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7. Hand and Wrist MCQs

Practice Set 86 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 1701

Topic: 7. Hand and Wrist

A 40-year-old male is evaluated for chronic wrist pain. Radiographs reveal Scaphoid Nonunion Advanced Collapse (SNAC). Which of the following carpal articulations is typically the FIRST to demonstrate degenerative arthritic changes in a SNAC wrist?

. Radiolunate joint
. Capitolunate joint
. Articulation between the distal scaphoid fragment and the radial styloid
. Articulation between the proximal scaphoid fragment and the scaphoid fossa of the radius
. Lunotriquetral joint

Correct Answer & Explanation

. Articulation between the distal scaphoid fragment and the radial styloid

Explanation

In a Scaphoid Nonunion Advanced Collapse (SNAC) wrist, the proximal scaphoid fragment typically remains attached to the lunate via the intact scapholunate interosseous ligament and maintains relative congruency with the radius. The distal fragment rotates and flexes, leading to abnormal kinematics and localized impingement. Consequently, the first joint to degenerate (Stage I SNAC) is the articulation between the distal scaphoid fragment and the radial styloid. The radiolunate joint is characteristically spared in both SNAC and SLAC (Scapholunate Advanced Collapse) patterns.

Question 1702

Topic: 7. Hand and Wrist

A 45-year-old woman presents with persistent, vague volar forearm pain and paresthesias in her thumb, index, and middle fingers. She lacks nocturnal pain. Physical examination reveals a negative Phalen's test but a positive Tinel's sign over the proximal volar forearm. Which of the following specific physical exam findings differentiates Pronator Syndrome from Carpal Tunnel Syndrome (CTS)?

. Weakness of the flexor pollicis longus (FPL)
. Sensory deficit over the thenar eminence
. Weakness of the abductor pollicis brevis (APB)
. Positive Froment's sign
. Inability to form a tight fist

Correct Answer & Explanation

. Sensory deficit over the thenar eminence

Explanation

Pronator syndrome is a proximal compression neuropathy of the median nerve. The palmar cutaneous branch of the median nerve, which supplies sensation to the thenar eminence, arises approximately 5 cm proximal to the transverse carpal ligament and travels superficial to it. Therefore, sensation over the thenar eminence is spared in Carpal Tunnel Syndrome (CTS) but can be decreased in Pronator Syndrome. Nocturnal pain is classic for CTS, while aching forearm pain exacerbated by activity is classic for Pronator Syndrome.

Question 1703

Topic: 7. Hand and Wrist
A 22-year-old rugby player presents with an inability to actively flex the distal interphalangeal (DIP) joint of his ring finger after grabbing an opponent's jersey. Radiographs reveal a bony fragment avulsed from the volar base of the distal phalanx. Surgical exploration demonstrates the flexor digitorum profundus (FDP) tendon is retracted into the palm, separate from the bony avulsion fragment. What is the correct classification of this injury?
. Leddy and Packer Type I
. Leddy and Packer Type II
. Leddy and Packer Type III
. Leddy and Packer Type IV
. Leddy and Packer Type V

Correct Answer & Explanation

. Leddy and Packer Type IV

Explanation

This is a Leddy and Packer Type IV Jersey finger. Type I involves FDP retraction to the palm (blood supply compromised, needs repair within 7-10 days). Type II involves retraction to the PIP joint level (held by vincula). Type III is a large bony avulsion that catches at the A4 pulley. Type IV is a bony avulsion fracture with concurrent avulsion of the FDP tendon directly off the bony fragment, allowing the tendon to retract further proximal than the fracture fragment.

Question 1704

Topic: 7. Hand and Wrist
A 35-year-old female presents with persistent wrist pain. Radiographs reveal advanced Kienbock's disease. The lunate is significantly collapsed and fragmented, the carpal height ratio is decreased, and the scaphoid is flexed (cortical ring sign). Ulnar variance is neutral. Which of the following surgical interventions is generally contraindicated in this specific stage of the disease?
. Proximal row carpectomy (PRC)
. Scaphocapitate (SC) fusion
. Scaphotrapeziotrapezoid (STT) fusion
. Radial shortening osteotomy (Joint Leveling)
. Total wrist arthrodesis

Correct Answer & Explanation

. Proximal row carpectomy (PRC)

Explanation

The patient has Lichtman Stage IIIB Kienbock's disease, defined by lunate fragmentation/collapse with secondary carpal instability (scaphoid flexion and decreased carpal height). Joint leveling procedures (like radial shortening osteotomy) are indicated for earlier stages (Stage II or IIIA, especially with negative ulnar variance) to unload the lunate. In Stage IIIB, because fixed carpal collapse and instability have already occurred, altering ulnar variance will not restore carpal mechanics or address the instability. Therefore, salvage procedures such as PRC, STT fusion, or SC fusion are required.

