Menu

7. Hand and Wrist MCQs

Practice Set 93 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 1841

Topic: 7. Hand and Wrist

Figures 46a through 46e show the radiographs of a 22-year-old man who injured his wrist in a motorcycle accident. He has no other injuries. What is the best course of action?

. Radiolunate fusion
. Open repair of the volar extrinsic wrist ligaments
. Open reduction and internal fixation
. Thumb spica cast immobilization for 6 weeks
. External fixator

Correct Answer & Explanation

. Open reduction and internal fixation

Explanation

The patient has a fracture-dislocation of the radiocarpal joint. Attached to the large radial styloid fragment are the extrinsic wrist ligaments to the carpus. This injury should be treated with open reduction and internal fixation of the styloid fracture. Radiolunate fusion or extrinsic ligament repair is suggested when the extrinsic ligaments are ruptured, resulting in ulnar translocation of the carpus. Dumontier C, Meyer ZU, Reckendorf G, et al: Radiocarpal dislocations: Classification and proposal for treatment: A review of twenty-seven cases. J Bone Joint Surg Am 2001;83:212.

Question 1842

Topic: 7. Hand and Wrist

An otherwise healthy 35-year-old woman reports dorsal wrist pain and has trouble extending her thumb after sustaining a minimally displaced fracture of the distal radius 3 months ago. What is the next most appropriate step in management?

Trauma Board Review 2006: High-Yield MCQs (Set 2) - Figure 9

. Neurophysiologic test to evaluate the posterior interosseous nerve
. Transfer of the extensor indicis proprius to the extensor pollicis longus tendon
. Interphalangeal joint arthrodesis of the thumb
. Extension splinting of the thumb
. Fine cut CT of the distal radius to evaluate Lister's tubercle

Correct Answer & Explanation

. Transfer of the extensor indicis proprius to the extensor pollicis longus tendon

Explanation

Extensor pollicis longus tendon rupture can occur after a fracture of the distal radius, even a minimally displaced one. Poor vascularity of the tendon within the third dorsal compartment is the suspected etiology, not the displaced fracture fragments. Tendon transfer will suitably restore active extension of the thumb interphalangeal joint. Christophe K: Rupture of the extensor pollicis longus tendon following Colles fracture. J Bone Joint Surg Am 1953;35:1003-1005.

Question 1843

Topic: 7. Hand and Wrist

A 19-year-old college student reports a 1-week history of wrist pain following an intramural rugby match. A PA radiograph is shown in Figure 6. He denies any prior wrist injury. What is the best course of action?

Trauma 2009 Practice Questions: Set 1 (Solved) - Figure 12

. Closed reduction and long arm cast immobilization
. Closed reduction and short arm cast immobilization
. Closed reduction and percutaneous pinning
. Open reduction and internal fixation with Kirschner wires
. Open reduction and internal fixation with a headless, cannulated compression screw

Correct Answer & Explanation

. Open reduction and internal fixation with a headless, cannulated compression screw

Explanation

The patient has a scaphoid fracture involving the proximal pole. Surgical treatment is recommended for such fractures because of the prolonged period of cast immobilization necessary and the increased risk of delayed union, nonunion, and/or osteonecrosis with nonsurgical management. A cannulated compression screw, inserted in the central scaphoid via a dorsal approach, is biomechanically advantageous and provides greater stability for fracture healing than Kirschner wires. Recently, good outcomes have been reported with arthroscopic-assisted percutaneous fixation of nondisplaced or minimally displaced scaphoid fractures. Rettig ME, Raskin KB: Retrograde compression screw fixation of acute proximal pole scaphoid fractures. J Hand Surg Am 1999;24:1206-1210. Chan KW, McAdams TR: Central screw placement in percutaneous screw scaphoid fixation: A cadaveric comparison of proximal and distal techniques. J Hand Surg Am 2004;29:74-79. Bedi A, Jebson PJ, Hayden RJ, et al: Internal fixation of acute non-displaced scaphoid waist fractures via a limited dorsal approach: An assessment or radiographic and functional outcomes. J Hand Surg Am 2007;32:326-333.

