap out of its groove during forearm supination, wrist flexion, and ulnar deviation.

Question 1667

Topic: Nerve & Tendon
A 22-year-old rugby player presents 3 days after injuring his right ring finger when grabbing an opponent's jersey. He is unable to actively flex the distal interphalangeal (DIP) joint. Physical examination reveals tenderness in the palm, and radiographs are negative for a fracture. Based on the Leddy-Packer classification, what is the pathophysiology and recommended timing for surgical repair?
. Type I injury; the tendon is retracted to the PIP joint; repair within 6 weeks
. Type I injury; the tendon is retracted to the palm with disrupted vincula; repair within 7-10 days
. Type II injury; the tendon is retracted to the PIP joint with disrupted vincula; repair within 7-10 days
. Type III injury; a large bony avulsion prevents retraction past the A4 pulley; repair within 6 weeks
. Type IV injury; simultaneous avulsion of the FDP and FDS tendons; immediate repair

Correct Answer & Explanation

. Type I injury; the tendon is retracted to the palm with disrupted vincula; repair within 7-10 days

Explanation

The patient has a "Jersey finger" (flexor digitorum profundus avulsion). A Leddy-Packer Type I injury involves the tendon retracting all the way into the palm. Because it retracts this far, both the long and short vincula are completely torn, severing the tendon's blood supply. To prevent severe tendon necrosis and permanent contracture, Type I injuries must be surgically repaired early, ideally within 7 to 10 days. A Type II retracts to the PIP joint (held by intact long vinculum) and Type III involves a large bony fragment catching at the A4 pulley; both have preserved blood supply and can be repaired slightly later if necessary.

Question 1668

Topic: 7. Hand and Wrist

A 65-year-old woman with neglected, severe carpal tunnel syndrome presents with profound thenar atrophy and complete inability to oppose her thumb. The surgeon plans a carpal tunnel release combined with a Bunnell (or Royle-Thompson) opponensplasty. Which of the following describes the most common tendon transfer and pulley utilized in this specific technique to restore true thumb opposition?

. Flexor digitorum superficialis (FDS) of the ring finger routed around the flexor carpi ulnaris (FCU) and pisiform
. Palmaris longus (PL) extended with palmar fascia without a pulley
. Extensor indicis proprius (EIP) routed around the distal ulna
. Flexor carpi radialis (FCR) routed through the interosseous membrane
. Abductor digiti minimi (ADM) transfer flipped on its neurovascular pedicle

Correct Answer & Explanation

. Flexor digitorum superficialis (FDS) of the ring finger routed around the flexor carpi ulnaris (FCU) and pisiform

Explanation

True thumb opposition requires abduction, flexion, and pronation. To achieve the correct vector of pull (from the thumb metacarpal/proximal phalanx directed toward the pisiform), a pulley is necessary on the ulnar aspect of the wrist. The Bunnell or Royle-Thompson opponensplasty classically utilizes the flexor digitorum superficialis (FDS) of the ring finger. The tendon is passed around the distal flexor carpi ulnaris (FCU) tendon and pisiform (which act as a pulley) to direct the line of pull correctly. The Camitz transfer (PL to APB) provides excellent abduction but lacks the ulnar vector required for true opposition.

Question 1669

Topic: Wrist & Carpus

A 26-year-old male presents with a persistent scaphoid nonunion and avascular necrosis of the proximal pole, featuring a humpback deformity and a 6 mm bone defect. Which of the following graft options provides both the structural integrity to correct the deformity and the robust blood supply necessary for this specific scenario?

. 1,2 Intercompartmental supraretinacular artery (ICSRA) pedicled graft
. Free vascularized medial femoral condyle (MFC) bone graft
. Non-vascularized iliac crest bone graft
. Vascularized distal radius bone graft pedicled on the pronator quadratus
. Demineralized bone matrix with platelet-rich plasma

Correct Answer & Explanation

. Free vascularized medial femoral condyle (MFC) bone graft

Explanation

The free vascularized medial femoral condyle (MFC) graft provides necessary structural support to correct large defects (>5 mm) and humpback deformities, along with a robust blood supply essential for healing AVN.

Question 1670

Topic: Nerve & Tendon

To restore elbow flexion in a patient with a traumatic C5-C6 brachial plexus root avulsion, an Oberlin transfer is planned. Which of the following describes the classic donor and recipient nerves in this procedure?

