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7. Hand and Wrist MCQs

Practice Set 89 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 1761

Topic: Nerve & Tendon

When comparing the single-incision anterior approach to the two-incision approach for distal biceps tendon repair, the single-incision approach is associated with a statistically higher risk of injury to which of the following structures?

. Posterior interosseous nerve (PIN)
. Lateral antebrachial cutaneous nerve (LABC)
. Median nerve
. Ulnar nerve
. Superficial radial nerve

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve (LABC)

Explanation

The single-incision anterior approach carries a higher risk of lateral antebrachial cutaneous nerve (LABC) neuropraxia, as the LABC exits between the biceps and brachialis and runs directly in the superficial field of the anterior approach. The two-incision approach carries a higher risk of heterotopic ossification and radioulnar synostosis.

Question 1762

Topic: 7. Hand and Wrist

Figures 62a and 62b show the radiographs of a 50-year-old man who has a long-standing history of wrist pain. What is the most likely cause of pain?

. Gout
. Sepsis
. Old trauma
. Rheumatoid arthritis
. Charcot arthroplasty

Correct Answer & Explanation

. Old trauma

Explanation

With review of the article below and close examination of the radiographs, the most likely cause of this patients pain is a SLAC wrist. The #1 cause of SLAC wrist is old trauma. The article below reviewed more than 4000 wrist radiographs and concluded that the normal progression of the SLAC wrist follows these guidelines: Degenerative changes first occur between the tip of the radial styloid and the scaphoid then progress along the scaphoradial joints. The radius-lunate joint is shared as the process progresses to the capitate-lunate joint.

Question 1763

Topic: 7. Hand and Wrist

A patient presents with neck pain radiating down the arm. Neurologic examination reveals a diminished triceps reflex, weakness in elbow extension and wrist flexion, and altered sensation over the dorsal middle finger. Which cervical nerve root is most likely compressed?

. C4
. C5
. C6
. C7
. C8

Correct Answer & Explanation

. C7

Explanation

Compression of the C7 nerve root classically presents with a diminished triceps reflex, weakness in the triceps (elbow extension) and wrist flexors, and numbness/tingling radiating to the middle finger.

Question 1764

Topic: 7. Hand and Wrist

A 65-year-old female presents 8 weeks after successful closed reduction and casting of a non-displaced distal radius fracture. She now reports a sudden inability to actively extend her thumb interphalangeal joint. What is the most likely pathophysiologic mechanism for her current presentation?

. Ischemic necrosis and mechanical attrition of the extensor pollicis longus tendon at Lister's tubercle
. Iatrogenic traction injury to the posterior interosseous nerve during reduction
. A displaced fracture fragment compressing the median nerve in the carpal tunnel
. An unrecognized concomitant scaphoid fracture with subsequent collapse
. Adhesion of the extensor pollicis brevis tendon within the first dorsal compartment

Correct Answer & Explanation

. Ischemic necrosis and mechanical attrition of the extensor pollicis longus tendon at Lister's tubercle

Explanation

Extensor pollicis longus (EPL) tendon rupture is a well-known complication of distal radius fractures, occurring most frequently in non-displaced or minimally displaced fractures. The tendon undergoes vascular ischemia (it is in a watershed zone) and mechanical attrition as it glides over fracture callus or sharp cortical edges at Lister's tubercle in the third dorsal compartment.

Question 1765

Topic: 7. Hand and Wrist

A 40-year-old manual laborer presents with advanced Scaphoid Nonunion Advanced Collapse (SNAC). Radiographs demonstrate severe radioscaphoid and capitolunate arthritis, but the radiolunate joint space is well preserved. Which of the following surgical interventions is most appropriate?