Question 1705

Topic: Wrist & Carpus

You are performing a volar (Henry) approach to the distal radius for open reduction and internal fixation of a distal radius fracture. After developing the interval between the flexor carpi radialis (FCR) tendon and the radial artery, which muscle must be reflected from radial to ulnar to adequately expose the volar surface of the distal radius?

. Flexor digitorum superficialis (FDS)
. Flexor pollicis longus (FPL)
. Pronator quadratus (PQ)
. Brachioradialis
. Flexor carpi ulnaris (FCU)

Correct Answer & Explanation

. Pronator quadratus (PQ)

Explanation

During the volar Henry approach to the distal radius, the deep dissection involves elevating the pronator quadratus (PQ) muscle. The PQ is carefully elevated from its radial insertion (leaving a small cuff of tissue for later repair) and reflected ulnarly to expose the volar cortex of the distal radius. This protects the anterior interosseous nerve (AIN) and artery, which travel deep to the PQ.

Question 1706

Topic: Wrist & Carpus

A 55-year-old male with a history of a remote distal radius fracture presents with difficulty extending his fingers and thumb, but normal sensory examination. He exhibits pain approximately 4 cm distal to the lateral epicondyle on resisted supination. Which structure is the most common site of compression for the nerve affected in this syndrome?

. Ligament of Struthers
. Lacertus fibrosus
. Arcade of Frohse
. Leash of Henry
. Distal edge of the supinator muscle

Correct Answer & Explanation

. Arcade of Frohse

Explanation

The clinical presentation describes Posterior Interosseous Nerve (PIN) syndrome, characterized by weakness in thumb and finger extension without sensory loss (as the superficial radial nerve branches off proximal to the compression). The most common site of PIN compression is the Arcade of Frohse, which is the thickened proximal aponeurotic edge of the superficial head of the supinator muscle.

Question 1707

Topic: 7. Hand and Wrist

A 50-year-old patient undergoes an LRTI (Ligament Reconstruction and Tendon Interposition) arthroplasty utilizing the Flexor Carpi Radialis (FCR) for advanced thumb carpometacarpal (CMC) joint arthritis. Six months post-operatively, the patient reports new-onset, deep aching pain at the base of the thumb that limits pinch strength. Radiographs show proximal migration of the first metacarpal. What is the most likely cause of this patient's pain?

. Neuroma of the palmar cutaneous branch of the median nerve
. Impingement of the first metacarpal base against the scaphoid
. Attritional rupture of the interpositioned FCR tendon
. Avascular necrosis of the first metacarpal base
. Complex regional pain syndrome (CRPS)

Correct Answer & Explanation

. Impingement of the first metacarpal base against the scaphoid

Explanation

A well-recognized complication of thumb CMC arthroplasty (such as trapeziectomy with or without LRTI) is subsidence (proximal migration) of the first metacarpal. If significant subsidence occurs, the base of the first metacarpal can impinge on the scaphoid (or distal radius/trapezoid), leading to pain, decreased grip/pinch strength, and loss of thumb length.

Question 1708

Topic: 7. Hand and Wrist

During carpal instability evaluation, a VISI (Volar Intercalated Segment Instability) pattern is identified on lateral radiographs. This deformity is primarily initiated by the disruption of which intrinsic carpal ligament?

. Scapholunate interosseous ligament
. Lunotriquetral interosseous ligament
. Radioscaphocapitate ligament
. Dorsal radiocarpal ligament
. Space of Poirier

Correct Answer & Explanation

. Lunotriquetral interosseous ligament

Explanation

A VISI (Volar Intercalated Segment Instability) pattern occurs primarily due to an injury to the Lunotriquetral (LT) interosseous ligament. Once disconnected from the extension force of the triquetrum, the lunate is allowed to rotate into volar flexion under the influence of the intact scaphoid. Conversely, DISI (Dorsal Intercalated Segment Instability) is caused by injury to the Scapholunate (SL) ligament.