. A portion of the intercostal nerves transferred to the musculocutaneous nerve
. A redundant fascicle of the ulnar nerve transferred to the biceps motor branch
. The spinal accessory nerve transferred to the suprascapular nerve
. A fascicle of the median nerve transferred to the brachialis motor branch
. The thoracodorsal nerve transferred to the musculocutaneous nerve

Correct Answer & Explanation

. A redundant fascicle of the ulnar nerve transferred to the biceps motor branch

Explanation

The classic Oberlin transfer utilizes a redundant fascicle from the ulnar nerve (usually the FCU motor fascicle) which is transferred directly to the biceps motor branch of the musculocutaneous nerve.

Question 1671

Topic: Wrist & Carpus

During an Adams-Berger anatomic reconstruction of the distal radioulnar joint (DRUJ) for chronic instability, a tendon graft is utilized to recreate the palmar and dorsal radioulnar ligaments. Where are the graft ends passed through the radius?

. Through tunnels at the dorsal and volar margins of the sigmoid notch
. Directly through the anatomic center of the radial styloid
. Around Lister's tubercle and sutured to the brachioradialis insertion
. Through the central medullary canal of the distal radius
. Subperiosteally along the volar metaphysis of the radius

Correct Answer & Explanation

. Through tunnels at the dorsal and volar margins of the sigmoid notch

Explanation

The Adams-Berger procedure reconstructs the radioulnar ligaments using a graft passed through an isometric tunnel in the ulnar fovea and secured through tunnels at the dorsal and volar margins of the sigmoid notch.

Question 1672

Topic: 7. Hand and Wrist

A 42-year-old carpenter presents with cold intolerance and a pulsatile mass in the hypothenar eminence of his dominant hand. Angiography reveals occlusion and aneurysmal dilation of the superficial palmar branch of the ulnar artery. Which bony structure contributes to the pathomechanics of this specific condition?

. Hook of the hamate
. Pisiform
. Trapezial ridge
. Lister's tubercle
. Base of the fifth metacarpal

Correct Answer & Explanation

. Hook of the hamate

Explanation

Hypothenar hammer syndrome involves thrombosis or aneurysm of the superficial palmar branch of the ulnar artery as it is repetitively crushed against the hook of the hamate during manual labor.

Question 1673

Topic: 7. Hand and Wrist

In Scapholunate Advanced Collapse (SLAC) of the wrist, progressive degenerative changes predictably involve specific articular surfaces while sparing others. Which radiocarpal articulation is classically spared from degenerative arthritis in the SLAC wrist?

. Radioscaphoid
. Radiolunate
. Capitolunate
. Scaphocapitate
. Scaphotrapezial

Correct Answer & Explanation

. Radiolunate

Explanation

The radiolunate joint is typically spared in SLAC wrists because the lunate's concentric articulation with the spherical lunate fossa of the radius maintains normal congruent mechanics despite surrounding instability.

Question 1674

Topic: 7. Hand and Wrist

A patient presents with an inability to form an "OK" sign with their thumb and index finger but maintains normal sensation throughout the hand. Which of the following muscles is typically spared in a complete, isolated anterior interosseous nerve (AIN) palsy?

. Flexor pollicis longus
. Flexor digitorum profundus to the index finger
. Flexor digitorum profundus to the middle finger
. Pronator quadratus
. Flexor carpi radialis

Correct Answer & Explanation

. Flexor carpi radialis

Explanation

The AIN innervates the FPL, the FDP to the index and middle fingers, and the pronator quadratus. The flexor carpi radialis (FCR) is innervated by the main branch of the median nerve proximal to the AIN origin.

Question 1675

Topic: 7. Hand and Wrist

A patient with a chronic lower brachial plexus injury (C8-T1) exhibits a severe claw hand deformity. A modified Stiles-Bunnell tendon transfer is planned to restore intrinsic function. Which of the following muscles is utilized as the donor in this procedure?

. Extensor carpi radialis brevis
. Flexor digitorum superficialis
. Brachioradialis
. Pronator teres
. Extensor indicis proprius

Correct Answer & Explanation

. Flexor digitorum superficialis

Explanation

The Stiles-Bunnell procedure utilizes a Flexor Digitorum Superficialis (FDS) tendon split into multiple slips and transferred to the lateral bands to correct clawing in intrinsic-minus hands.

