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 1861
Topic: 7. Hand and Wrist
A 36-year-old nurse has had redness, pain, and small vesicles on the pulp of her middle finger for the past 3 days. Management should consist of
Correct Answer & Explanation
. observation.
Explanation
Small vesicles on the fingers of a health care worker suggest a herpetic infection, and the management of choice is observation. Incision and drainage may result in a bacterial infection. Marsupialization is used in the treatment of a chronic paronychia. Calcium gluconate is used for hydrofluoric acid burns, and copper sulfate is used for white phosphorus burns. Fowler JR: Viral Infections. Hand Clin 1989;5:613-627.
Question 1862
Topic: 7. Hand and Wrist
The vessel seen in the clinical photographs shown in Figures 50a and 50b (1,2 intercompartmental supraretinacular artery) is being dissected to be used as a source of vascularized bone graft for a patient who is scheduled to undergo internal fixation of a scaphoid nonunion. This vessel is a branch of what artery?
Correct Answer & Explanation
. Radial
Explanation
The 1,2 intercompartmental supraretinacular artery is a branch of the radial artery. The vessel provides a reliable source of vascularized bone graft with an adequate pedicle length for use in scaphoid nonunions. Sheetz KK, Bishop AT, Berger RA: The arterial blood supply of the distal radius and ulna and its potential use in vascularized pedicled bone grafts. J Hand Surg 1995;20:902-914.
Question 1863
Topic: 7. Hand and Wrist
Figures 44a through 44c show the radiographs of an 18-year-old female soccer player who fell on her outstretched hand 1 day ago. She denies any history of wrist pain. Examination reveals tenderness at the anatomic snuffbox. Management should consist of
Correct Answer & Explanation
. open reduction and internal fixation with a differential pitch screw via a dorsal approach.
Explanation
The treatment of choice for proximal pole scaphoid fractures is open reduction and internal fixation with a differential pitch screw via a dorsal approach. Healing rates of 100% have been reported for these acute fractures. Casting results in slow healing, with recommendations including 16 weeks or more in a cast. Vascularized bone grafts are not indicated for acute fractures. Rettig ME, Raskin KB: Retrograde compression screw fixation of acute proximal pole scaphoid fractures. J Hand Surg 1999;24:1206-1210.
Question 1864
Topic: 7. Hand and Wrist
A 45-year-old man sustains a low-velocity gunshot wound to the base of the right thumb. The open wound is allowed to heal by secondary intention, resulting in a contracture of the first web space. Clinical photographs are shown in Figures 49a through 49c. Treatment should now consist of
Correct Answer & Explanation
. a posterior interosseous fasciocutaneous flap.
Explanation
The contracture is too large for a Z-plasty, which allows a 75% increase in length. Excision of the scar with placement of a skin graft is prone to contracture. A posterior interosseous fasciocutaneous flap will provide enough well-vascularized tissue and is well suited to reach the first dorsal web space. Buchler U, Frey HP: Retrograde posterior interosseous flap. J Hand Surg Am 1991;16:283-292.
Question 1865
Topic: 7. Hand and Wrist
A 54-year-old woman with idiopathic carpal tunnel syndrome undergoes open carpal tunnel release with a flexor tenosynovectomy. The pathology from the tenosynovium is likely to show
Correct Answer & Explanation
. fibrosis and edema.
Explanation
The tenosynovium excised at the time of a carpal tunnel release for idiopathic carpal tunnel syndrome rarely shows signs of acute or chronic inflammation. Fibrosis, edema, and vascular sclerosis are the most common histologic findings. A tenosynovectomy with a carpal tunnel release usually is not necessary in the treatment of idiopathic carpal tunnel syndrome. Shum C, Parisien M, Strauch RJ, et al: The role of flexor tenosynovectomy in the operative treatment of carpal tunnel syndrome. J Bone Joint Surg Am 2002;84:221-225. Fuchs PC, Nathan PA, Myers LD: Synovial histology in carpal tunnel syndrome. J Hand Surg Am 1991;16:753-758.
Question 1866
Topic: 7. Hand and Wrist
What is the most important factor in determining recovery after surgical repair of a complete laceration of a nerve at the wrist?
