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7. Hand and Wrist MCQs

Practice Set 96 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 1901

Topic: 7. Hand and Wrist

A 30-year-old woman sustains a transverse amputation of the distal phalanx of the index finger, leaving exposed bone. What is the most appropriate management of the soft-tissue defect?

. Dressing changes and healing by secondary intention
. Split-thickness skin grafting
. V-Y advancement flap
. Moberg (volar advancement flap)
. First dorsal metacarpal artery-island pedicled flap

Correct Answer & Explanation

. V-Y advancement flap

Explanation

V-Y advancement flaps are ideal for fingertip amputations that are transverse or dorsal oblique in nature. Healing by secondary intention is contraindicated with exposed bone. Shortening of exposed bone to allow primary skin closure is a possible alternative, as long as significant shortening of the index finger is avoided. A Moberg flap is useful only for distal amputations of the thumb. The first dorsal metacarpal artery-island pedicled flap uses tissue from the dorsum of the proximal index finger, and is typically used to resurface defects of the thumb. Fassler PR: Fingertip injuries: Evaluation and treatment. J Am Acad Orthop Surg 1996;4:84-92.

Question 1902

Topic: 7. Hand and Wrist

A 38-year-old man caught his index finger in a volleyball net. He noted an angular deformity of the finger that was reduced when a teammate pulled on his finger. Three weeks later, he now reports trouble extending his finger. A clinical photograph is shown in Figure 55. What anatomic structure is most likely injured?

Trauma Board Review 2009: High-Yield MCQs (Set 4) - Figure 13

. Spiral oblique retinacular ligament
. Sagittal bands
. Volar plate
. Central slip of the extensor tendon
. Terminal extensor tendon

Correct Answer & Explanation

. Central slip of the extensor tendon

Explanation

The clinical photograph shows a classic boutonniere deformity. It is likely that the patient sustained a volar dislocation of the proximal interphalangeal joint, with a concomitant rupture of the central slip insertion of the extensor tendon. Peimer CA, Sullivan DJ, Wild DR: Palmar dislocation of the proximal interphalangeal joint. J Hand Surg Am 1984;9:39-48.

Question 1903

Topic: 7. Hand and Wrist

A 45-year-old man who smokes reports the rapid onset of color changes and coolness in the fingers. Examination shows an abnormal Allen test. Plain radiographs of the hand and wrist are normal. Which of the following studies will best aid in diagnosis?

Anatomy 2002 Practice Questions: Set 1 (Solved) - Figure 22

. Contrast CT of the hand and wrist
. MRI of the hand and wrist
. Contrast angiography of the involved upper extremity
. Digital subtraction angiography
. Single-shot fluoroscopic angiography

Correct Answer & Explanation

. Contrast angiography of the involved upper extremity

Explanation

The patient has symptoms typical of Raynaud's phenomenon secondary to underlying vascular disease. The next most appropriate step in the management of this patient should be to perform contrast angiography on the involved upper extremity to look for proximal or distal arterial lesions or insufficiencies. MRI and contrast CT are not as specific as angiography for the identification of vascular lesions of the upper extremity. Although patients with primary Raynaud's vasospastic disease can have normal angiographic findings, they typically are younger than age 40 years, are female, and have normal results on an Allen test. Green DP, Hotchkiss RN, Pederson WC (eds): Operative Hand Surgery, ed 4. New York, NY, Churchill Livingstone, 1999, pp 2288-2290.

Question 1904

Topic: 7. Hand and Wrist

A patient sustained a sharp laceration to the base of his left, nondominant thumb 4 months ago. Examination reveals no active flexion but full passive motion of the interphalangeal joint. What is the best treatment option?

Upper Extremity Board Review 2008: High-Yield MCQs (Set 2) - Figure 9

. Interphalangeal joint fusion
. Intercalary tendon graft
. Silicone rod placement
. Primary flexor pollicis longus repair
. Flexor digitorum superficialis transfer

Correct Answer & Explanation

. Flexor digitorum superficialis transfer

Explanation

The patient has a chronic flexor tendon laceration. There are options to restore motion and strength; therefore, fusion is not necessary. Full range of motion is present so the soft tissues are suitable for a tendon transfer. A transfer of the flexor digitorum superficialis of the ring finger to the insertion of the flexor pollicis longus on the distal phalanx provides good results with a one-stage operation. Schneider LH, Wiltshire D: Restoration of flexor pollicis longus function by flexor digitorum superficialis transfer. J Hand Surg Am 1983;8:98-101.