Question 1844

Topic: Wrist & Carpus

A patient is treated with volar plating for a distal radius fracture. The CT scan shown in Figure 15 is obtained after union of the fracture because the patient reports ongoing symptoms. The prominent hardware is most likely injuring what tendon?

Anatomy 2008 Practice Questions: Set 1 (Solved) - Figure 34

. Extensor pollicis brevis (EPB)
. Extensor carpi radialis brevis (ECRB)
. Extensor digitorum communis (EDC)
. Extensor carpi ulnaris (ECU)
. Extensor carpi radialis longus (ECRL)

Correct Answer & Explanation

. Extensor digitorum communis (EDC)

Explanation

Extensor tendon injuries have been reported after volar plating of distal radius fractures. The CT scan shows prominent dorsal hardware a few millimeters ulnar to Lister's tubercle. The second compartment, the ECRL and ECRB, is radial to Lister's tubercle. The ECU runs along the distal ulna. The contents of the fourth dorsal compartment run just ulnar to Lister's tubercle. The EDC tendon is likely irritated in this patient. The EPB runs along the radial border of the radius and is well away from prominent hardware. Benson EC, Decarvalho A, Mikola EA, et al: Two potential causes of EPL rupture after distal radius volar plate fixation. Clin Orthop Relat Res 2006;451:218-222.

Question 1845

Topic: Wrist & Carpus

A 36-year-old woman is placed in a short arm cast for a nondisplaced extra-articular distal radius fracture. Seven weeks later she notes the sudden inability to extend her thumb. What is the most likely cause of her condition?

General Orthopedics Board Review 2026: High-Yield MCQs (Set 10) - Figure 82

. Posterior interosseous nerve palsy
. Cervical disk herniation
. Entrapment of the flexor pollicis longus tendon
. Rupture of the extensor pollicis longus tendon
. Metacarpophalangeal joint dislocation

Correct Answer & Explanation

. Rupture of the extensor pollicis longus tendon

Explanation

Detailed A recent review of 200 consecutive distal radius fractures noted that the overall incidence of extensor pollicis longus rupture was 3%. The causes are believed to be mechanical irritation, attrition, and vascular impairment. The fracture is usually nondisplaced and the patient notes weeks to months after injury the sudden, painless inability to extend the thumb. Treatment involves extensor indicis proprius tendon transfer or free palmaris longus tendon grafting. Skoff HD: Postfracture extensor pollicis longus tenosynovitis and tendon rupture: A scientific study and personal series. Am J Orthop 2003;32:245-247. Bonatz E, Kramer TD, Masear VR: Rupture of the extensor pollicis longus tendon. Am J Orthop 1996;25:118-122.

Question 1846

Topic: 7. Hand and Wrist

A purulent flexor tenosynovitis of the thumb may communicate with the small finger flexor through which of the following structures?

Anatomy 2002 Practice Questions: Set 1 (Solved) - Figure 23

. Hypothenar space
. Thenar space
. Midpalmar space
. Distal forearm (Parona's space)
. Lumbrical canal

Correct Answer & Explanation

. Distal forearm (Parona's space)

Explanation

Only the flexor sheaths of the thumb and small finger are continuous from the digit through the carpal canal and into the distal forearm. If one of the sheaths ruptures from synovitis, it may contaminate the other sheath through Parona's space in the distal forearm. This potential space lies superficial to the pronator quadratus and deep to the flexor tendons. Green DP, Hotchkiss RN, Pederson WC (eds): Operative Hand Surgery, ed 4. New York, NY, Churchill Livingstone, 1999, pp 1044-1045.

Question 1847

Topic: 7. Hand and Wrist

When performing a bunionectomy with a release of the lateral soft-tissue structures, the surgeon is cautioned against releasing the conjoined tendon that inserts along the lateral base of the proximal phalanx of the great toe. This conjoined tendon is made up of what two muscles?