Question 1709

Topic: Wrist & Carpus

A patient with Ulnar Impaction Syndrome presents with chronic ulnar-sided wrist pain. Diagnostic arthroscopy reveals a Palmer Type 2C tear of the Triangular Fibrocartilage Complex (TFCC), characterized by a central perforation, chondromalacia of the ulnar head, and a complete tear of the lunotriquetral (LT) interosseous ligament. Ulnar variance is measured at +3 mm. What is the most appropriate surgical treatment?

. Arthroscopic Wafer procedure
. Ulnar shortening osteotomy
. Darrach procedure
. Sauve-Kapandji procedure
. Open direct repair of the central TFCC perforation

Correct Answer & Explanation

. Ulnar shortening osteotomy

Explanation

In a patient with Ulnar Impaction Syndrome and positive ulnar variance of +3 mm, especially in the presence of a concomitant lunotriquetral (LT) ligament tear (Palmer 2C), an ulnar shortening osteotomy (USO) is the treatment of choice. USO unloads the ulnocarpal joint and has the added biomechanical advantage of tightening the ulnocarpal ligaments (ulnolunate and ulnotriquetral), which helps stabilize the incompetent LT joint. The Wafer procedure is typically reserved for positive variance of <2 mm and does not tighten the ulnocarpal ligaments. Central TFCC tears (degenerative) are typically debrided, not repaired.

Question 1710

Topic: 7. Hand and Wrist

A 24-year-old male presents with a persistent scaphoid nonunion 2 years after conservative management of a proximal pole fracture. MRI confirms avascular necrosis of the proximal pole. There is no evidence of carpal collapse or radiocarpal arthritis. Which of the following is the most appropriate grafting procedure to optimize the chance of union?

. Free vascularized medial femoral condyle (MFC) bone graft
. 1,2 Intercompartmental supraretinacular artery (ICSRA) pedicled graft
. Non-vascularized iliac crest bone graft
. Proximal row carpectomy
. Scaphoid excision and four-corner fusion

Correct Answer & Explanation

. Free vascularized medial femoral condyle (MFC) bone graft

Explanation

For a proximal pole scaphoid nonunion with avascular necrosis and no arthritis, a vascularized bone graft is indicated. The free vascularized medial femoral condyle (MFC) graft has demonstrated superior union rates in this specific scenario compared to the pedicled 1,2 ICSRA graft, primarily because the MFC graft provides a robust, independent blood supply and structural corticocancellous bone. Non-vascularized grafts have an unacceptably high failure rate in the setting of AVN. Salvage procedures (PRC or 4-corner fusion) are reserved for cases with established arthritis (SLAC/SNAC wrist).

Question 1711

Topic: 7. Hand and Wrist
A 48-year-old manual laborer presents with chronic wrist pain after an untreated scapholunate injury 10 years ago. Radiographs reveal narrowing of the radioscaphoid joint and the capitolunate joint. The radiolunate joint is well preserved. Which of the following is the most appropriate definitive surgical intervention?
. Scaphoid excision and four-corner arthrodesis
. Proximal row carpectomy (PRC)
. Total wrist arthrodesis
. Scaphoid excision and capitolunate arthrodesis
. Radial styloidectomy

Correct Answer & Explanation

. Scaphoid excision and four-corner arthrodesis

Explanation

This patient has Scapholunate Advanced Collapse (SLAC) Stage III, characterized by arthritis involving the radioscaphoid and capitolunate joints, while the radiolunate joint is characteristically spared. The treatment of choice is scaphoid excision and four-corner fusion (capitate, lunate, triquetrum, hamate). Proximal row carpectomy (PRC) is contraindicated in SLAC Stage III because it relies on articulating the capitate head with the lunate fossa; if the capitate head is arthritic (as in Stage III), PRC will lead to continued pain and failure.

Question 1712

Topic: Nerve & Tendon

A 32-year-old woman presents with severe, excruciating pain in the tip of her left index finger, which is severely exacerbated by cold weather. On exam, there is pinpoint tenderness beneath the nail bed. Application of a tourniquet to the base of the finger completely relieves her pain during the examination. This specific physical exam finding is known as:

. Hildreth's sign
. Love's test
. Tinel's sign
. Finkelstein's test
. Froment's sign

Correct Answer & Explanation

. Hildreth's sign

Explanation

The clinical picture is classic for a glomus tumor. Hildreth's sign is the relief of pain upon the application of a tourniquet to the ischemic digit, which is highly specific for a glomus tumor. Love's test refers to pinpoint pain reproducible by applying localized pressure (e.g., with the tip of a paperclip) over the lesion. Cold sensitivity is the third component of the classic triad for glomus tumors.