Question 1905

Topic: 7. Hand and Wrist

A 32-year-old woman sustained an elbow dislocation, and management consisted of early range of motion. Examination at the 3-month follow-up appointment reveals that she has regained elbow motion but has a weak pinch. A clinical photograph is shown in Figure 21. What is the most likely diagnosis?

Upper Extremity Board Review 2008: High-Yield MCQs (Set 2) - Figure 25

. Flexor pollicis longus rupture
. Median nerve palsy
. Ulnar nerve palsy
. Anterior interosseous nerve palsy
. Posterior interosseous nerve palsy

Correct Answer & Explanation

. Anterior interosseous nerve palsy

Explanation

The photograph shows the characteristic attitude of the hand when an anterior interosseous nerve palsy is present. The patient is unable to flex the interphalangeal joint to the joint of the thumb. Anterior interosseous nerve palsies are often misdiagnosed as tendon ruptures. Schantz K, Reigels-Nielsen P: The anterior interosseous nerve syndrome. J Hand Surg Br 1992;17:510-512.

Question 1906

Topic: Nerve & Tendon

Which of the following statements best describes why the ulnar nerve is most prone to neuropathy at the elbow?

Shoulder 2002 Practice Questions: Set 1 (Solved) - Figure 1

. It has the least longitudinal excursion required to accommodate elbow range of motion.
. It is subjected to both compression and traction during elbow motion.
. It passes between two muscle heads as it enters the forearm.
. The dimensions of the entrance of the cubital tunnel do not change with elbow motion.
. The vascular supply leaves a watershed area of diminished arterial supply.

Correct Answer & Explanation

. It has the least longitudinal excursion required to accommodate elbow range of motion.

Explanation

The ulnar nerve is more prone to neuropathy than the radial or median nerves for many reasons. It has the greatest longitudinal excursion required to accommodate elbow range of motion, subjecting it to potential traction forces. The dimensions of the entrance of the cubital tunnel change with elbow motion, potentially causing compression in flexion. For these two reasons, the ulnar nerve is subjected to both compression and traction during elbow motion. Although it passes between two muscle heads as it enters the forearm, so do the median and radial nerves. Finally, the vascular supply is adequate because of the anastamoses between the superior ulnar collateral artery, the posterior ulnar recurrent artery, and the inferior ulnar collateral artery. Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 369-378. Prevel CD, Matloub HS, Ye Z, Sanger JR, Yousif NJ: The extrinsic blood supply of the ulnar nerve at the elbow: An anatomic study. J Hand Surg Am 1993;18:433-438.

Question 1907

Topic: 7. Hand and Wrist
A collegiate golfer sustains a hook of the hamate fracture. After 12 weeks of splinting and therapy, the hand is still symptomatic. What is the most appropriate management to allow return to competitive activity?
. Continued observation
. Open reduction and internal fixation of the fracture
. Excision of the hook of the hamate
. Carpal tunnel release
. Guyon's canal release

Correct Answer & Explanation

. Excision of the hook of the hamate

Explanation

Excision of the fracture fragment typically leads to rapid return to function. Fixation techniques are difficult to perform because of the size of the bone; hardware prominence is common. Nerve deficits are not typically noted in this injury. The motor branch of the ulnar nerve in Guyon's canal must be protected during the surgical approach.

Question 1908

Topic: 7. Hand and Wrist

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 are shown in Figures 10a and 10b. Definitive management should consist of

. 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. May MM, Lawton JN, Blazar PE: Ulnar styloid fractures associated with distal radius fractures: Incidence and implications for distal radioulnar joint instability. J Hand Surg Am 2002;27:965-971.

Question 1909

Topic: 7. Hand and Wrist
A 24-year-old male falls on an extended wrist. Radiographs are shown. In Mayfield's progressive stages of perilunate instability, what is the final ligamentous structure to fail, resulting in a true lunate dislocation (Stage IV)?
. Scapholunate interosseous ligament
. Lunotriquetral interosseous ligament
. Dorsal radiocarpal ligament
. Radioscaphocapitate ligament
. Dorsal radiolunate ligament

Correct Answer & Explanation

. Dorsal radiolunate ligament

Explanation

According to Mayfield's progressive stages of perilunate instability: Stage I involves the scapholunate ligament; Stage II involves the space of Poirier (capitolunate failure); Stage III involves the lunotriquetral ligament (perilunate dislocation); Stage IV involves failure of the dorsal radiolunate ligament, allowing the lunate to dislocate volarly into the carpal tunnel.