Correct Answer & Explanation
. Patient's age
Explanation
All other factors being equal, a patient's age is the most important factor in determining outcome after peripheral nerve injury. Repair of a nerve laceration within the first 2 weeks is generally considered appropriate. Fascicular repair may be of benefit in larger proximal nerves to reapproximate appropriate nerve bundles; distally perineural or epineural repair is sufficient. Use of a fibrin tissue sealant for nerve repair does not result in improved outcomes over suture repair. Nerve conduits have shown promise in digital nerves but do not have proven benefit in larger caliber nerves. Sunderland S: Nerve Injuries and Their Repair: A Critical Appraisal. New York, NY, Churchill Livingstone, 1991. Wilgis ES, Brushart TM: Nerve repair and grafting, in Green DP, Hotchkiss RN (eds): Operative Hand Surgery, ed 3. New York, NY, Churchill Livingstone, 1993, p 1325. Narakas A: The use of fibrin glue in repair of peripheral nerves. Orthop Clin North Am 1988;19:187-199.
Question 1867
Topic: 7. Hand and Wrist
An excessively large radial styloidectomy poses a risk for wrist instability. What ligament is at greatest risk for injury?
Correct Answer & Explanation
. Radioscaphocapitate
Explanation
The radioscaphocapitate ligament is the most radial of the extrinsic volar ligaments of the wrist. It has a mean attachment to the radius 4 mm from the tip of the radial styloid.
Question 1868
Topic: 7. Hand and Wrist
In Dupuytren's disease, the retrovascular cord typically displaces the radial proper digital nerve of the ring finger in what direction?
Correct Answer & Explanation
. Palmarly and ulnarly
Explanation
Retrovascular cords are common in Dupuytren's disease and commonly require surgical treatment. Nerve injury in Dupuytren's surgery is an infrequent complication that occurs partly because the digital nerves can be displaced from their normal anatomic relationships by retrovascular cords. The nerves are displaced superficially, toward the center of the digit (palmarly and ulnarly). This displacement is typically seen at the level of the metacarpophalangeal joint.
Question 1869
Topic: 7. Hand and Wrist
A 35-year-old man sustained a 1-inch stab incision in his proximal forearm while trying to use a screwdriver 2 weeks ago. The laceration was routinely closed, and no problems about the incision site were noted. He now reports that he has been unable to straighten his fingers or thumb completely since the injury. Clinical photographs shown in Figures 30a and 30b show the man passively flexing the wrist. What is the most appropriate management?
Correct Answer & Explanation
. Exploration and repair of the posterior interosseous nerve
Explanation
The clinical photographs indicate that the tenodesis effect of digit flexion with passive wrist extension and digit extension with passive wrist flexion is intact, indicating no discontinuity of the extensor or flexor tendons. The most likely injury is a laceration of the posterior interosseous nerve.
Question 1870
Topic: 7. Hand and Wrist
Figures 35a and 35b show the radiographs of a 20-year-old man who is unable to rotate his dominant forearm. Examination reveals that the arm is fixed in supination. To regain motion, management should consist of
Correct Answer & Explanation
. resection of the synostosis.
Explanation
The patient has a proximal synostosis; therefore, resection of the synostosis is considered the best option to regain motion. While forearm osteotomy can place the hand in a more functional position, rotation will not be restored. Proximal radial excision can provide forearm rotation; however, this procedure is reserved for patients who have a proximal radioulnar synostosis that is too extensive to allow a safe resection, involves the articular surface, and is associated with an anatomic deformity. Motion will not be restored with dynamic splinting. Kamineni S, Maritz NG, Morrey BF: Proximal radial resection for posttraumatic radioulnar synostosis: A new technique to improve forearm rotation. J Bone Joint Surg Am 2002;84:745-751.
Question 1871
Topic: 7. Hand and Wrist
What are the most likely symptoms and examination findings related to the mass in zone 2 of Guyon's canal seen in Figure 17?
Correct Answer & Explanation
. Weakness and atrophy of the first dorsal interosseous
Explanation
The lesion lies in zone II of the ulnar tunnel. In that zone the deep motor branch of the ulnar nerve is susceptible to compression. Distal to the hook of the hamate, the motor branch of the ulnar nerve dives deep to innervate the interossei as it begins to move from an ulnar to radial direction. Because of its course, it has little or no give in response to a mass effect from the floor of Guyon's canal. Ganglions are the most common cause of ulnar nerve entrapment in the wrist. Lesions in zone I can affect both sensory and motor aspects of the ulnar nerve as well as the motor innervation of the hypothenar muscles. Lesions at the elbow or mid-to-proximal forearm are associated with dorsal hand numbness and tingling. Kuschner SH, Gelberman RH, Jennings C: Ulnar nerve compression at the wrist. J Hand Surg Am 1988;13:577-580.