. Proximal row carpectomy (PRC)
. Scaphoid excision and four-corner fusion
. Total wrist arthrodesis
. Radial styloidectomy
. Open reduction internal fixation of the scaphoid with vascularized bone grafting

Correct Answer & Explanation

. Scaphoid excision and four-corner fusion

Explanation

This patient has Stage 3 SNAC wrist, characterized by capitolunate arthritis in addition to radioscaphoid arthritis, with sparing of the radiolunate articulation. A proximal row carpectomy (PRC) is contraindicated because it relies on a healthy capitate articular surface to articulate with the lunate fossa of the radius. Scaphoid excision and four-corner fusion (capitate, lunate, hamate, triquetrum) is the procedure of choice as it fuses the arthritic midcarpal joint while preserving functional flexion/extension through the spared radiolunate joint.

Question 1766

Topic: Nerve & Tendon
A 25-year-old sustains a volar laceration to the index finger in Zone II. Surgical exploration reveals complete transection of the FDS and FDP tendons. Following a 4-strand core repair of the FDP and an epitendinous repair, there is noticeable catching of the repair site on the A2 pulley during passive flexion, limiting glide. What is the most appropriate next step?
. Perform a WALANT assessment postoperatively to intentionally break adhesions
. Resect the FDS slips completely to reduce volume and allow FDP gliding
. Vent the A2 pulley up to 50% of its length to accommodate the repair site
. Excise the A2 pulley completely and reconstruct it with a palmaris longus autograft
. Revise the repair to a 2-strand core suture to reduce bulk

Correct Answer & Explanation

. Vent the A2 pulley up to 50% of its length to accommodate the repair site

Explanation

Historically, preservation of the entire A2 and A4 pulleys was considered absolute to prevent bowstringing. However, modern flexor tendon repair protocols dictate that venting up to 50% or even 75% of the A2 pulley (typically the proximal or distal aspect) is acceptable and preferred to allow smooth tendon gliding and prevent triggering or repair rupture. 4-strand or 6-strand repairs are preferred for early active motion protocols, so downgrading to a weaker 2-strand repair is inappropriate.

Question 1767

Topic: 7. Hand and Wrist

A 28-year-old man sustains a complete laceration of the ulnar nerve in the proximal arm. To maximize the chance of restoring intrinsic hand function before irreversible motor endplate loss occurs, a distal nerve transfer is planned. Which donor nerve is most commonly utilized for transfer to the deep motor branch of the ulnar nerve?

. Terminal branch of the posterior interosseous nerve (PIN)
. Branch of the median nerve to the flexor digitorum superficialis (FDS)
. Branch of the anterior interosseous nerve (AIN) to the pronator quadratus
. Superficial sensory branch of the radial nerve (SBRN)
. Palmar cutaneous branch of the median nerve

Correct Answer & Explanation

. Branch of the anterior interosseous nerve (AIN) to the pronator quadratus

Explanation

For high ulnar nerve injuries, recovery of the intrinsic muscles of the hand is exceptionally poor due to the long distance the regenerating axons must travel. The standard 'supercharged' end-to-side or complete end-to-end nerve transfer involves taking the terminal branch of the anterior interosseous nerve (AIN) that innervates the pronator quadratus and transferring it to the deep motor branch of the ulnar nerve at the wrist.

Question 1768

Topic: 7. Hand and Wrist

A 24-year-old gymnast falls onto a hyperextended wrist. Imaging reveals a transverse fracture of the scaphoid waist and a transverse fracture of the capitate. Notably, the proximal capitate fragment is rotated 180 degrees. What is the classic eponym for this specific injury pattern?

. Naviculocapitate syndrome
. Fenton's syndrome
. Barton's syndrome
. Chauffeur's fracture complex
. SLAC wrist variant

Correct Answer & Explanation

. Naviculocapitate syndrome

Explanation

This injury pattern is classically known as scaphocapitate syndrome or Fenton's syndrome. The proposed mechanism involves extreme hyperextension of the wrist where the dorsal lip of the radius strikes the capitate causing a fracture, and the scaphoid fractures simultaneously. The proximal capitate fragment often rotates 90 to 180 degrees. Treatment requires open reduction and internal fixation of both fractures to prevent nonunion and avascular necrosis.