Question 1713

Topic: 7. Hand and Wrist

Following a flexor tendon laceration in Zone II of the hand, careful repair and preservation of the flexor tendon sheath are required. To prevent bowstringing of the flexor tendons and significant loss of mechanical advantage, which two annular pulleys are the most critical to preserve or reconstruct?

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

Correct Answer & Explanation

. A2 and A4

Explanation

The flexor tendon sheath consists of 5 annular (A) and 3 cruciform (C) pulleys. The A2 pulley (located over the proximal phalanx) and the A4 pulley (located over the middle phalanx) are biomechanically the most critical for preventing bowstringing of the flexor tendons during digit flexion. Disruption of these pulleys leads to a significant decrease in the mechanical advantage and excursion efficiency of the tendons.

Question 1714

Topic: 7. Hand and Wrist

A 55-year-old woman presents with a recurrent, fluid-filled mass on the dorsal aspect of the distal interphalangeal (DIP) joint of her right middle finger. She complains of progressive grooving of the adjacent fingernail. To minimize the risk of recurrence during surgical excision, which of the following must be included in the procedure?

. Simple aspiration and corticosteroid injection
. Excision of the cyst wall only
. Excision of the cyst and the underlying marginal osteophyte
. DIP joint arthrodesis
. Amputation of the distal phalanx

Correct Answer & Explanation

. Excision of the cyst and the underlying marginal osteophyte

Explanation

Mucous cysts of the DIP joint are typically associated with underlying osteoarthritis. They originate from the joint capsule and are often intimately related to marginal osteophytes. To minimize the risk of recurrence, surgical management must include not only excision of the cyst and its stalk communicating with the joint but also debridement/excision of the underlying osteophyte. Failure to remove the osteophyte is the most common cause of recurrence.

Question 1715

Topic: 7. Hand and Wrist
A 26-year-old male presents with chronic wrist pain 3 years after a fall on an outstretched hand. Radiographs show a scaphoid waist nonunion with early degenerative changes localized strictly to the articulation between the radial styloid and the distal pole of the scaphoid. The midcarpal joint is preserved. This corresponds to which stage of Scaphoid Nonunion Advanced Collapse (SNAC), and what is the recommended bone-preserving treatment?
. SNAC Stage I; Radial styloidectomy, scaphoid ORIF, and bone grafting
. SNAC Stage II; Proximal row carpectomy
. SNAC Stage III; Four-corner fusion
. SNAC Stage I; Total wrist arthrodesis
. SNAC Stage II; Scaphoid excision and capitolunate fusion

Correct Answer & Explanation

. SNAC Stage I; Radial styloidectomy, scaphoid ORIF, and bone grafting

Explanation

SNAC Stage I is characterized by arthritis localized to the radioscaphoid joint, specifically between the radial styloid and the distal pole of the scaphoid. Treatment for Stage I involves a radial styloidectomy to remove the arthritic impingement, combined with scaphoid ORIF and bone grafting to address the nonunion. Stage II involves the scaphocapitate joint, and Stage III involves the periscaphoid joints and capitolunate joint.

Question 1716

Topic: 7. Hand and Wrist
A 35-year-old man presents with dorsal wrist pain. Radiographs demonstrate negative ulnar variance and sclerosis of the lunate with coronal fracture lines, but the lunate height is preserved and there is no fixed carpal collapse (Lichtman Stage IIIA Kienböck's disease). Which of the following is the most appropriate initial surgical management?
. Distal radius core decompression
. Joint leveling procedure (radial shortening osteotomy)
. Proximal row carpectomy
. Total wrist fusion
. Excision of the lunate alone

Correct Answer & Explanation

. Joint leveling procedure (radial shortening osteotomy)

Explanation

In Kienböck's disease (avascular necrosis of the lunate), treatment depends on the Lichtman stage and ulnar variance. Stage IIIA involves lunate fragmentation/collapse without fixed carpal collapse. In a patient with negative ulnar variance, a joint leveling procedure (such as a radial shortening osteotomy) is the treatment of choice to decompress the lunate by shifting loads to the ulnocarpal joint. Salvage procedures (PRC, fusion) are reserved for Stage IIIB (with fixed carpal collapse) or Stage IV (radiocarpal arthritis).