Question 1910

Topic: Nerve & Tendon

A 40-year-old mechanic complains of lateral forearm pain that worsens with resisted forearm pronation and supination. There is no demonstrable motor weakness. He has local tenderness approximately 4 cm distal to the lateral epicondyle. Injection of local anesthetic provides temporary relief. The nerve involved is most likely compressed by which of the following structures?

. Ligament of Struthers
. Lacertus fibrosus
. Arcade of Frohse
. Osborne's fascia
. Arcade of Struthers

Correct Answer & Explanation

. Arcade of Frohse

Explanation

This clinical presentation is characteristic of Radial Tunnel Syndrome (pain predominantly, without motor weakness, as opposed to PIN syndrome). The most common site of compression of the deep branch of the radial nerve / posterior interosseous nerve (PIN) in this region is the Arcade of Frohse, the proximal fibrous edge of the superficial head of the supinator muscle.

Question 1911

Topic: 7. Hand and Wrist

A 28-year-old carpenter sustains a volar laceration to his index finger at the level of the proximal phalanx.

Surgical exploration reveals a complete transection of both the Flexor Digitorum Profundus (FDP) and Flexor Digitorum Superficialis (FDS) within Zone II. A core suture repair is planned. Which of the following core suture configurations provides the highest tensile strength and gap resistance to allow for early active mobilization?

. 2-strand modified Kessler
. 4-strand cruciate
. 6-strand M-Tang
. 2-strand Tajima
. 4-strand Strickland

Correct Answer & Explanation

. 6-strand M-Tang

Explanation

Biomechanical studies consistently show that the tensile strength of a flexor tendon repair is directly proportional to the number of core suture strands crossing the repair site. A 6-strand repair (such as the M-Tang or 6-strand Lim/Tsai) provides significantly greater gap resistance and tensile strength compared to 2-strand or 4-strand techniques, making it safer for modern early active motion protocols.

Question 1912

Topic: Wrist & Carpus

A 62-year-old female is 6 months post-operative from a volar locked plating of a comminuted distal radius fracture. She presents to the clinic complaining of a new inability to actively flex the interphalangeal (IP) joint of her thumb. Passive IP flexion is intact. Which of the following technical errors during the initial surgery is most likely responsible for this complication?

. Placement of the volar plate distal to the watershed line
. Use of excessively long dorsal screws irritating the extensor pollicis longus (EPL)
. Iatrogenic traction injury to the median nerve during the modified Henry approach
. Failure to repair the pronator quadratus during closure
. Prominent hardware violating the distal radioulnar joint (DRUJ)

Correct Answer & Explanation

. Placement of the volar plate distal to the watershed line

Explanation

Loss of active thumb IP joint flexion after volar distal radius plating points to an attritional rupture of the Flexor Pollicis Longus (FPL) tendon. The most common iatrogenic cause of FPL rupture in this setting is the placement of the volar plate distal to the 'watershed line' of the distal radius. This prominence acts as a mechanical fulcrum, causing friction, fraying, and eventual attritional rupture of the FPL.

Question 1913

Topic: 7. Hand and Wrist
A 35-year-old manual laborer presents with chronic, progressive central dorsal wrist pain. Grip strength is markedly decreased. Radiographs demonstrate sclerosis and collapse of the lunate, without fixed scaphoid rotation or adjacent carpal degenerative changes (Lichtman Stage IIIA Kienböck's disease). Radiographic ulnar variance is determined to be negative 3 mm. Which of the following surgical interventions is considered the primary, most appropriate biomechanical treatment for this patient?
. Proximal row carpectomy
. Radial shortening osteotomy
. Ulnar lengthening osteotomy
. Scaphoid-trapezium-trapezoid (STT) arthrodesis
. Capitate shortening osteotomy

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

Kienböck's disease is avascular necrosis of the lunate. In patients with early-stage collapse (Stage IIIA) who have negative ulnar variance, joint-leveling procedures are indicated to mechanically unload the radiolunate articulation. Radial shortening osteotomy is biomechanically and biologically preferred over ulnar lengthening, as ulnar lengthening carries a significantly higher risk of nonunion and implant irritation.

