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7. Hand and Wrist MCQs

Practice Set 92 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 1821

Topic: 7. Hand and Wrist

In zone II flexor tendon injuries, preserving or reconstructing the annular pulley system is crucial to prevent bowstringing and maintain digital flexion efficiency. Biomechanically, which two pulleys are the most critical to preserve?

. A1 and A3
. A2 and A4
. A3 and A5
. A1 and A5
. A2 and C1

Correct Answer & Explanation

. A2 and A4

Explanation

The A2 pulley (located over the proximal aspect of the proximal phalanx) and the A4 pulley (located over the middle of the middle phalanx) are the most biomechanically critical components of the flexor tendon sheath. Loss of these specific pulleys leads to profound bowstringing, diminished active range of motion, and loss of mechanical advantage during finger flexion.

Question 1822

Topic: Wrist & Carpus

In Scapholunate Advanced Collapse (SLAC) of the wrist, progressive osteoarthritis occurs in a predictable pattern, typically advancing from the radioscaphoid joint to the capitolunate joint. Which biomechanical factor best explains why the radiolunate joint is consistently spared?

. The radiolunate ligaments undergo early pathological contracture.
. The capitate translates ulnarly, unloading the radiolunate joint.
. The lunate is devoid of hyaline cartilage on its proximal articular surface.
. The spherical congruency of the lunate fossa prevents pathological shear forces.
. The triangular fibrocartilage complex (TFCC) redistributes loads away from the lunate.

Correct Answer & Explanation

. The spherical congruency of the lunate fossa prevents pathological shear forces.

Explanation

In the SLAC wrist, the radioscaphoid joint degenerates first because the distal pole of the scaphoid rotates into flexion, creating incongruence and pathological shear stresses against the elliptical scaphoid fossa. In contrast, the lunate fossa of the distal radius and the proximal lunate are spherically congruent. Even when the lunate rotates into extension (DISI deformity), it remains concentrically loaded without abnormal shear forces, thereby preserving the radiolunate articular cartilage.

Question 1823

Topic: Wrist & Carpus

In a volar Barton's fracture, the carpus typically subluxates volarly in conjunction with the volar marginal fracture fragment of the distal radius. Which of the following ligaments remains firmly attached to the lunate facet fragment, pulling the carpus volarly?

. Radioscaphocapitate ligament
. Short radiolunate ligament
. Long radiolunate ligament
. Scapholunate interosseous ligament
. Volar radioulnar ligament

Correct Answer & Explanation

. Short radiolunate ligament

Explanation

A volar Barton's fracture involves the volar lip of the distal radius lunate fossa. The short radiolunate ligament attaches firmly to this specific volar marginal fragment. When the fragment fractures and displaces volarly, the short radiolunate ligament pulls the lunate (and thus the rest of the carpus) along with it, causing the characteristic volar radiocarpal subluxation.

Question 1824

Topic: Nerve & Tendon

To prevent significant biomechanical bowstringing of the flexor pollicis longus (FPL) tendon and loss of thumb interphalangeal flexion strength, which pulley within the thumb flexor pulley system is considered the most critical to preserve during surgery?

. A1 pulley
. A2 pulley
. Oblique pulley
. Annular pulley
. Palmar aponeurosis pulley

Correct Answer & Explanation

. Oblique pulley

Explanation

The thumb flexor pulley system consists of the A1, oblique, and A2 pulleys. The oblique pulley is classically considered the most biomechanically critical pulley in the thumb to prevent bowstringing of the FPL tendon and maintain effective excursion and flexion of the IP joint. Loss of the oblique pulley, especially in combination with the A1 pulley, leads to significant bowstringing.

Question 1825

Topic: 7. Hand and Wrist

A 40-year-old mechanic sustains a fall onto an outstretched hand, resulting in a complex carpal injury. Subsequent radiographs demonstrate a volar intercalated segment instability (VISI) deformity. This specific carpal alignment pattern is most strongly associated with a complete tear of which of the following ligaments?

. Scapholunate interosseous ligament
. Lunotriquetral interosseous ligament
. Radioscaphocapitate ligament
. Dorsal radiocarpal ligament
. Ulnocarpal ligament complex

Correct Answer & Explanation

. Lunotriquetral interosseous ligament

Explanation

A VISI deformity occurs when the lunate flexes volarly, typically due to the loss of the extending force from the triquetrum following a lunotriquetral interosseous ligament tear. In contrast, scapholunate tears lead to a dorsal intercalated segment instability (DISI) pattern.