Question 1717

Topic: Wrist & Carpus
A 40-year-old carpenter presents with ulnar-sided wrist pain. Radiographs show a +3 mm ulnar variance with cystic changes in the lunate and ulnar head. MRI demonstrates a central perforation of the triangular fibrocartilage complex (TFCC). Arthroscopy confirms the TFCC tear but shows pristine, intact articular cartilage at the distal radioulnar joint (DRUJ). What is the most appropriate surgical treatment?
. Darrach procedure
. Sauvé-Kapandji procedure
. Ulnar shortening osteotomy
. Ulnar head replacement
. Arthroscopic wafer procedure

Correct Answer & Explanation

. Ulnar shortening osteotomy

Explanation

This patient has Ulnar Impaction Syndrome with a large positive ulnar variance (+3 mm) and intact DRUJ cartilage. The gold standard treatment for ulnar impaction with intact DRUJ cartilage and >2 mm of positive variance is an ulnar shortening osteotomy (USO). The arthroscopic wafer procedure is generally limited to patients with <2 mm of positive variance. The Darrach and Sauvé-Kapandji procedures are salvage operations indicated when there is concurrent DRUJ arthritis, which this patient does not have.

Question 1718

Topic: 7. Hand and Wrist
A 42-year-old male with rheumatoid arthritis presents with a finger deformity characterized by PIP joint flexion and DIP joint hyperextension. Which of the following anatomical disruptions is the primary initiator of this specific deformity?
. Rupture of the flexor digitorum superficialis tendon
. Disruption or attenuation of the central slip of the extensor mechanism
. Attenuation of the volar plate at the PIP joint
. Rupture of the terminal extensor tendon
. Contracture of the oblique retinacular ligament

Correct Answer & Explanation

. Disruption or attenuation of the central slip of the extensor mechanism

Explanation

This deformity (PIP flexion and DIP hyperextension) is a Boutonnière deformity. It is primarily initiated by the disruption or attenuation of the central slip of the extensor tendon at its insertion on the middle phalanx. This allows the lateral bands to subluxate volarly to the axis of rotation of the PIP joint, causing them to act as PIP flexors while continuing to exert extension force on the DIP joint.

Question 1719

Topic: Hand Trauma & Infection

A 39-year-old butcher presents to the ER 48 hours after sustaining a small puncture wound to his right index finger. He exhibits signs of pyogenic flexor tenosynovitis. Which of the following is NOT one of Kanavel's cardinal signs for this condition?

. Finger held in slight flexion
. Fusiform swelling of the entire digit
. Tenderness strictly along the flexor tendon sheath
. Pain with active flexion of the digit
. Pain with passive extension of the digit

Correct Answer & Explanation

. Pain with active flexion of the digit

Explanation

Kanavel's four cardinal signs of infectious flexor tenosynovitis are: 1) Finger held in slight resting flexion, 2) Fusiform (sausage-like) swelling of the digit, 3) Tenderness along the entire course of the flexor tendon sheath, and 4) Severe pain on passive extension of the digit. Pain with active flexion is not considered one of the specific cardinal signs, as passive extension is the hallmark test that stretches the inflamed sheath.

Question 1720

Topic: 7. Hand and Wrist

When reconstructing a soft tissue defect on the volar surface of the hand, a surgeon must decide between a split-thickness skin graft (STSG) and a full-thickness skin graft (FTSG). Compared to an STSG, what is a major advantage of utilizing an FTSG in the hand?

. It has a lower metabolic requirement for survival during the initial imbibition phase.
. It undergoes less primary contraction upon harvest.
. It undergoes less secondary contraction during the healing phase.
. It is more likely to survive on a poorly vascularized wound bed.
. It revascularizes much faster due to the thinner dermal layer.

Correct Answer & Explanation

. It undergoes less secondary contraction during the healing phase.

Explanation

A full-thickness skin graft (FTSG) contains the entire epidermis and dermis. Because of the thicker dermis, it undergoes MORE primary contraction (immediate recoil upon harvest) but LESS secondary contraction (contracture during wound healing) compared to an STSG. Less secondary contraction is a significant advantage in the hand and joint surfaces to prevent flexion contractures. STSG requires less metabolic demand and survives better on poorer beds, but it shrinks and contracts significantly over time.

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