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7. Hand and Wrist MCQs

Practice Set 87 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 1721

Topic: Nerve & Tendon
A 50-year-old female with long-standing rheumatoid arthritis develops a swan neck deformity in her long finger. The intrinsic tightness test is positive. If left untreated, what is the primary structural pathology that permits the hyperextension at the PIP joint in a swan neck deformity?
. Volar subluxation of the lateral bands at the PIP joint
. Attenuation or rupture of the volar plate at the PIP joint
. Rupture of the central slip of the extensor tendon
. Contracture of the terminal extensor tendon at the DIP joint
. Laxity of the collateral ligaments at the MCP joint

Correct Answer & Explanation

. Attenuation or rupture of the volar plate at the PIP joint

Explanation

A swan neck deformity consists of PIP hyperextension and DIP flexion. The PIP hyperextension is permitted by the attenuation or stretching of the volar plate at the PIP joint. In RA, synovitis stretches this capsuloligamentous structure, allowing the dorsal extensor forces (often exacerbated by intrinsic tightness or MCP subluxation) to pull the joint into severe hyperextension. Volar subluxation of the lateral bands and central slip rupture cause Boutonnière deformity, not swan neck.

Question 1722

Topic: 7. Hand and Wrist
A 28-year-old male sustains a high-energy fall onto an extended, ulnarly deviated wrist. Radiographs reveal a dorsal perilunate dislocation. According to Mayfield's progressive stages of perilunate instability, what is the correct anatomical sequence of ligamentous disruption?
. Scapholunate, lunotriquetral, dorsal radiocarpal, volar radiolunate
. Scapholunate, capitolunate, lunotriquetral, dorsal radiocarpal
. Lunotriquetral, capitolunate, scapholunate, volar radiolunate
. Volar radiolunate, scapholunate, capitolunate, lunotriquetral
. Dorsal radiocarpal, lunotriquetral, capitolunate, scapholunate

Correct Answer & Explanation

. Scapholunate, lunotriquetral, dorsal radiocarpal, volar radiolunate

Explanation

Mayfield described 4 stages of progressive perilunate instability surrounding the lunate (starting radially and progressing ulnarly). Stage I: Disruption of the Scapholunate (SL) ligament. Stage II: Disruption of the Capitolunate articulation (space of Poirier). Stage III: Disruption of the Lunotriquetral (LT) ligament (classic perilunate dislocation). Stage IV: Failure of the dorsal radiocarpal ligament allowing the lunate to dislocate volarly into the carpal tunnel.

Question 1723

Topic: 7. Hand and Wrist

A 14-month-old child is undergoing surgical release for a simple, complete syndactyly between the long and ring fingers. To optimize functional outcome and prevent long-term flexion contractures as the child grows, which of the following surgical principles must be strictly adhered to?

. Use of straight longitudinal incisions along the volar and dorsal surfaces of the digits.
. Use of full-thickness skin grafts (FTSG) to cover the lateral digital defects created after separation.
. Avoidance of skin grafting entirely, allowing the lateral defects to heal by secondary intention.
. Immediate, simultaneous complete release of all web spaces in complex hands.
. Use of split-thickness skin grafts (STSG) to maximize graft take over exposed neurovascular bundles.

Correct Answer & Explanation

. Use of full-thickness skin grafts (FTSG) to cover the lateral digital defects created after separation.

Explanation

In syndactyly release, zig-zag (Bruner-type) or geometrically designed incisions must be used to prevent linear scar contracture as the child grows. Because the circumference of two separated fingers is greater than the circumference of the joined digits, there is always a shortage of skin. This lateral skin defect must be covered with full-thickness skin grafts (FTSG, usually from the groin or lower abdomen) to minimize secondary contraction. STSG contracts too much and leads to joint contractures.

Question 1724

Topic: 7. Hand and Wrist

In a standard tendon transfer (modified Jones) for high radial nerve palsy, which of the following transfers is most universally utilized to restore functional wrist extension?

