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7. Hand and Wrist MCQs

Practice Set 88 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 1741

Topic: 7. Hand and Wrist

A 40-year-old patient develops a severe, painful end-neuroma of the superficial radial nerve following a distal radius fracture surgery. Conservative management has failed. If surgical resection is pursued, what is considered an effective strategy to minimize the recurrence of a symptomatic neuroma when grafting is not planned?

. Ligation of the nerve end and placing it in the subcutaneous fat
. Chemical ablation with phenol at the resection stump
. Capping the nerve stump with a silicone tube
. Transposition and deep burial of the nerve stump into the brachioradialis muscle
. Performing a side-to-side anastomosis to the intact median nerve

Correct Answer & Explanation

. Transposition and deep burial of the nerve stump into the brachioradialis muscle

Explanation

Excision of a painful end-neuroma often leads to recurrence if the nerve stump is left in a mobile or superficial area subject to mechanical irritation. Burying the freshly resected proximal nerve stump deep into a well-vascularized muscle belly (such as the brachioradialis or pronator quadratus for the SRN) is a widely accepted technique to prevent mechanical stimulation and symptomatic recurrence.

Question 1742

Topic: Wrist & Carpus
A 45-year-old active mechanic complains of severe ulnar-sided wrist pain and DRUJ instability 1 year after nonoperative treatment of a distal radius fracture. Radiographs show a distal radius malunion with 25 degrees of dorsal tilt and 5 mm of positive ulnar variance. What is the best surgical management?
. Darrach procedure
. Sauvé-Kapandji procedure
. Ulnar shortening osteotomy
. Distal radius corrective osteotomy with structural bone graft and volar plating
. Hemiresection interposition arthroplasty (Bowers procedure)

Correct Answer & Explanation

. Distal radius corrective osteotomy with structural bone graft and volar plating

Explanation

In a young, active patient with a symptomatic distal radius malunion causing secondary DRUJ incongruity and instability, the ideal treatment is to correct the primary deformity. A corrective opening wedge osteotomy of the distal radius with a structural bone graft and rigid fixation restores normal anatomy, corrects the relative positive ulnar variance, and realigns the DRUJ, thereby preserving joint mechanics.

Question 1743

Topic: Wrist & Carpus
A 30-year-old man with Lichtman Stage II Kienböck's disease undergoes a joint-leveling procedure and a pedicled vascularized bone graft from the dorsal distal radius based on the 4+5 Extensor Compartmental Artery (ECA). Anatomically, this vascular pedicle is harvested between which two extensor compartments?
. First and Second
. Second and Third
. Third and Fourth
. Fourth and Fifth
. Fifth and Sixth

Correct Answer & Explanation

. Third and Fourth

Explanation

Pedicled vascularized bone grafts from the dorsal distal radius are a standard treatment for Kienböck's disease. The 4+5 ECA (extensor compartmental artery) graft is harvested from the dorsal radius with its pedicle lying between the fourth dorsal compartment (extensor digitorum communis, extensor indicis proprius) and the fifth dorsal compartment (extensor digiti minimi).

Question 1744

Topic: 7. Hand and Wrist

A 28-year-old worker sustains a complete sharp amputation of his dominant index finger at the base of the proximal phalanx. The amputated digit is properly prepared in a watertight bag submerged in ice-water slush. What is the maximum acceptable cold ischemia time for replantation of a digit?

. 6 hours
. 12 hours
. 24 hours
. 36 hours
. 48 hours

Correct Answer & Explanation

. 24 hours

Explanation

Ischemia times vary based on the presence of muscle. Digits contain no muscle belly, making them highly resistant to ischemic necrosis. The maximum acceptable cold ischemia time for digits is widely cited as 24 hours (with some literature suggesting up to 30 hours). In contrast, for major limb amputations containing muscle (macro-replantation), the maximum cold ischemia time is 12 hours, and warm ischemia is 6 hours.