Question 1826

Topic: Nerve & Tendon

A 21-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. Examination shows tenderness in the palm. Imaging confirms a Type 1 flexor digitorum profundus (FDP) avulsion (Jersey finger) retracted into the palm. What is the most critical timing consideration for surgical repair of this specific injury type?

. Repair must be performed within 7 to 10 days
. Repair should be delayed until 6 weeks post-injury
. Repair must be performed within 24 hours as an emergency
. Nonoperative management in an extension splint for 8 weeks
. Immediate two-stage tendon grafting is required

Correct Answer & Explanation

. Repair must be performed within 7 to 10 days

Explanation

A Type 1 Jersey finger involves retraction of the FDP tendon into the palm, disrupting both vincula and depriving the tendon of its blood supply. Surgical repair must be performed within 7 to 10 days to prevent permanent tendon necrosis and contracture.

Question 1827

Topic: Nerve & Tendon

A patient with severe chronic cubital tunnel syndrome is asked to pinch a piece of paper between their thumb and index finger. The examiner notes compensatory hyperflexion of the thumb interphalangeal (IP) joint (a positive Froment's sign). This clinical finding is driven by the weakness of which of the following specific muscles?

. Adductor pollicis
. Abductor pollicis brevis
. Flexor pollicis longus
. Opponens pollicis
. First dorsal interosseous

Correct Answer & Explanation

. Adductor pollicis

Explanation

Froment's sign occurs due to weakness of the ulnar-innervated adductor pollicis muscle. To compensate for the inability to strongly adduct the thumb during pinch, the patient recruits the median-innervated flexor pollicis longus, leading to thumb IP hyperflexion.

Question 1828

Topic: Wrist & Carpus

A 32-year-old male sustains a distal radius fracture combined with a distal radioulnar joint (DRUJ) dislocation. Following anatomic reduction and fixation of the radius, the DRUJ remains grossly unstable in supination. The primary anatomical stabilizer of the DRUJ that is likely disrupted in this injury is the:

. Triangular Fibrocartilage Complex (TFCC)
. Extensor carpi ulnaris (ECU) subsheath
. Interosseous membrane
. Pronator quadratus muscle
. Volar radiocarpal ligament

Correct Answer & Explanation

. Triangular Fibrocartilage Complex (TFCC)

Explanation

The Triangular Fibrocartilage Complex (TFCC), specifically its deep dorsal and volar radioulnar ligaments (ligamentum subcruentum), is the primary stabilizer of the distal radioulnar joint (DRUJ). Disruption leads to gross DRUJ instability despite anatomic radius fixation.

Question 1829

Topic: 7. Hand and Wrist
A 55-year-old woman underwent a volar plating of an extra-articular distal radius fracture 2 weeks ago. She is experiencing weakness with flexion of the interphalangeal (IP) thumb joint. IP joint flexion was normal before surgery. What is the best next step?
. Observation
. Electromyogram/nerve conduction study (EMG/NCS)
. CT scan
. Immediate exploration

Correct Answer & Explanation

. Observation

Explanation

Prevalence of flexor tendon rupture after distal radius fracture is between 2% and 12%. The FPL tendon is the most common flexor tendon rupture associated with volar plating. FPL weakness after volar distal radius plating is common and has been seen in as many as 50% of patients. This usually recovers spontaneously by 2 months, and no treatment is needed. A nerve conduction study would be indicated if an anterior interosseous nerve compression were considered, but it is too early for this test. A CT scan could be obtained to judge the alignment of the fracture fragment and position of the screws, but it is not indicated in this case. Exploration could be performed if an FPL rupture were considered, but because it is only 2 weeks after surgery and there is some FPL function, immediate exploration is not indicated.

Question 1830

Topic: Wrist & Carpus

A 26-year-old man falls off a motorcycle and injures his left wrist. There are no open wounds and the neurovascular examination is normal. Radiographs

. closed reduction and casting.
. external fixation and percutaneous pinning of the distal radius.
. open reduction and internal fixation of the distal radius.
. open reduction and internal fixation of the distal radius and open repair of the ulnar styloid.
. nonbridging external fixation of the distal radius.

Correct Answer & Explanation

. open reduction and internal fixation of the distal radius.