. Pronator teres to extensor carpi radialis brevis
. Flexor carpi ulnaris to extensor digitorum communis
. Palmaris longus to extensor pollicis longus
. Flexor digitorum superficialis to extensor carpi radialis longus
. Flexor carpi radialis to extensor digitorum communis

Correct Answer & Explanation

. Pronator teres to extensor carpi radialis brevis

Explanation

The pronator teres (PT) is the classic and most mechanically advantageous donor muscle for restoring wrist extension, specifically transferred to the extensor carpi radialis brevis (ECRB). The ECRB is chosen over the ECRL because its central insertion at the base of the third metacarpal minimizes radial deviation during wrist extension.

Question 1725

Topic: 7. Hand and Wrist

A 35-year-old carpenter sustains a volar thumb pulp amputation measuring 2.5 x 2.0 cm with exposed distal phalanx bone. Which of the following local flap options provides sensate coverage without significantly increasing the risk of interphalangeal (IP) joint flexion contracture?

. Moberg advancement flap
. First dorsal metacarpal artery (FDMA) island flap
. V-Y advancement (Atasoy) flap
. Thenar flap
. Cross-finger flap

Correct Answer & Explanation

. First dorsal metacarpal artery (FDMA) island flap

Explanation

The First Dorsal Metacarpal Artery (FDMA) or Foucher flap provides sensate, single-stage coverage for large thumb defects. The Moberg advancement flap relies on both neurovascular bundles but is generally limited to defects of 1.5 cm or less; pushing its advancement past this limit highly risks a permanent thumb IP joint flexion contracture. V-Y flaps are for smaller defects, while cross-finger and thenar flaps are historically insensate unless specifically innervated.

Question 1726

Topic: 7. Hand and Wrist

During a routine electrodiagnostic study for suspected carpal tunnel syndrome, the neurologist notes an anomalous innervation pattern consisting of a Martin-Gruber anastomosis. Which of the following best describes the anatomical pathway of this connection?

. Median nerve to ulnar nerve connection in the forearm
. Ulnar nerve to median nerve connection in the forearm
. Motor branch of the median nerve to the deep branch of the ulnar nerve in the hand
. Sensory connection between the ulnar and median nerves in the palmar surface of the digits
. Superficial radial nerve to the dorsal sensory branch of the ulnar nerve

Correct Answer & Explanation

. Median nerve to ulnar nerve connection in the forearm

Explanation

A Martin-Gruber anastomosis is a common anatomical variant involving a neural connection from the median nerve (or its anterior interosseous branch) to the ulnar nerve in the forearm. It typically carries motor fibers that innervate intrinsic hand muscles. Riche-Cannieu is a median-to-ulnar connection in the hand; Marinacci is an ulnar-to-median connection in the forearm; Berrettini is a sensory ulnar-to-median connection in the hand.

Question 1727

Topic: Wrist & Carpus
A 40-year-old heavy laborer presents with severe, symptomatic post-traumatic distal radioulnar joint (DRUJ) osteoarthritis. He requires preservation of maximum grip strength and forearm rotation for work. Which of the following salvage procedures is designed to eliminate DRUJ pain while explicitly preserving the ulnocarpal ligament complex and carpal support?
. Sauvé-Kapandji procedure
. Darrach procedure
. Hemiresection interposition arthroplasty (Bowers)
. Distal ulna prosthetic replacement
. Ulnar shortening osteotomy

Correct Answer & Explanation

. Sauvé-Kapandji procedure

Explanation

The Sauvé-Kapandji procedure involves arthrodesis of the DRUJ with a creation of a pseudoarthrosis in the distal ulnar metaphysis to allow forearm rotation. Because the ulnar head remains securely articulated and fused with the sigmoid notch, the ulnocarpal ligaments and triangular fibrocartilage complex (TFCC) attachments are preserved, maintaining ulnocarpal support and minimizing ulnar translation of the carpus. The Darrach procedure removes the distal ulna entirely, sacrificing this support.

Question 1728

Topic: 7. Hand and Wrist

When planning a reverse radial forearm flap for soft tissue coverage of a dorsal hand defect, the primary blood supply relies on retrograde flow through the radial artery. This reverse flow is anatomically sustained primarily via the anastomosis with which of the following structures?