Question 1745

Topic: 7. Hand and Wrist

In the classic index finger pollicization (Buck-Gramcko technique) for a severely hypoplastic thumb, what does the index finger metacarpophalangeal (MCP) joint become in the newly constructed thumb?

. Interphalangeal (IP) joint
. Metacarpophalangeal (MCP) joint
. Carpometacarpal (CMC) joint
. Scaphotrapezial joint
. Radiocarpal joint

Correct Answer & Explanation

. Carpometacarpal (CMC) joint

Explanation

During an index finger pollicization, the index metacarpal shaft is resected. The index metacarpal head acts as the new trapezium. The native index MCP joint is positioned to become the new carpometacarpal (CMC) joint of the thumb. Consequently, the index proximal interphalangeal (PIP) joint becomes the new thumb MCP joint, and the index DIP joint becomes the thumb IP joint.

Question 1746

Topic: 7. Hand and Wrist

A 1-year-old child undergoes release of a simple complete syndactyly between the long and ring fingers. A full-thickness skin graft (FTSG) is preferred over a split-thickness skin graft (STSG) to cover the resulting lateral digit defects primarily because a FTSG:

. Has a higher rate of initial 'take' over avascular structures
. Decreases the risk of secondary contracture
. Requires less meticulous defatting of the graft
. Prevents the need for a tie-over bolster dressing
. Provides better sensory reinnervation for two-point discrimination

Correct Answer & Explanation

. Decreases the risk of secondary contracture

Explanation

In syndactyly release, full-thickness skin grafts (FTSG) are favored over split-thickness skin grafts (STSG) because FTSGs undergo significantly less secondary contraction during the healing phase. This decreased secondary contracture is vital in the hand to prevent recurrent web creep and flexion contractures of the growing digits.

Question 1747

Topic: Wrist & Carpus
In a patient with Stage III Scapholunate Advanced Collapse (SLAC) wrist, the radiolunate joint is characteristically spared from degenerative changes. Which of the following biomechanical or anatomic factors is the primary reason for this preservation?
. The robust interosseous blood supply to the lunate
. The shielding effect of the intact triangular fibrocartilage complex (TFCC)
. The elliptical articulation of the radiolunate joint that disperses sheer stress
. The congruent spherical articulation of the radiolunate joint
. The absence of rotational forces on the lunate following scapholunate dissociation

Correct Answer & Explanation

. The congruent spherical articulation of the radiolunate joint

Explanation

In SLAC wrist, the radiolunate joint is typically spared from osteoarthritis due to its congruent spherical articulation. When the scaphoid rotates into a flexed position, its elliptical proximal pole creates incongruous point-loading on the scaphoid fossa of the radius, leading to rapid degeneration (Stage I and II). The lunate, however, maintains a spherical, congruent relationship with the lunate fossa even when extended (DISI deformity), evenly distributing forces and sparing the cartilage.

Question 1748

Topic: 7. Hand and Wrist

A patient presents with an ulnar claw hand deformity following a laceration to the ulnar nerve at the wrist. The examiner performs the Bouvier test by passively preventing hyperextension of the metacarpophalangeal (MCP) joints, which subsequently allows the patient to actively extend the interphalangeal (IP) joints. A positive Bouvier test indicates the functional competence of which of the following structures?

. Lumbricals
. Palmar interossei
. Extensor mechanism (central slip and lateral bands)
. Flexor digitorum profundus
. Sagittal bands

Correct Answer & Explanation

. Extensor mechanism (central slip and lateral bands)

Explanation

A positive Bouvier test occurs when blocking the MCP joint from hyperextending allows the long extensors to transmit force distally, resulting in IP joint extension. This indicates that the extrinsic extensor mechanism (central slip and lateral bands) is intact and functionally competent. It helps determine if a simple MCP stabilization procedure (e.g., Zancolli lasso or capsulodesis) will successfully correct the claw deformity.