. Flexor hallucis longus and flexor hallucis brevis
. Flexor hallucis longus and adductor hallucis
. Flexor hallucis brevis and adductor hallucis
. Flexor hallucis longus and abductor hallucis
. Flexor hallucis brevis and abductor hallucis

Correct Answer & Explanation

. Flexor hallucis brevis and adductor hallucis

Explanation

Owens and Thordardson cautioned surgeons not to release the conjoined tendon from the base of the proximal phalanx of the great toe because of an increased risk of iatrogenic hallux varus. Release of the transverse and oblique heads of the adductor hallucis is largely accomplished by releasing the soft tissue adjacent to the lateral sesamoid, without releasing tissue from the base of the proximal phalanx. The conjoined tendon is made up of the flexor hallucis brevis and the adductor hallucis. Owens S, Thordardson DB: The adductor hallucis revisited. Foot Ankle Int 2001;22:186-191.

Question 1848

Topic: 7. Hand and Wrist

A 24-year-old man who plays golf noted the immediate onset of pain on the ulnar side of his hand and has been unable to swing a club for the past 6 weeks after striking a tree root with his club during his golf swing. Examination reveals full motion of the wrist, diminished grip strength, and tenderness over the hypothenar region. A CT scan of the hand and wrist is shown in Figure 26. Management should consist of

Sports Medicine 2001 Practice Questions: Set 3 (Solved) - Figure 4

. immobilization of the wrist until the fracture heals.
. excision of the hook of the hamate.
. internal fixation of the fractured hook of the hamate.
. ultrasound therapy to promote fracture healing.
. limited intercarpal arthrodesis.

Correct Answer & Explanation

. immobilization of the wrist until the fracture heals.

Explanation

Fractures of the hook of the hamate frequently are not identified in the acute phase. Because the fracture can be difficult to see on plain radiographs, the lack of findings can lead to a painful nonunion. A carpal tunnel view may show the fracture, but a CT scan will best detect the injury. Immobilization is the treatment of choice and will result in union in most patients unless the diagnosis is delayed. However, excision of the fragment may be necessary for patients who have nonunion, persistent pain, or ulnar nerve palsy. Carroll RE, Lakin JF: Fracture of the hook of the hamate: Acute treatment. J Trauma 1993;34:803-805.

Question 1849

Topic: 7. Hand and Wrist

A 37-year-old patient with type I diabetes mellitus has a flexor tenosynovitis of the thumb flexor tendon sheath following a kitchen knife puncture wound to the volar aspect of the thumb. Left unattended, this infection will likely first spread proximally creating an abscess in which of the following spaces of the palm?

Anatomy Board Review 2008: High-Yield MCQs (Set 2) - Figure 28

. Central space
. Hypothenar space
. Carpal tunnel
. Posterior adductor space
. Thenar space

Correct Answer & Explanation

. Thenar space

Explanation

Flexor tenosynovitis of the thumb flexor tendon sheath can spread proximally and form an abscess within the thenar space of the palm. The flexor pollicis longus tendon does not pass through the central space of the palm or the hypothenar space of the palm. The flexor pollicis longus tendon does pass through the carpal tunnel, but this is not a palmar space. The three palmar spaces include the hypothenar space, the thenar space, and the central space. The posterior adductor space would likely only be involved secondarily after spread from a thenar space infection. Hollinshead W: Anatomy for Surgeons: The Back and Limbs, ed 3. Philadelphia, PA, Harper and Row, 1982, vol 3, pp 478-479.

Question 1850

Topic: 7. Hand and Wrist

Figure 53 shows the arteriogram of a 45-year-old man who has severe vasculitis. What do the findings show?

Anatomy Board Review 2008: High-Yield MCQs (Set 4) - Figure 21

. A patent ulnar artery and deep palmar arch
. A patent ulnar artery and superficial palmar arch
. A patent radial artery and deep palmar arch
. A patent radial artery and superficial palmar arch
. A patent radial artery and an ulnar artery aneurysm

Correct Answer & Explanation

. A patent radial artery and deep palmar arch

Explanation

The arterial supply to the hand is abundant and normally duplicated. The deep palmar arch as shown in this arteriogram typically receives its primary contribution from the radial artery which travels deep to the first dorsal compartment tendons and then returns to the volar aspect of the palm through the first web space. The superficial palmar arch receives its supply from the ulnar artery and is not visualized in this patient.