Question 1769

Topic: 7. Hand and Wrist

A 28-year-old carpenter amputates the tip of his right index finger. Examination reveals a volar oblique amputation with 4 mm of exposed distal phalanx bone. The nail bed is largely intact dorsally. Which of the following is the most appropriate reconstructive option for providing durable, sensate coverage?

. V-Y advancement flap (Atasoy)
. Bilateral V-Y advancement flaps (Kutler)
. Volar advancement flap (Moberg)
. Cross-finger flap
. Healing by secondary intention

Correct Answer & Explanation

. Cross-finger flap

Explanation

A volar oblique fingertip amputation with exposed bone requires soft tissue coverage, as healing by secondary intention is inappropriate for exposed bone >1-2 cm or prominent bone. The cross-finger flap is the workhorse for volar oblique amputations in the fingers, transferring dorsal skin from an adjacent digit. The Moberg flap is largely restricted to the thumb due to its independent dorsal blood supply. Atasoy and Kutler flaps are best for transverse or dorsal oblique amputations.

Question 1770

Topic: 7. Hand and Wrist

A 30-year-old male sustains a closed, isolated, transverse shaft fracture of the second metacarpal (index finger) of his dominant hand. Radiographs show 25 degrees of apex dorsal angulation and no rotational deformity. What is the most appropriate treatment?

. Buddy taping and immediate motion
. Ulnar gutter splinting for 4 weeks
. Radial gutter splinting for 4 weeks
. Closed reduction and percutaneous pinning
. Open reduction and internal fixation

Correct Answer & Explanation

. Open reduction and internal fixation

Explanation

The carpometacarpal (CMC) joints of the index and long fingers are highly rigid, offering virtually no compensatory motion in the sagittal plane. Therefore, fractures of the 2nd and 3rd metacarpals tolerate very little apex dorsal angulation (acceptable limits are typically <10 to 15 degrees). An angulation of 25 degrees will lead to a painful grip and a pseudoclaw deformity. Operative intervention (ORIF or CRPP, but ORIF is definitive for 25 deg in the 2nd MC) is indicated. In contrast, the 4th and 5th metacarpals tolerate much greater angulation (up to 30-40+ degrees) due to their mobile CMC joints.

Question 1771

Topic: Wrist & Carpus

Six months following open reduction and internal fixation of a distal radius fracture with a volar locking plate, a 55-year-old woman is unable to actively flex the interphalangeal joint of her thumb. Which of the following technical errors during the index procedure is the most likely cause of this complication?

. Placement of the plate proximal to the watershed line
. Prominence of the plate distal to the watershed line
. Drilling past the dorsal cortex with a sharp drill bit
. Failure to repair the pronator quadratus during closure
. Use of locking screws that are too long in the distal row

Correct Answer & Explanation

. Prominence of the plate distal to the watershed line

Explanation

Rupture of the flexor pollicis longus (FPL) tendon is a well-recognized complication of volar plating of the distal radius. It is most commonly caused by hardware prominence distal to the watershed line (the most volar margin of the radius). The tendon glides over the sharp distal edge of the plate, leading to attritional rupture. Placement proximal to the watershed line is the correct technique to avoid this. Long distal screws would cause extensor tendon rupture, not flexor.

Question 1772

Topic: 7. Hand and Wrist

A 25-year-old man sustains a low-velocity civilian gunshot wound to the anterior right elbow. Radiographs show a nondisplaced supracondylar humerus fracture. Neurological exam reveals an inability to flex the IP joint of the thumb and the DIP joint of the index finger, with complete loss of two-point discrimination over the volar tip of the index finger. What is the most appropriate management of the nerve injury?