Question 1749

Topic: 7. Hand and Wrist

During surgical fasciectomy for severe Dupuytren's contracture of the ring finger, the surgeon isolates the neurovascular bundle to protect it. In the presence of a spiral cord, which of the following normal fascial structures is NOT a component of the spiral cord and thus typically spares the neurovascular bundle from dorsal displacement?

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

Correct Answer & Explanation

. Cleland's ligament

Explanation

The spiral cord in Dupuytren's disease is responsible for causing PIP joint contracture and displacing the neurovascular bundle centrally and superficially. It is formed by diseased tissue from four structures: the pretendinous band, spiral band, lateral digital sheet, and Grayson's ligament. Cleland's ligament is dorsal to the neurovascular bundle and is characteristically NOT involved in Dupuytren's disease.

Question 1750

Topic: 7. Hand and Wrist

A 62-year-old female with long-standing rheumatoid arthritis presents with a sudden inability to actively flex the interphalangeal joint of her right thumb. She denies any preceding trauma. Radiographs reveal diffuse carpal advanced changes and prominent volar osteophytes. This presentation is most consistent with attritional rupture of the flexor pollicis longus (FPL) tendon. Which structure is the most likely source of attrition?

. Volar lip of the distal radius
. Hook of the hamate
. Tubercle of the trapezium
. Volar spur of the scaphoid
. Pisiform

Correct Answer & Explanation

. Volar spur of the scaphoid

Explanation

This clinical scenario describes a Mannerfelt lesion (Mannerfelt-Norman syndrome), which is an attritional rupture of the flexor pollicis longus (FPL) tendon in patients with rheumatoid arthritis. It is most commonly caused by friction against a bony spur extending from the volar aspect of the scaphoid (often penetrating the floor of the carpal tunnel).

Question 1751

Topic: 7. Hand and Wrist
A 45-year-old manual laborer with Stage III Kienböck's disease is evaluated for surgical intervention. The surgeon is considering a proximal row carpectomy (PRC). To ensure the success of a PRC, articular cartilage must be preserved on the lunate fossa of the radius and which other critical structure?
. Distal pole of the scaphoid
. Proximal pole of the capitate
. Trapezoid
. Hamate
. Triquetrum

Correct Answer & Explanation

. Proximal pole of the capitate

Explanation

Proximal row carpectomy (PRC) involves the excision of the scaphoid, lunate, and triquetrum. This converts the wrist into a simple hinge joint where the proximal pole of the capitate articulates directly with the lunate fossa of the distal radius. Therefore, PRC is strictly contraindicated if there is significant degenerative arthritis or cartilage loss at the proximal pole of the capitate.

Question 1752

Topic: 7. Hand and Wrist

A 55-year-old female presents with inability to extend her thumb 6 weeks after a non-displaced distal radius fracture. The surgeon diagnoses an extensor pollicis longus (EPL) tendon rupture and plans an extensor indicis proprius (EIP) to EPL tendon transfer. During the harvest of the EIP tendon at the level of the metacarpal head, where is the EIP tendon located relative to the extensor digitorum communis (EDC) tendon of the index finger?

. Radial and dorsal
. Ulnar and volar
. Ulnar and dorsal
. Radial and volar
. Directly superficial

Correct Answer & Explanation

. Ulnar and volar

Explanation

During the surgical harvest for an EIP to EPL transfer, the Extensor Indicis Proprius (EIP) tendon is identified at the level of the index metacarpophalangeal (MCP) joint hood. The EIP tendon consistently lies ulnar and volar (deep) to the Extensor Digitorum Communis (EDC) tendon of the index finger.

Question 1753

Topic: 7. Hand and Wrist

An 18-year-old male sustains a proximal pole scaphoid fracture. The high risk of avascular necrosis and nonunion in this region is primarily due to the unique retrograde intraosseous blood supply of the scaphoid. The predominant blood supply to the proximal 80% of the scaphoid enters the bone at which location?