Question 1851

Topic: Nerve & Tendon

A 25-year-old professional baseball pitcher reports a 4-month history of gradually increasing medial elbow pain that occurs during the late cocking and acceleration phases of throwing. The pain occasionally refers distally along the ulnar aspect of the forearm. He denies any weakness; however, he notes occasional paresthesias. A nerve conduction velocity study demonstrates increased latency across the cubital tunnel. Management consisting of 6 weeks of rest and rehabilitation fails to provide relief as the symptoms returned when he resumed throwing. What is the best course of action?

. Further rehabilitation
. Corticosteroid injection
. Reconstruction of the medial collateral ligament
. Subcutaneous transposition of the ulnar nerve
. Arthroscopic debridement of medial osteophytes

Correct Answer & Explanation

. Subcutaneous transposition of the ulnar nerve

Explanation

In the thrower's elbow, ulnar neuritis is felt to result from both chronic compression and traction on the nerve that occurs during the throwing motion. Occasionally, subluxation of the nerve also can lead to symptoms. If nonsurgical management fails to provide relief, transposition of the nerve to an anterior subcutaneous location is the surgical procedure of choice. The nerve is held in its new position by one or two fascial slings created from the fascia of the common flexor origin. Schickendantz MS: Diagnosis and treatment of elbow disorders in the overhead athlete. Hand Clin 2002;18:65-75.

Question 1852

Topic: 7. Hand and Wrist

A 1-year-old infant has the hand deformities shown in Figure 40. What pathologic process is the most likely cause of these deformities?

Pediatrics 2004 Practice Questions: Set 3 (Solved) - Figure 31

. Genetic mutation
. Teratogen exposure
. Amniotic rupture
. Iatrogenic influences
. Developmental field disruption

Correct Answer & Explanation

. Amniotic rupture

Explanation

Streeter's dysplasia is clearly related to rupture of the amnion in utero and is now most commonly referred to as premature amnion rupture sequence. The deformities arise from amniotic bands that wrap about protruding parts and from uterine packing because of the accompanying oligohydramnios. Clubfoot can develop as a result of the latter mechanism. Three limb involvement is most commonly seen, along with syndactyly. Treatment involves resection of bands and Z-plasty of skin. The disease is not genetic and has not been related to teratogen exposure or to iatrogenic influences such as amniocentesis. Developmental field disruption is not seen in this disease, and the growth potential of the involved parts is normal unless neurovascular disruption has arisen from band formation.

Question 1853

Topic: 7. Hand and Wrist

A 22-year-old skier reports painful range of motion in the left thumb after falling forward on his outstretched hand while holding his ski pole. Examination of the left thumb reveals increased AP laxity and 45 degrees of valgus laxity at the metacarpophalangeal (MCP) joint. Examination of the right thumb shows 25 degrees of valgus laxity at the MCP joint. Radiographs are normal. Management should consist of

. primary repair of the ulnar collateral ligament.
. volar plate arthroplasty.
. pinning of the MCP joint for 6 weeks.
. a thumb spica cast.
. a hand-based thumb spica splint.

Correct Answer & Explanation

. primary repair of the ulnar collateral ligament.

Explanation

The patient has a complete tear of the ulnar collateral ligament as defined by MCP joint laxity of greater than 30 degrees (or 15 degrees greater laxity compared with the opposite side). Primary repair is the treatment of choice because displacement of the ligament superficial to the adductor aponeurosis (Stener lesion) must be corrected. Any volar plate injury can be addressed during repair of the ulnar collateral ligament.

Question 1854

Topic: 7. Hand and Wrist

A 58-year-old woman has a fracture through a metacarpal lesion after a motor vehicle accident. She denies any preinjury symptoms and the fracture heals uneventfully. Based on the radiograph and MRI scans shown in Figures 22a through 22c obtained following fracture healing, follow-up management should consist of

. curettage.
. radiation therapy.
. observation.
. bisphosphonates.
. ray resection.

Correct Answer & Explanation

. observation.