. Immediate surgical exploration of the median nerve
. Delayed exploration at 3 weeks if no improvement is seen
. Observation and EMG at 3 months if no recovery is noted
. Immediate nerve grafting of the anterior interosseous nerve
. Prophylactic fasciotomy and carpal tunnel release

Correct Answer & Explanation

. Observation and EMG at 3 months if no recovery is noted

Explanation

The patient has a median nerve palsy (involving AIN motor branches and proper sensory branches to the index finger). Neurological deficits associated with low-velocity gunshot wounds to the extremities are typically neurapraxias or axonotmesis resulting from the concussive shock wave of the bullet. The standard of care is non-operative observation initially. If there is no clinical recovery by 3 months, an EMG is obtained, and surgical exploration is considered if no reinnervation potentials are present. Immediate exploration is reserved for vascular injury, severe contamination, or if the deficit occurs after reduction.

Question 1773

Topic: 7. Hand and Wrist

A 30-year-old skier presents with a painful, swollen thumb metacarpophalangeal (MCP) joint after a fall. Examination demonstrates 40 degrees of radial deviation laxity when the MCP joint is stressed in 30 degrees of flexion, with no palpable endpoint. Ultrasound confirms a Stener lesion. Which of the following accurately describes the anatomy of a Stener lesion?

. The distal avulsion of the UCL is displaced superficial to the adductor pollicis aponeurosis
. The proximal avulsion of the UCL is displaced deep to the adductor pollicis aponeurosis
. The volar plate is interposed between the ruptured ends of the UCL
. The extensor pollicis brevis tendon prevents spontaneous reduction of the UCL
. The distal UCL is trapped beneath the transverse carpal ligament

Correct Answer & Explanation

. The distal avulsion of the UCL is displaced superficial to the adductor pollicis aponeurosis

Explanation

A Stener lesion occurs in complete ruptures of the ulnar collateral ligament (UCL) of the thumb (Skier's thumb). The ligament typically avulses from its distal insertion on the proximal phalanx. In a Stener lesion, the torn distal end retracts and displaces superficial to the adductor pollicis aponeurosis. Because the aponeurosis becomes interposed between the ligament and its insertion site, spontaneous healing is impossible, and operative repair is indicated.

Question 1774

Topic: Hand Trauma & Infection

A 32-year-old dishwasher presents with a swollen, throbbing index finger 3 days after sustaining a puncture wound from a dirty wire brush. Examination reveals uniform fusiform swelling of the digit, a semi-flexed posture of the finger, severe pain on passive extension, and exquisite tenderness along the entire flexor tendon sheath. Which of the following organisms is the most common cause of this condition?

. Streptococcus pyogenes
. Staphylococcus aureus
. Pasteurella multocida
. Eikenella corrodens
. Mycobacterium marinum

Correct Answer & Explanation

. Staphylococcus aureus

Explanation

The patient exhibits Kanavel's four cardinal signs of infectious flexor tenosynovitis: fusiform swelling, flexed posture, pain on passive extension, and tenderness along the flexor sheath. Staphylococcus aureus is by far the most common causative organism for this surgical emergency. Pasteurella is associated with cat bites, Eikenella with human bites, and Mycobacterium marinum with fish tank exposures.

Question 1775

Topic: 7. Hand and Wrist

A 55-year-old woman is 6 months postoperative from an open reduction and internal fixation of a distal radius fracture with a volar locked plate. She now presents with a new inability to actively flex the interphalangeal joint of her thumb. Radiographs reveal the plate is positioned distal to the watershed line. Which of the following structures is most likely injured?

. Flexor carpi radialis (FCR)
. Flexor pollicis longus (FPL)
. Flexor digitorum profundus (FDP) to the index finger
. Median nerve
. Extensor pollicis longus (EPL)

Correct Answer & Explanation

. Flexor pollicis longus (FPL)

Explanation

The flexor pollicis longus (FPL) tendon lies directly over the volar distal radius. Volar plates placed distal to the watershed line (the volar margin of the distal radius articular surface) prominent hardware can cause attrition and subsequent rupture of the FPL tendon. The EPL tendon is at risk from screws penetrating the dorsal cortex.

Question 1776

Topic: 7. Hand and Wrist

Avascular necrosis of the proximal pole of the scaphoid is a frequent complication following a scaphoid waist fracture. The primary blood supply to the proximal pole is derived from which of the following vessels?