. Volar tubercle via branches of the superficial palmar arch
. Dorsal ridge via branches of the radial artery
. Distal articular surface via the deep palmar arch
. Scapholunate interosseous ligament via the anterior interosseous artery
. Proximal pole via direct branches from the ulnar artery

Correct Answer & Explanation

. Dorsal ridge via branches of the radial artery

Explanation

The scaphoid relies heavily on its retrograde blood supply. Approximately 70-80% of the scaphoid (including the entire proximal pole) is supplied by the dorsal carpal branch of the radial artery, which enters the non-articular dorsal ridge and flows proximally. The volar branches of the radial artery supply only the distal 20-30% at the region of the tuberosity.

Question 1754

Topic: 7. Hand and Wrist

A patient presents with a 1.2 cm volar soft tissue defect over the distal phalanx of the thumb with exposed bone. A Moberg volar advancement flap is planned. Which of the following is a recognized disadvantage or common complication of this specific flap?

. Loss of protective sensation at the fingertip
. Cortical misrepresentation of sensory input
. Interphalangeal joint flexion contracture
. Necessity of a secondary skin graft on the volar surface
. Venous congestion due to retrograde flow

Correct Answer & Explanation

. Interphalangeal joint flexion contracture

Explanation

The Moberg volar advancement flap is ideal for volar thumb defects up to 1.5 cm. It involves advancing the entire volar skin of the thumb along with both neurovascular bundles. Because the flap is advanced distally, it requires the interphalangeal (IP) joint to be flexed during healing, frequently resulting in a mild to moderate IP joint flexion contracture. Sensation is perfectly maintained and cortical misrepresentation (seen in heterodigital island flaps like the Littler flap) does not occur.

Question 1755

Topic: 7. Hand and Wrist
A 32-year-old male is diagnosed with Kienböck's disease. Radiographs reveal sclerosis and fragmentation of the lunate, and the radioscaphoid angle measures 65 degrees, indicating fixed scaphoid rotation and carpal collapse. Which Lichtman stage best categorizes this presentation?
. Stage II
. Stage IIIA
. Stage IIIB
. Stage IV
. Stage I

Correct Answer & Explanation

. Stage IIIB

Explanation

Lichtman Stage IIIB Kienböck's disease is characterized by lunate fragmentation/collapse combined with fixed coronal rotation of the scaphoid (radioscaphoid angle > 60 degrees) and resulting carpal height collapse. Stage IIIA has lunate collapse but normal carpal alignment and scaphoid position. Stage IV involves secondary pancarpal osteoarthritis.

Question 1756

Topic: 7. Hand and Wrist

A 40-year-old male sustains a complete laceration of the ulnar nerve near the elbow. Examination reveals profound weakness of the intrinsic hand muscles but relatively mild clawing of the ring and small fingers compared to a patient with an ulnar nerve injury at the wrist. This phenomenon is commonly known as the 'Ulnar Paradox.' What is the anatomic basis for this presentation?

. Cross-innervation from the median nerve via a Martin-Gruber anastomosis
. Intact extensor digitorum communis compensating for lumbrical loss
. Simultaneous denervation of the flexor digitorum profundus to the ring and small fingers
. Spasticity of the palmar interossei pulling the proximal phalanx into flexion
. Preservation of the deep motor branch of the ulnar nerve at the wrist

Correct Answer & Explanation

. Simultaneous denervation of the flexor digitorum profundus to the ring and small fingers

Explanation

The 'Ulnar Paradox' states that a high ulnar nerve injury produces a less severe claw hand deformity than a low ulnar nerve injury. The claw deformity (MCP hyperextension, IP flexion) is driven by the unopposed action of the extensor digitorum communis and the flexor digitorum profundus (FDP) when the lumbricals are paralyzed. In a high injury, the ulnar-innervated FDP to the ring and small fingers is also paralyzed, removing the strong flexor force at the IP joints and thereby softening the claw appearance.