. Deep palmar arch
. Superficial palmar arch
. Anterior interosseous artery
. Posterior interosseous artery
. Princeps pollicis artery

Correct Answer & Explanation

. Deep palmar arch

Explanation

The reverse radial forearm flap is a distally based pedicled flap. Ligation of the radial artery proximally means the flap relies on retrograde flow. This flow is provided by the deep palmar arch, which is primarily formed by the terminal continuation of the radial artery after it passes through the anatomical snuffbox, anastomosing with the deep branch of the ulnar artery.

Question 1729

Topic: 7. Hand and Wrist

A 25-year-old man sustains a severe traumatic brachial plexus injury resulting in an isolated, complete C5-C6 root avulsion. Six months post-injury, he has no active elbow flexion or shoulder abduction, but hand and wrist functions are normal. You plan an Oberlin transfer to restore elbow flexion. Which of the following describes the classic Oberlin transfer?

. Transfer of an expendable ulnar nerve fascicle to the biceps motor branch
. Transfer of the medial pectoral nerve to the musculocutaneous nerve
. Transfer of three intercostal nerves directly to the musculocutaneous nerve
. Transfer of the spinal accessory nerve to the suprascapular nerve
. Transfer of a median nerve fascicle to the axillary nerve

Correct Answer & Explanation

. Transfer of an expendable ulnar nerve fascicle to the biceps motor branch

Explanation

The classic Oberlin transfer utilizes a redundant motor fascicle of the ulnar nerve (often the fascicle innervating the flexor carpi ulnaris) and transfers it directly to the motor branch of the biceps muscle to restore elbow flexion in upper trunk brachial plexus injuries. A 'double' Oberlin transfer also includes transferring a median nerve fascicle to the brachialis motor branch.

Question 1730

Topic: 7. Hand and Wrist

In the pathoanatomy of Dupuytren's disease, the 'spiral cord' is primarily responsible for the contracture of the proximal interphalangeal (PIP) joint and the resultant central, superficial, and proximal displacement of the neurovascular bundle. Which of the following normal fascial structures does NOT contribute to the formation of the spiral cord?

. Natatory ligament
. Pretendinous band
. Spiral band
. Lateral digital sheet
. Grayson's ligament

Correct Answer & Explanation

. Natatory ligament

Explanation

The spiral cord in Dupuytren's disease is formed by diseased elements of four specific fascial structures: the pretendinous band, the spiral band, the lateral digital sheet, and Grayson's ligament. The natatory ligament contributes to the web space contractures but is not a component of the spiral cord.

Question 1731

Topic: Nerve & Tendon

A 42-year-old woman complains of severe, paroxysmal pain at the tip of her left ring finger. The pain is exacerbated by cold weather. On examination, a subtle bluish discoloration is seen under the nail plate, and exquisite point tenderness is noted. Which of the following clinical tests is most specific for diagnosing this condition?

. Hildreth test
. Phalen's test
. Finkelstein's test
. Tinel's sign
. Grind test

Correct Answer & Explanation

. Hildreth test

Explanation

The clinical presentation is classic for a glomus tumor (cold sensitivity, paroxysmal severe pain, point tenderness—the classic triad). The Hildreth test is highly specific for glomus tumors: the point tenderness is assessed, a tourniquet is inflated to create ischemia, and the tenderness disappears. Once the tourniquet is released, the pain and tenderness return.

Question 1732

Topic: 7. Hand and Wrist
A 35-year-old laborer with advanced Scapholunate Advanced Collapse (SLAC) stage III wrist arthritis undergoes a four-corner arthrodesis (capitate, lunate, triquetrum, hamate) with scaphoid excision. To preserve postoperative wrist motion and ensure the success of this specific salvage procedure, which of the following joints MUST be radiographically free of advanced arthritic changes preoperatively?
. Radiolunate joint
. Radioscaphoid joint
. Lunotriquetral joint
. Distal radioulnar joint
. Capitohamate joint

Correct Answer & Explanation

. Radiolunate joint

Explanation

The four-corner fusion (capitate, lunate, triquetrum, hamate) creates a single carpal block that articulates exclusively with the radius via the radiolunate facet. Therefore, an absolute prerequisite for a successful four-corner fusion is an intact, cartilage-spared radiolunate joint. In SLAC wrist, the radiolunate joint is characteristically spared until the final stages, unlike the radioscaphoid joint, which degenerates early.