. Volar carpal branch of the radial artery
. Dorsal carpal branch of the radial artery
. Anterior interosseous artery
. Superficial palmar arch
. Deep palmar arch

Correct Answer & Explanation

. Dorsal carpal branch of the radial artery

Explanation

The scaphoid has a retrograde blood supply. The major blood supply to the scaphoid (and specifically the proximal pole) enters the dorsal ridge distal to the waist via the dorsal carpal branch of the radial artery. Fractures at the waist or proximally interrupt this retrograde flow, leading to avascular necrosis of the proximal pole.

Question 1777

Topic: 7. Hand and Wrist

A 22-year-old boxer sustains a Bennett fracture. The fracture pattern consists of a small volar-ulnar base fragment with proximal, dorsal, and radial subluxation of the metacarpal shaft. Which ligament securely anchors the small volar-ulnar fragment in its anatomical position?

. Dorsal radial ligament
. Volar oblique ligament (Anterior oblique ligament)
. Ulnar collateral ligament
. Intermetacarpal ligament
. Radial collateral ligament

Correct Answer & Explanation

. Volar oblique ligament (Anterior oblique ligament)

Explanation

In a Bennett fracture, the shaft of the thumb metacarpal is pulled proximally, dorsally, and radially by the abductor pollicis longus (APL). However, the small volar-ulnar base fragment remains precisely in its anatomical location, securely tethered to the trapezium by the strong volar oblique ligament (also known as the anterior oblique ligament).

Question 1778

Topic: 7. Hand and Wrist

A 32-year-old manual laborer presents with progressive dorsal wrist pain. Radiographs demonstrate sclerosis, cystic changes, and fragmentation of the lunate, with an ulnar variance of minus 3 mm. Which of the following is the most appropriate surgical treatment for this patient?

. Proximal row carpectomy
. Radial shortening osteotomy
. Ulnar shortening osteotomy
. Four-corner fusion
. Scaphoid excision

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

The clinical scenario describes Kienbock's disease (avascular necrosis of the lunate). In patients with negative ulnar variance (ulna minus) who do not yet have advanced radiocarpal arthritis or complete carpal collapse, joint-leveling procedures are indicated to unload the lunate. A radial shortening osteotomy is the standard joint-leveling procedure used in this scenario.

Question 1779

Topic: Nerve & Tendon

During an anterior subcutaneous transposition of the ulnar nerve for cubital tunnel syndrome, the nerve must be completely mobilized. Failure to release which of the following structures located approximately 8 cm proximal to the medial epicondyle can lead to new iatrogenic compression of the ulnar nerve?

. Osborne's fascia
. Arcade of Struthers
. Ligament of Struthers
. Medial intermuscular septum
. Aponeurosis of the flexor carpi ulnaris

Correct Answer & Explanation

. Arcade of Struthers

Explanation

The Arcade of Struthers is a fascial band extending from the medial head of the triceps to the medial intermuscular septum, located about 8 cm proximal to the medial epicondyle. If not divided during anterior transposition, it creates a new tethering point for the ulnar nerve. (Note: The Ligament of Struthers is associated with the median nerve and a supracondylar process, which is a classic distractor).

Question 1780

Topic: 7. Hand and Wrist
According to the Mayfield classification of progressive perilunate instability, a Stage III injury is defined by the disruption of which of the following specific structures?
. Scapholunate interosseous ligament
. Radioscaphocapitate ligament
. Lunotriquetral interosseous ligament
. Dorsal radiocarpal ligament
. Palmar radiolunate ligament

Correct Answer & Explanation

. Dorsal radiocarpal ligament

Explanation

Mayfield described four stages of progressive perilunate instability that occur in a sequential, C-shaped pattern around the lunate: Stage I (scapholunate ligament tear), Stage II (capitolunate disruption/space), Stage III (lunotriquetral ligament tear, resulting in a perilunate dislocation), and Stage IV (dorsal radiocarpal ligament tear with volar dislocation of the lunate into the carpal tunnel).

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