Question 1757

Topic: 7. Hand and Wrist

During flexor tendon reconstruction, it is critical to preserve or reconstruct specific pulleys to prevent bowstringing of the tendon and significant loss of active flexion arc. Which two pulleys are considered the most critical for preventing bowstringing, and from what anatomical structures do they primarily originate?

. A1 and A3 pulleys; arising from the volar plates of the MCP and PIP joints
. A2 and A4 pulleys; arising from the volar plates of the PIP and DIP joints
. A2 and A4 pulleys; arising from the periosteum of the proximal and middle phalanges
. A1 and A5 pulleys; arising from the periosteum of the metacarpal and distal phalanx
. A3 and A5 pulleys; arising from the interosseous intrinsic fascial bands

Correct Answer & Explanation

. A2 and A4 pulleys; arising from the periosteum of the proximal and middle phalanges

Explanation

The A2 and A4 pulleys are mechanically the most crucial pulleys for maintaining tendon apposition to the bone and preventing bowstringing. These are the diaphyseal pulleys, arising broadly and robustly from the periosteum of the proximal phalanx (A2) and middle phalanx (A4). The A1, A3, and A5 are joint pulleys and arise from the volar plates.

Question 1758

Topic: 7. Hand and Wrist

A 55-year-old female presents with a highly comminuted distal radius fracture involving a displaced volar marginal fragment of the lunate facet (volar ulnar corner). Which of the following carpal ligaments originates from this specific fracture fragment, making its anatomical stabilization critical to prevent volar carpal subluxation?

. Scapholunate interosseous ligament
. Short radiolunate ligament
. Radioscaphocapitate ligament
. Dorsal radiocarpal ligament
. Long radiolunate ligament

Correct Answer & Explanation

. Short radiolunate ligament

Explanation

The short radiolunate ligament securely attaches the volar marginal fragment of the lunate facet (often termed the 'tear-drop' fragment) to the lunate. If this volar ulnar corner is not recognized and rigidly fixed, the entire carpus can subluxate volarly with the lunate, leading to catastrophic radiocarpal instability and poor functional outcomes.

Question 1759

Topic: Wrist & Carpus

A 55-year-old woman presents to the clinic unable to actively extend the interphalangeal joint of her thumb. She was treated non-operatively 6 weeks ago for a non-displaced distal radius fracture. What is the primary pathophysiological cause of this late complication?

. Iatrogenic transaction of the tendon during a hematoma block
. Mechanical attrition and local ischemia of the tendon at Lister's tubercle
. Entrapment of the tendon within the healing fracture site
. Primary osteoarthritis of the carpometacarpal joint
. Compression of the nerve by the extensor retinaculum

Correct Answer & Explanation

. Mechanical attrition and local ischemia of the tendon at Lister's tubercle

Explanation

Spontaneous rupture of the extensor pollicis longus (EPL) tendon is a classic complication that occurs weeks after a non-displaced distal radius fracture. It is primarily caused by mechanical attrition from bony irregularity at Lister's tubercle, compounded by localized ischemia of the tendon within the unyielding third extensor compartment due to fracture hematoma and swelling.

Question 1760

Topic: Wrist & Carpus

During volar locking plate fixation of a distal radius fracture, the surgeon accidentally places a screw that protrudes through the dorsal cortex of the distal radius into the third extensor compartment. Which tendon is at the highest risk for attrition and rupture?

. Extensor digitorum communis
. Extensor carpi radialis longus
. Extensor pollicis longus
. Extensor indicis proprius
. Extensor carpi radialis brevis

Correct Answer & Explanation

. Extensor pollicis longus

Explanation

Prominent dorsal screws protruding through the third extensor compartment specifically place the Extensor Pollicis Longus (EPL) tendon at risk for attritional rupture. Proper screw length measurement is critical to avoid this complication.

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