Question 1872
Topic: 7. Hand and Wrist
Figures 12a through 12c show the radiographs of a 28-year-old professional baseball player who has ulnar-sided wrist pain and numbness and tingling in the fourth and fifth digits for the past 6 weeks. Management should consist of
Correct Answer & Explanation
. excision of the fragment.
Explanation
Hook of the hamate fractures typically occur as a result of direct force from swinging a bat, golf club, or racket. Pain is localized to the hypothenar eminence. The injury is best seen on a carpal tunnel view. CT will confirm the diagnosis. Chronic cases can be associated with neuropathy of the ulnar nerve. Excision of the hook through the fracture site usually yields satisfactory results, allowing the athlete to return to competition. Parker RD, Berkowitz MS, Brahms MA, et al: Hook of the hamate fractures in athletes. Am J Sports Med 1986;14:517-523.
Question 1873
Topic: 7. Hand and Wrist
A 52-year-old woman slips in her bathroom and strikes her right hand on a cabinet. She notes swelling, ecchymosis, and pain with attempted motion. There are no open wounds. Radiographs are shown in Figures 5a through 5c. What is the most appropriate treatment?
Correct Answer & Explanation
. Immobilization of the hand with the metacarpophalangeal (MCP) joints in flexion and the interphalangeal (IP) joints in extension
Explanation
Nondisplaced transverse fractures of the phalanges are stable. Immobilization in the intrinsic plus position will prevent MCP joint stiffness. Displaced oblique fractures are more at risk for instability. Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green's Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 281.
Question 1874
Topic: 7. Hand and Wrist
A woman injures the metacarpophalangeal (MCP) joint of her thumb while skiing. Examination reveals tenderness along the ulnar aspect of the MCP joint. Radially directed stress of the joint in full extension produces 5 degrees of angulation. When the MCP joint is flexed 30 degrees, a radially directed stress produces 45 degrees of angulation. Radiographs are otherwise normal. Management should consist of
Correct Answer & Explanation
. a thumb spica cast and reassessment in 3 weeks.
Explanation
Injuries to the ulnar collateral ligament of the MCP joint of the thumb commonly occur in recreational skiers. Historically, this injury has been referred to as "gamekeeper's thumb." The ligament consists of the proper collateral ligament and the more volar accessory collateral ligament. In extension, the accessory ligament is taut, and in flexion, the proper ligament is taut. For a complete tear of the ligament complex to occur, there must be laxity in full extension. Incomplete tears respond well to thumb spica splinting or casting for 2 to 3 weeks and gradual resumption of range of motion. Prolonged immobilization of incomplete injuries leads to higher rates of MCP joint stiffness. Stener B: Displacement of the ruptured ulnar collateral ligament of the metacarpo-phalangeal joint of the thumb: A clinical and anatomical study. J Bone Joint Surg Br 1971;44:869.
Question 1875
Topic: 7. Hand and Wrist
Examination of a carpenter who hit his thumb with a hammer reveals that the nail plate is broken but in place, and there is a 100% subungual hematoma that covers 100% of the area under the nail plate. Radiographs reveal a comminuted distal phalangeal tuft fracture. Management should consist of
Correct Answer & Explanation
. nail plate removal, nail bed repair, oral antibiotics, and a fingertip splint.
Explanation
This is a classic situation for a distal phalanx tuft fracture with associated nail bed injury and subungual hematoma. In general, when the subungual hematoma is greater than 50% of the surface area under the nail plate, treatment should consist of nail plate removal, nail bed repair, oral antibiotics, and a fingertip splint. Oral antibiotics and fingertip splinting alone do not address the nail bed laceration, which will most likely lead to nail plate deformity if not repaired. Kirschner pin stabilization is not indicated because these fractures are nondisplaced and usually are inherently stable after nail bed repair. The use of IV antibiotics alone does not address the nail bed laceration surgically. Casting, followed by hydrotherapy and topical antibiotics, is not indicated because it does not address the nail bed laceration. Further, a nondisplaced distal phalangeal tuft fracture does not require cast immobilization. Stern PJ: Fractures of the metacarpals and phalanges, in Green DP, Hotchkiss RN, Pederson WC (eds): Green's Operative Hand Surgery, ed 4. Philadelphia, PA, 1999, pp 711-771.
Question 1876
Topic: Nerve & Tendon
The arrow in the axial T1-weighted MRI scan shown in Figure 18 is pointing to which of the following structures?