Explanation

The patient has a high-energy injury with resultant comminution of the distal radius metaphysis. Cast immobilization is likely to lead to radial shortening and angulation due to the comminution. Similarly, while external fixation and pinning has been successful in the past, some loss of radial length and volar angulation is typically noted. Present plate fixation devices for the distal radius employing locking screw technology have a superior ability to resist radial shortening and dorsal angulation. Fixation of the ulnar styloid is warranted when there is distal radioulnar joint instability or significant displacement of the styloid. This is more likely to occur with a fracture at the base of the styloid. In this instance, the distal radioulnar joint does not appear to be disrupted.

Question 1831

Topic: 7. Hand and Wrist

A 25-year-old woman has had continuous pain after falling on her outstretched wrist 12 weeks ago. A current radiograph is shown in Figure 11. Management should consist of

Trauma 2000 Practice Questions: Set 1 (Solved) - Figure 30

. open reduction and internal fixation with bone grafting.
. closed reduction and percutaneous pin fixation.
. aspiration and steroid injection.
. closed manipulation and a long arm cast.
. in situ open bone grafting.

Correct Answer & Explanation

. open reduction and internal fixation with bone grafting.

Explanation

The patient has a scaphoid fracture with cystic resorption of the distal aspect of the midthird of the scaphoid. This fracture is unlikely to heal without intervention. Percutaneous pinning, closed manipulation, and bone grafting will not restore alignment. Treatment requires restoration of scaphoid length, bone grafting, and internal fixation to obtain healing with normal alignment. Cooney WP, Linscheid RL, Dobyns JH, Wood MB: Scaphoid nonunion: Role of anterior interpositional bone grafts. J Hand Surg Am 1988;13:635-650. Fernandez DL: A technique for anterior wedge-shaped grafts for scaphoid nonunions with carpal instability. J Hand Surg Am 1984;9:733-737. Stark HH, Rickard TA, Zemel NP, Ashworth CR: Treatment of ununited fractures of the scaphoid by illiac bone grafts and Kirschner-wire fixation. J Bone Joint Surg Am 1988;70:982-991.

Question 1832

Topic: 7. Hand and Wrist

A 32-year-old amateur bowler has progressive pain in the lateral aspect of the proximal forearm and elbow. Nonsurgical management consisting of a tennis elbow brace, nonsteroidal anti-inflammatory drugs, and activity modification has failed to provide relief. Examination reveals tenderness in the lateral aspect of the proximal forearm and exacerbation of symptoms with resisted finger extension. Radiographs of the elbow reveal no abnormalities. Which of the following studies will aid in diagnosis?

. MRI of the elbow and forearm
. Bone scan
. Electrodiagnostic studies
. Radial tunnel injection
. Radiographs of the wrist

Correct Answer & Explanation

. Radial tunnel injection

Explanation

It is often difficult to accurately discern between lateral epicondylitis and radial tunnel syndrome. Neither MRI nor a bone scan is likely to reveal abnormalities. Electrodiagnostic studies are often inconclusive, and radial tunnel syndrome often presents without motor weakness. The symptoms of radial tunnel syndrome are expected to improve with an injection of lidocaine into the radial tunnel; therefore, this is the test of choice in this clinical scenario. Radiographs of the wrist will not assist in making the diagnosis. Eversmann WW Jr: Entrapment and compression neuropathies, in Green DP (ed): Operative Hand Surgery, ed 3. New York, NY, Churchill Livingston, 1993, pp 1341-1385.

Question 1833

Topic: 7. Hand and Wrist

A 22-year-old college quarterback is tackled and sustains a reducible first carpometacarpal dislocation. What is the recommended treatment?

. Closed reduction and casting
. Closed reduction and percutaneous pinning
. First carpometacarpal arthrodesis
. Dorsal capsulodesis
. Ligament reconstruction using tendon autograft

Correct Answer & Explanation

. Ligament reconstruction using tendon autograft

Explanation

When comparing closed reduction and pinning to ligament reconstruction, the reconstruction group had slightly better abduction and pinch strength. The volar oblique ligament usually tears off the first metacarpal in a subperiosteal fashion. In this young patient, motion-sparing procedures are preferred. Simonian PT, Trumble TE: Traumatic dislocation of the thumb carpometacarpal joint: Early ligamentous reconstruction versus closed reduction and pinning. J Hand Surg Am 1996;21;802-806.