Explanation

Enchondromas are the most common benign skeletal lesions identified in the bones of the hand. Most are incidentally found or initially become clinically evident after a pathologic fracture. If the patient has a fracture, the hand is immobilized until union. If the lesion is large and further pathologic fractures are expected, then an intralesional curettage and grafting procedure may be warranted. In this patient, the lesion has not significantly altered the size, shape, or morphology of the involved metacarpal head and recurrent fracture is unlikely. Observation with follow-up radiographs is considered appropriate management. Campanacci M: Bone and Soft Tissue Tumors, ed 2. New York, NY, Springer-Verlag, 1999, pp 213-228.

Question 1855

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. What type of injury pattern is shown?

. Scaphoid fracture
. Radiocarpal dislocation
. Midcarpal dislocation
. Transscaphoid dorsal perilunate dislocation
. Volar lunate dislocation

Correct Answer & Explanation

. Transscaphoid dorsal perilunate dislocation

Explanation

The patient has a transscaphoid dorsal perilunate dislocation. The radiographs clearly define a dorsal dislocation of the capitolunate joint, and the scaphoid fracture component is easily visible on the AP view. A scaphoid fracture alone is an unlikely diagnosis because of the midcarpal dislocation component. The radiocarpal joint is not dislocated because the lunate is sitting in the lunate fossa of the radius. Isolated radiocarpal dislocations are not associated with a midcarpal disruption. While a midcarpal dislocation is a component of a dorsal perilunate dislocation, this diagnosis does not address the scaphoid fracture. A volar lunate dislocation is not seen because the lunate is reduced in the lunate fossa of the distal radius. Volar lunate dislocations are in the spectrum of injury of perilunate dislocations and fracture-dislocations; however, the radiographs show a transscaphoid dorsal perilunate dislocation. Mayfield JK, Johnson RP, Kilcoyne RK: Carpal dislocations: Pathomechanics and progressive perilunar instability. J Hand Surg Am 1980;5:226-241.

Question 1856

Topic: 7. Hand and Wrist

A 16-year-old high school football player has diffuse pain with attempted digital flexion after injuring the ring finger of the dominant hand 1 week ago. Examination reveals that he is unable to flex the distal interphalangeal joint. Management should consist of

. surgical exploration and tendon reinsertion of the flexor digitorum profundis.
. surgical exploration and tendon reinsertion of the flexor digitorum superficialis.
. steroids and physical therapy.
. surgical release of the anterior interosseous nerve.
. surgical release of the median nerve.

Correct Answer & Explanation

. surgical exploration and tendon reinsertion of the flexor digitorum profundis.

Explanation

The patient has an avulsion of the flexor digitorum profundus. Treatment should include surgical exploration and tendon reinsertion. This is not an avulsion of the flexor digitorum superficialis because the patient's deficiency is the inability to flex the distal interphalangeal joint, not the proximal interphalangeal joint. Surgical release of the anterior interosseous nerve is not indicated because the flexor digitorum profundus of the ring finger is innervated by the ulnar nerve. A median nerve contusion causes wrist pain and/or numbness and tingling in the median nerve distribution. Strickland JW: Flexor tendons: Acute injuries, in Green DP, Hotchkiss RN, Pederson WC (eds): Green's Operative Hand Surgery, ed 4. Philadelphia, PA, 1999, pp 1851-1897.

Question 1857

Topic: 7. Hand and Wrist

A 25-year-old man reports wrist pain following a motorcycle accident. Examination reveals minimal swelling, slightly limited active range of motion, and point tenderness in the snuff box region. AP and oblique radiographs are shown in Figures 40a and 40b. Management should consist of

. closed reduction and a short arm cast for 10 weeks.
. closed reduction and a long arm cast for 10 weeks.
. open reduction and internal fixation.
. limited intercarpal fusion.
. proximal row carpectomy.

Correct Answer & Explanation

. open reduction and internal fixation.

Explanation

The radiographs reveal a scaphoid fracture with displacement and comminution and an unstable fracture pattern. Treatment should consist of open reduction and internal fixation. In displaced scaphoid fractures and fractures with unstable fracture patterns, closed reduction is ineffective and is likely to lead to nonunion. Limited intercarpal fusion and proximal row carpectomy are used to correct a variety of traumatic and posttraumatic problems of the wrist. Amadio PC, Taleisnik J: Fractures of the carpal bone, in Green DP, Hotchkiss RN, Pederson WC (eds): Green's Operative Hand Surgery, ed 4. Philadelphia, PA, 1999, pp 809-823. Rettig ME, Kozin SH, Cooney WP: Open reduction and internal fixation of acute displaced scaphoid waist fractures. J Hand Surg Am 2001;26:271-276. Cooney WP, Dobyns JH, Linscheid RL: Fractures of the scaphoid: A rational approach to management. Clin Orthop 1980;149:90-97.