Question 1733

Topic: 7. Hand and Wrist

Madelung deformity is a congenital dyschondrosteosis of the wrist characterized by a bowed, shortened radius and a dorsally prominent distal ulna. This deformity is the direct result of premature growth arrest of which specific anatomic portion of the distal radius physis?

. Volar-ulnar portion
. Dorsal-ulnar portion
. Volar-radial portion
. Dorsal-radial portion
. Central portion

Correct Answer & Explanation

. Volar-ulnar portion

Explanation

Madelung deformity arises from a partial premature closure or growth arrest of the volar-ulnar aspect of the distal radius physis. As the rest of the physis continues to grow, the distal articular surface of the radius tilts excessively in a volar and ulnar direction, leading to carpal subsidence and a relatively long, dorsally prominent distal ulna.

Question 1734

Topic: Wrist & Carpus

A 28-year-old man sustains a Galeazzi fracture-dislocation (fracture of the distal third of the radius with associated distal radioulnar joint [DRUJ] disruption). Following rigid plate fixation of the radius, intraoperative assessment reveals that the DRUJ subluxates dorsally when the forearm is in pronation but completely reduces and is stable when the forearm is placed in supination. What is the most appropriate management of the DRUJ?

. Immobilization of the forearm in supination for 4 to 6 weeks
. Immobilization of the forearm in pronation for 4 to 6 weeks
. Immediate open reduction and primary repair of the triangular fibrocartilage complex (TFCC)
. Transfixion pinning of the DRUJ with the forearm in neutral rotation
. Resection of the distal ulna (Darrach procedure)

Correct Answer & Explanation

. Immobilization of the forearm in supination for 4 to 6 weeks

Explanation

In a classic Galeazzi fracture, after anatomic and rigid fixation of the radius, the DRUJ must be assessed. If the DRUJ reduces and is stable in a specific position (most commonly supination for a dorsal DRUJ dislocation), the standard of care is closed management with immobilization (sugar-tong splint or long arm cast) in that stable position (supination) for 4 to 6 weeks. Pinning or open repair is reserved for DRUJs that remain unstable in all positions of rotation or are irreducible.

Question 1735

Topic: 7. Hand and Wrist
A 45-year-old woman presents with wrist pain and is diagnosed with Lichtman Stage IIIA Kienböck's disease (lunate sclerosis and collapse, but without fixed scaphoid rotation or carpal height loss). Radiographs reveal an ulnar-negative variance of 3 mm. Which of the following surgical interventions is most appropriate to halt progression and relieve pain?
. Radial shortening osteotomy
. Proximal row carpectomy
. Scaphoid-trapezium-trapezoid (STT) fusion
. Lunate excision and capitate shortening
. Total wrist arthrodesis

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

In early to intermediate Kienböck's disease (Lichtman Stages I, II, and IIIA) presenting with ulnar-negative variance, joint leveling procedures are the treatment of choice. A radial shortening osteotomy unloads the radiolunate fossa, redistributing compressive forces to the ulnocarpal articulation and halting the progression of lunate collapse. PRC or salvage fusions are reserved for Stage IIIB (fixed scaphoid rotation/carpal collapse) or Stage IV (pancarpal arthritis).

Question 1736

Topic: Nerve & Tendon

A patient with an isolated low ulnar nerve palsy exhibits a pronounced claw deformity of the ring and small fingers. A Bouvier test is performed and is positive (the patient is able to actively extend the PIP joints when the examiner blocks the MCP joints in slight flexion). Based on this finding, which of the following procedures is most appropriate to dynamically correct the deformity?

. Zancolli lasso procedure (FDS to A1 pulley transfer)
. Extensor indicis proprius to extensor pollicis longus transfer
. Pronator teres to extensor carpi radialis brevis transfer
. Brachioradialis to flexor pollicis longus transfer
. Flexor carpi ulnaris to extensor digitorum communis transfer

Correct Answer & Explanation

. Zancolli lasso procedure (FDS to A1 pulley transfer)

Explanation

A positive Bouvier test indicates that the extensor apparatus over the PIP joint is intact and functional if the deforming hyperextension force at the MCP joint is eliminated. Therefore, an MCP flexion block procedure, such as the Zancolli lasso (transferring the flexor digitorum superficialis to the A1 pulley), will prevent MCP hyperextension, allowing the extrinsic extensors to effectively extend the PIP joints and dynamically correct the claw hand.