Question 1676

Topic: 7. Hand and Wrist

In a Bennett fracture-dislocation of the thumb, the metacarpal shaft is displaced by the deforming forces of specific muscles. Which muscle is primarily responsible for the dorsal, proximal, and radial displacement of the first metacarpal shaft?

. Abductor pollicis longus (APL)
. Abductor pollicis brevis (APB)
. Adductor pollicis (AP)
. Extensor pollicis longus (EPL)
. Flexor pollicis longus (FPL)

Correct Answer & Explanation

. Abductor pollicis longus (APL)

Explanation

The APL inserts on the base of the first metacarpal and exerts a strong proximal and radial pull on the shaft fragment, resulting in the classic displacement seen in a Bennett fracture.

Question 1677

Topic: Nerve & Tendon

Vascularized nerve grafts (e.g., vascularized ulnar nerve graft) are considered theoretically superior to standard non-vascularized nerve autografts in which of the following specific clinical scenarios?

. Bridging nerve defects less than 3 cm in length
. Reconstructing digital nerve gaps in a well-vascularized finger bed
. Bridging large defects in heavily scarred or irradiated tissue beds
. Repairing the recurrent motor branch of the median nerve
. Performing primary nerve repair with excessive tension

Correct Answer & Explanation

. Bridging large defects in heavily scarred or irradiated tissue beds

Explanation

Vascularized nerve grafts maintain their own blood supply and do not rely on creeping angiogenesis from the surrounding bed, making them ideal for large gaps in poorly vascularized, scarred, or irradiated tissues.

Question 1678

Topic: Wrist & Carpus

A 25-year-old male presents with a scaphoid nonunion demonstrating a humpback deformity and avascular necrosis of the proximal pole on MRI. The proximal fragment measures 6 mm. Which of the following is the most appropriate vascularized bone graft to restore scaphoid geometry and maximize the likelihood of union?

. 1,2 intercompartmental supraretinacular artery (1,2 ICSRA) graft
. Pedicled pronator quadratus bone graft
. Free medial femoral condyle vascularized bone graft
. Pedicled capitate vascularized bone graft
. Non-vascularized iliac crest bone graft

Correct Answer & Explanation

. Free medial femoral condyle vascularized bone graft

Explanation

A free medial femoral condyle vascularized bone graft provides structural corticocancellous bone capable of correcting a humpback deformity while revascularizing the proximal pole. Pedicled distal radius grafts like the 1,2 ICSRA are often too thin to correct significant humpback deformities and have higher failure rates in advanced AVN.

Question 1679

Topic: 7. Hand and Wrist
A 45-year-old manual laborer presents with Stage III Scapholunate Advanced Collapse (SLAC). Radiographs reveal advanced arthritis at the radioscaphoid and capitolunate joints, with sparing of the radiolunate joint. What is the most appropriate definitive surgical management?
. Proximal row carpectomy (PRC)
. Scaphoid excision and four-corner arthrodesis
. Radial styloidectomy
. Total wrist arthroplasty
. Scaphotrapeziotrapezoid (STT) arthrodesis

Correct Answer & Explanation

. Proximal row carpectomy (PRC)

Explanation

Stage III SLAC wrist involves the capitolunate joint, which makes proximal row carpectomy (PRC) contraindicated because the capitate will articulate directly with the lunate fossa. Scaphoid excision with four-corner fusion relies on the preserved radiolunate joint.

Question 1680

Topic: Nerve & Tendon

A 19-year-old rugby player sustains a closed jersey finger injury of the ring finger. Radiographs show no fracture, and the flexor digitorum profundus (FDP) tendon is palpable in the palm. To prevent irreversible contracture and tendon necrosis due to disrupted vincular blood supply, definitive repair should ideally be performed within what timeframe?

. 24 hours
. 7 to 10 days
. 3 to 4 weeks
. 6 to 8 weeks
. 3 months

Correct Answer & Explanation

. 7 to 10 days

Explanation

A Type I FDP avulsion retracts into the palm, rupturing both the short and long vincula and severely compromising the tendon's blood supply. Repair should be performed within 7 to 10 days to prevent tendon necrosis and irreversible contracture.

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