Correct Answer & Explanation
. Ulnar nerve in Guyon's canal
Explanation
The arrow is pointing to the ulnar nerve within Guyon's canal. Guyon's canal is approximately 4 cm long, beginning at the proximal extent of the transverse carpal ligament and ending at the aponeurotic arch of the hypothenar muscles. Many structures comprise the boundaries of Guyon's canal. The floor, for example, consists of the transverse carpal ligament, the pisohamate and pisometacarpal ligaments, and the opponens digiti minimi. Within Guyon's canal, the ulnar nerve bifurcates into the superficial and deep branches, with the deep branch of the ulnar nerve persisting distal to the canal. The ulnar artery is immediately adjacent and radial to the ulnar nerve. The median nerve is visualized within the carpal tunnel. The radial artery is on the radial side of the wrist. The hook of the hamate is clearly seen in the figure, orienting the observer to the ulnar side of the wrist. Goss MS, Gelberman RH: The anatomy of the distal ulnar tunnel. Clin Orthop 1985;196:238-247.
Question 1877
Topic: 7. Hand and Wrist
An 18-year-old rugby player has had pain in his ring finger after missing a tackle 1 week ago. Examination reveals tenderness in the distal palm, and he is unable to actively flex the distal interphalangeal (DIP) joint. Radiographs are normal. What is the most appropriate management?
Correct Answer & Explanation
. Acute tendon repair
Explanation
Flexor digitorum profundus rupture or "rugger jersey finger" often occurs in the ring finger after the player misses a tackle and catches the digit on the shirt of the opposing player. Surgical repair is required for zone I-type injuries. Moiemen NS, Elliot D: Primary flexor tendon repair in zone I. J Hand Surg Br 2000;25:78-84.
Question 1878
Topic: 7. Hand and Wrist
Figures 34a and 34b show the radiographs of a 28-year-old man who fell on his outstretched arm with significant force while mountain biking. The nerve deficit most likely to occur would result in weakness of
Correct Answer & Explanation
. thumb extension.
Explanation
The patient has a Monteggia fracture-dislocation (proximal ulnar fracture and radial head dislocation). The posterior interosseous nerve branch of the radial nerve is the most likely to be injured and could result in weakness of thumb extension and finger metacarpal extension. Considerably less likely are injuries to the more proximal radial nerve branches supplying the extensor carpi radialis longus and brevis, resulting in weak wrist extension; the ulnar nerve supplying the digital intrinsics, resulting in weak finger abduction; the anterior interosseous branch of the median nerve, resulting in weakness of the flexor pollicis longus; and the distal median nerve, resulting in weakness of thumb opposition. Bado JL: The Monteggia lesion. Clin Orthop 1967;50:71-86.
Question 1879
Topic: 7. Hand and Wrist
What is the most common complication following interscalene nerve block for shoulder surgery?
Correct Answer & Explanation
. Temporary paresthesia to the affected arm and hand for up to 6 months
Explanation
All of these complications have been documented after interscalene nerve block. Other serious complications such as cardiac arrest and respiratory distress have also been noted. However, the most common complication after interscalene nerve block appears to be temporary paresthesia to the hand that can occur in up to 2.3% of the patients. Bishop JY, Sprague M, Gelber J, et al: Interscalene regional anesthesia for shoulder surgery. J Bone Joint Surg Am 2005;87:974-979.
Question 1880
Topic: 7. Hand and Wrist
A 41-year-old man who plays golf regularly has had ulnar-sided wrist pain for the past several days after striking a tree root with a golf club. Examination reveals significant pain with resisted flexion of the ring and small fingers and tenderness over the hook of the hamate. Which of the following radiographic views would be most helpful in identifying the pathology of this injury?
Correct Answer & Explanation
. Carpal tunnel view
Explanation
The history and examination findings suggest an acute fracture of the hook of the hamate. The radiographic study considered most helpful in identifying this type of fracture is the carpal tunnel view. PA and lateral views of the wrist will not adequately visualize the hook of the hamate. Bruerton's view is intended for the assessment of the metacarpophalangeal joints. Pathology would not be suspected in the scaphoid, metacarpals, or the phalanges, so the scaphoid view and the PA, lateral, and oblique views of the hand would not be helpful. Green DP, Hotchkiss RN, Pederson WC (eds): Operative Hand Surgery, ed 4. New York, NY, Churchill Livingstone, 1999, p 855.
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