Question 1834

Topic: 7. Hand and Wrist

A 25-year-old construction worker lands on his outstretched hand in a fall. The position of his wrist at the time of impact causes a force that leads to hyperextension, ulnar deviation, and intercarpal supination. Radiographs are shown in Figures 48a and 48b. Management should consist of

. closed reduction and a long arm cast.
. closed reduction, percutaneous pin fixation, and a long arm cast.
. closed reduction and an external fixator.
. open reduction and internal fixation and soft-tissue repair.
. proximal row carpectomy.

Correct Answer & Explanation

. open reduction and internal fixation and soft-tissue repair.

Explanation

Open reduction and internal fixation is the treatment of choice for accurate reduction of the disrupted intercarpal ligaments. In addition, the displaced scaphoid fracture will require open reduction and internal fixation and possible bone grafting. Closed reduction and long arm casting will not allow accurate reduction of the dislocated intracarpal intervals, and it is unlikely to allow accurate reduction of the scaphoid. The maneuver required to effect closed reduction of a displaced scaphoid fracture will most likely cause the scaphoid lunate interval to displace. Closed reduction with percutaneous pin fixation or with an external fixator is unable to effect anatomic reduction of the injury. Proximal row carpectomy is used as a salvage procedure for a variety of degenerative and posttraumatic problems of the wrist. Kozin SH: Perilunate injuries: Diagnosis and treatment. J Am Acad Orthop Surg 1998;6:114-120. Herzberg G, Comtet JJ, Linscheid RL, Amadio PC, Cooney WP, Stalder J: Perilunate dislocations and fracture-dislocations: A multicenter study. J Hand Surg Am 1993;18:768-779.

Question 1835

Topic: 7. Hand and Wrist

A patient with rheumatoid arthritis has a rupture of the extensor digitorum communis to 4 and 5. You are planning to perform an extensor indicis proprius (EIP) tendon transfer. What effect will this have on index finger extension?

. No effect
. Index finger weakness
. Index metacarpophalangeal hyperextension
. Index metacarpophalangeal hyperflexion
. Index metacarpophalangeal ulnar deviation

Correct Answer & Explanation

. No effect

Explanation

EIP transfer results in no functional deficit. If the tendon is cut proximal to the sagittal band, there will be no extensor deficit. Browne EX, Teague MA, Snyder CC: Prevention of extensor lag after indicis proprius transfer. J Hand Surg Am 1979;4:168-172.

Question 1836

Topic: 7. Hand and Wrist

Figure 20 shows the radiograph of a 21-year-old college basketball player who jammed his left index finger on the rim. He reports pain and tenderness over the dorsum of the distal interphalangeal (DIP) joint. Examination reveals that he is unable to actively extend the DIP joint; however, the skin is intact. Management should consist of

Sports Medicine Board Review 2004: High-Yield MCQs (Set 2) - Figure 17

. buddy taping to the adjacent digit.
. open reduction and surgical fixation of the bony fragment.
. excision of the bony fragment and advancement of the terminal extensor mechanism.
. splinting of the DIP joint with intermittent removal and range-of-motion exercises to prevent stiffness.
. full-time splinting of the DIP joint in slight hyperextension for 6 weeks.

Correct Answer & Explanation

. full-time splinting of the DIP joint in slight hyperextension for 6 weeks.

Explanation

Mallet fingers without DIP joint subluxation can be treated with extension splinting. Surgical fixation may be necessary in bony mallet injuries when the joint is subluxated. Size of the bony fragment, while often correlating with stability, is not always an indication for fixation. Buddy taping allows motion; therefore, the fragment will not heal in the appropriate position. Intermittent splinting with range-of-motion exercises also will not allow the fragment to heal in the appropriate position. Crawford GP: The molded polyethylene splint for mallet finger deformities. J Hand Surg Am 1984;9:231-237.

Question 1837

Topic: 7. Hand and Wrist

An 8-month-old infant has an infection of the fingertip as shown in Figure 22. If neglected, the anticipated path of ascending infection is the fingertip, the flexor sheath, and the

Anatomy Board Review 2005: High-Yield MCQs (Set 2) - Figure 15

. midpalmar space.
. thenar space.
. hypothenar space.
. ulnar bursa.
. radial bursa.

Correct Answer & Explanation

. midpalmar space.