Question 1737

Topic: 7. Hand and Wrist

A 32-year-old male sustains a high-energy volar Barton's fracture of the distal radius, characterized by a displaced volar marginal articular fragment. The carpus demonstrates associated volar subluxation. Which of the following robust radiocarpal ligaments remains firmly attached to this volar fragment, directly causing the carpus to translate volarly with the bone piece?

. Radioscaphocapitate ligament
. Dorsal radiocarpal ligament
. Scapholunate interosseous ligament
. Lunotriquetral interosseous ligament
. Dorsal intercarpal ligament

Correct Answer & Explanation

. Radioscaphocapitate ligament

Explanation

A volar Barton's fracture involves a shear fracture of the volar articular margin of the distal radius. The strong extrinsic volar radiocarpal ligaments, including the radioscaphocapitate (RSC) and the long and short radiolunate ligaments, originate from this volar rim. When the rim fractures and displaces volarly, these intact ligaments pull the carpus along with the bone fragment, causing the characteristic volar subluxation of the wrist joint.

Question 1738

Topic: Nerve & Tendon

A 32-year-old carpenter sustains a severe volar forearm laceration resulting in a 4 cm segmental defect of the median nerve. After appropriate debridement, what is the most appropriate reconstructive strategy for this nerve gap?

. Primary end-to-end repair under tension
. Use of a synthetic polyglycolic acid nerve conduit
. Bridging with an acellular nerve allograft
. Reconstruction using an autologous nerve cable graft
. End-to-side neurorrhaphy to the ulnar nerve

Correct Answer & Explanation

. Reconstruction using an autologous nerve cable graft

Explanation

Autologous nerve cable grafting (e.g., using the sural nerve or medial antebrachial cutaneous nerve) remains the gold standard for peripheral nerve defects greater than 3 cm. Conduits and acellular nerve allografts are generally reserved for non-critical sensory nerves with gaps less than 3 cm due to poor outcomes in longer or mixed/motor nerve defects.

Question 1739

Topic: 7. Hand and Wrist

A 4-year-old boy presents to the emergency department after a clean, sharp amputation of the distal phalanx tip (Zone 1) of the long finger in a door hinge. The amputated part was kept clean and brought in on an ice slurry. What is the most appropriate management for the amputated digit?

. Terminalization of the digit and primary closure
. Volar V-Y advancement flap
. Cross-finger flap from the adjacent digit
. Reattachment as a non-vascularized composite graft
. Microvascular replantation with vein grafting

Correct Answer & Explanation

. Reattachment as a non-vascularized composite graft

Explanation

In children under 6 years of age, clean fingertip amputations distal to the distal interphalangeal joint (Zone 1) have an exceptionally high success rate when reattached as a non-vascularized composite graft (often referred to as 'cap' replacement). Microvascular replantation is technically challenging at this level in a toddler and often unnecessary given the success of composite grafting.

Question 1740

Topic: 7. Hand and Wrist

A reverse radial forearm flap is planned for coverage of a complex dorsal hand wound. The venous drainage of this distally based flap relies primarily on which of the following mechanisms?

. Retrograde flow through the cephalic vein bypassing functional valves
. Antegrade flow through the basilic vein via the palmar arch
. Retrograde flow through the venae comitantes of the radial artery
. Retrograde flow through the median cubital vein
. Collateral drainage via the dorsal venous arch of the hand

Correct Answer & Explanation

. Retrograde flow through the venae comitantes of the radial artery

Explanation

The reverse radial forearm flap is a distally based pedicled flap. Its arterial supply relies on retrograde flow from the ulnar artery via the palmar arches to the radial artery. Venous drainage relies on retrograde flow through the venae comitantes of the radial artery. The blood bypasses venous valves through numerous communicating cross-branches between the paired venae comitantes.

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