Question 1858

Topic: 7. Hand and Wrist

Examination of a 9-year-old girl who injured her left elbow in a fall reveals tenderness and swelling localized to the medial aspect of the elbow. Motor and sensory examinations of the hand are normal, and circulation is intact. A radiograph is seen in Figure 28. Management should consist of

Pediatrics 2004 Practice Questions: Set 3 (Solved) - Figure 7

. long arm cast immobilization.
. open reduction and internal fixation, followed by cast immobilization.
. closed reduction and percutaneous pin fixation.
. anterior transposition of the ulnar nerve.
. excision of the loose fragment and repair of the common flexor origin.

Correct Answer & Explanation

. long arm cast immobilization.

Explanation

Avulsion fractures of the medial epicondyle are caused by a valgus stress applied to the immature elbow and usually occur in children between the ages of 9 and 14 years. Long-term studies have shown that isolated fractures of the medial epicondyle with between 5 to 15 mm of displacement heal well. Brief immobilization (1 to 2 weeks) in a long arm cast or splint yields results similar to open reduction and internal fixation. Fibrous union of the fragment is not associated with significant symptoms or diminished function. Surgical excision of the fragment yielded the worst results in one study and should be avoided. Open reduction is best reserved for those injuries in which the medial epicondylar fragment becomes entrapped in the elbow joint during reduction and cannot be extracted by closed manipulation. Farsetti P, Potenza V, Caterini R, Ippolito E: Long-term results of treatment of fractures of the medial humeral epicondyle in children. J Bone Joint Surg Am 2001;83:1299-1305.

Question 1859

Topic: 7. Hand and Wrist

Figure 30 shows an axial cross section of extensor tendon anatomy in zone 7 of the wrist. What letter best depicts the location of the posterior interosseous nerve?

Anatomy 2002 Practice Questions: Set 3 (Solved) - Figure 7

. A
. B
. C
. D
. E

Correct Answer & Explanation

. C

Explanation

The posterior interosseous nerve in contained in the floor of the fourth dorsal compartment of the wrist, which is labelled C in this diagram. Tubiana R, McCullough CJ, Masquelet AC: An Atlas of Surgical Exposures of the Upper Extremity. Philadelphia, PA, JB Lippincott, 1990, p 224.

Question 1860

Topic: 7. Hand and Wrist
A 17-year-old football player is unable to flex the distal interphalangeal (DIP) joint of his ring finger. He states that he injured the finger 6 weeks ago while attempting to tackle another player who pulled free from his grip, but he did not inform his coach at the time of the injury. Current radiographs show an observable fleck of bone volar to the base of the proximal phalanx. Treatment should consist of
. fusion of the DIP joint with no reconstruction of the tendon.
. advancement and repair of the tendon to the base of the distal phalanx.
. two-stage reconstruction of the profundus tendon.
. Z-plasty advancement of the profundus tendon.
. tenodesis of the distal tendon remnant with the flexor digitorum sublimis.

Correct Answer & Explanation

. advancement and repair of the tendon to the base of the distal phalanx.

Explanation

Flexor digitorum profundus ruptures are classified into three types. In type I, the tendon retracts into the palm. In type II, the tendon retracts to the level of the proximal phalanx, the vinculum remains intact, and the blood supply is preserved to the tendon. A small fleck of bony fragment observed at the A2 pulley is pathognomonic for a type II rupture. Successful primary repair of the type II rupture has been reported as late as 2 months after the injury. Type III injuries have large fragments of the distal phalanx attached and are caught distally by the A1 pulley. Type III ruptures can be repaired up to several months after the injury.

Test Yourself

Switch to an interactive, timed exam simulation to truly master this topic.

On this Page