Explanation

The flexor sheaths are in continuity with the deep spaces of the hand. The flexor sheaths of the thumb and little finger communicate with the radial and ulnar bursae, respectively, and these two bursae commonly communicate. The central digits do not communicate as readily with deep spaces of the hand but if flexor tendon sheath infection of the index, long, and right fingers is neglected, the potential exists for rupture into the deep midpalmar spaces. Peimer CA (ed): Surgery of the Hand and Upper Extremity: Acute and Chronic Sepsis. New York, NY, Mcgraw Hill, 1996, pp 1735-1741.

Question 1838

Topic: 7. Hand and Wrist

Figures 45a and 45b show the radiographs of a 14-year-old boy who sustained a distal radius fracture while playing hockey. After 1 year the patient is asymptomatic. Follow-up and comparison radiographs and an MRI scan are shown in Figures 45c and 45d. What is the next most appropriate step in management?

. Resection of radius growth arrest
. Performing growth arrest of the ulna
. Repair of the ulnar styloid fracture
. Perform lengthening of the radius
. Continued observation

Correct Answer & Explanation

. Performing growth arrest of the ulna

Explanation

The patient sustained a growth plate fracture of the distal radius and ulna. Although treated with closed reduction and casting, the follow-up radiographs demonstrate shortening of the radius in comparison to the ulna, and the MRI scan confirms thinning of the distal radius growth plate and bony bars consistent with a growth arrest. At this time, the discrepancy in length is too minor to consider lengthening of the radius; in addition, excision of a physeal bar with minimal growth potential is not likely to restore the gross discrepancy. Ulnar styloid fractures are rarely symptomatic and do not require treatment in the asymptomatic patient. Closure of the distal ulna growth plate will prevent further discrepancy between the radius and ulna. Vanheest A: Wrist deformities after fracture. Hand Clin 2006;22:113-120.

Question 1839

Topic: 7. Hand and Wrist

A 30-year-old man caught his dominant little finger on the straps of his windsurfing board 10 days ago. He reports swelling about the distal phalanx and has difficulty completely extending the distal interphalangeal joint. A radiograph is shown in Figure 47. What is the most appropriate treatment for this injury?

General Orthopedics Board Review 2026: High-Yield MCQs (Set 2) - Figure 26

. Extension splinting of the proximal interphalangeal and distal interphalangeal joints
. Extension splinting of the distal interphalangeal joint
. Transarticular pinning of the distal interphalangeal joint
. Extension block pinning of the distal interphalangeal joint
. Open reduction and internal fixation of the distal phalanx

Correct Answer & Explanation

. Extension splinting of the distal interphalangeal joint

Explanation

Detailed The radiograph reveals a "bony mallet injury." As the distal phalanx is not volarly subluxated, extension splinting, similar to a classic mallet injury without bony involvement, is appropriate. If there is volar subluxation associated with a large bony fragment, surgical intervention is appropriate. Baratz ME, Schmidt CC, Hughes TB: Extensor tendon injuries, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green's Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 192.

Question 1840

Topic: 7. Hand and Wrist

A patient who sustained a knife wound to the axilla 4 months ago now has profound interosseous wasting and generalized hand weakness. A brachial plexus injury is likely at which of the following locations in Figure 29?

Anatomy 2005 Practice Questions: Set 3 (Solved) - Figure 4

. B
. C
. K
. L
. O

Correct Answer & Explanation

. L

Explanation

Penetrating sharp wounds in proximity to major nerve or vascular structures should always be acutely explored. Because this patient did not seek treatment for a potentially treatable injury, interosseous wasting implies injury to the C8 and T1 nerve roots that contribute to ulnar nerve function. The most likely location for the brachial plexus injury is the location marked L or the inferior trunk. A wrist drop that is the result of radial nerve dysfunction would be expected with an injury at K or O. An upper brachial plexus palsy with loss of elbow flexion and shoulder abduction would be expected with an injury at B. A loss of elbow flexion alone would be expected following an injury at C. Netter F: The Ciba Collection of Medical Illustrations: The Musculoskeletal System. Part 1, Anatomy, Physiology and Metabolic Disorders. West Caldwell, NJ, Ciba-Geigy, 1991, vol 8, pp 28-29. Wolock B, Millesi H: Brachial plexus-applied anatomy and operative exposure, in Gelberman RH (ed): Operative Nerve Repair and Reconstruction. Philadelphia, PA, JB Lippincott, 1991, vol 2, pp 1255-1272.

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