Question 1914

Topic: 7. Hand and Wrist
A 32-year-old manual laborer presents with progressive dorsal wrist pain and decreased range of motion. Radiographs demonstrate Kienböck's disease characterized by sclerosis, fragmentation, and collapse of the lunate. The scaphoid demonstrates fixed flexion, resulting in a radioscaphoid angle of 65 degrees, but there are no signs of radiocarpal or midcarpal osteoarthritis. What Lichtman stage does this represent?
. Stage II
. Stage IIIA
. Stage IIIB
. Stage IIIC
. Stage IV

Correct Answer & Explanation

. Stage IIIA

Explanation

The Lichtman classification is used to stage Kienböck's disease (avascular necrosis of the lunate). Stage II features lunate sclerosis with no collapse. Stage III involves lunate collapse. Stage III is subdivided: Stage IIIA indicates lunate collapse with normal carpal alignment and normal scaphoid rotation; Stage IIIB indicates lunate collapse with fixed scaphoid flexion (rotary subluxation of the scaphoid, radioscaphoid angle > 60 degrees) and decreased carpal height. Stage IIIC includes coronal fractures of the lunate. Stage IV is characterized by the addition of radiocarpal or midcarpal osteoarthritis.

Question 1915

Topic: 7. Hand and Wrist

In the surgical repair of lacerated flexor tendons within Zone II of the hand, maintaining gliding function while resisting early active motion protocols is paramount. Biomechanical studies have demonstrated that the ultimate tensile strength of the tendon repair immediately postoperatively is most directly correlated with which of the following factors?

. The use of braided versus monofilament suture material
. The length of the core suture purchase away from the cut ends
. The number of core suture strands crossing the repair site
. The use of an epitendinous running repair
. The strict preservation of the A3 annular pulley

Correct Answer & Explanation

. The number of core suture strands crossing the repair site

Explanation

The immediate tensile strength of a flexor tendon repair is directly proportional to the number of core suture strands crossing the repair site. For instance, a 4-strand repair is significantly stronger than a 2-strand repair, and a 6-strand repair is stronger than a 4-strand repair. While adding an epitendinous repair does improve strength (by ~20%) and reduces gap formation, the absolute number of core strands is the primary determinant of ultimate tensile strength. Preserving the pulleys is important to prevent bowstringing, not to improve the direct strength of the repair construct itself.

Question 1916

Topic: 7. Hand and Wrist

A 24-year-old man sustains a proximal pole scaphoid fracture. The high risk of avascular necrosis (AVN) in this fracture pattern is primarily due to the retrograde intraosseous blood supply of the scaphoid. The predominant vascular supply enters the scaphoid at the dorsal ridge. From which artery does this critical vessel directly originate?

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

Correct Answer & Explanation

. Dorsal carpal branch of the radial artery

Explanation

The scaphoid receives 70-80% of its blood supply from the dorsal carpal branch of the radial artery, which enters the bone distally at the dorsal ridge and supplies the proximal pole in a retrograde fashion. A fracture at the proximal pole disrupts this retrograde flow, leading to a high rate of AVN and nonunion.

Question 1917

Topic: 7. Hand and Wrist

During an open carpal tunnel release, the transverse carpal ligament is divided. If the surgical incision is extended proximally across the wrist flexion creases in a radial direction (radial to the palmaris longus tendon), which nerve is at greatest risk of iatrogenic transection?

. Recurrent motor branch of the median nerve
. Deep branch of the ulnar nerve
. Palmar cutaneous branch of the median nerve
. Superficial branch of the radial nerve
. Anterior interosseous nerve

Correct Answer & Explanation

. Palmar cutaneous branch of the median nerve

Explanation

The palmar cutaneous branch of the median nerve branches off approximately 5 cm proximal to the transverse carpal ligament and travels longitudinally on the ulnar side of the flexor carpi radialis (FCR), radial to the palmaris longus. Incisions extending proximally and radially into the forearm cross directly over its path, predisposing it to injury and subsequent painful neuroma formation.

Question 1918

Topic: 7. Hand and Wrist

A 30-year-old male presents with a comminuted intra-articular fracture of the first metacarpal base.

What are the primary deforming forces acting on the metacarpal shaft in this injury?

. Extensor pollicis longus and flexor pollicis longus
. Abductor pollicis longus and adductor pollicis
. Extensor pollicis brevis and abductor pollicis brevis
. Opponens pollicis and first dorsal interosseous
. Flexor pollicis brevis and adductor pollicis

Correct Answer & Explanation

. Extensor pollicis longus and flexor pollicis longus

Explanation

In intra-articular fractures of the thumb metacarpal base (Bennett and Rolando fractures), the palmar ulnar fragment remains attached to the anterior oblique ligament (beak ligament). The metacarpal shaft is pulled proximally, dorsally, and radially by the abductor pollicis longus (APL), while the adductor pollicis (AP) pulls the metacarpal head into the palm, resulting in the classic supination and adduction deformity.

Question 1919

Topic: 7. Hand and Wrist

A patient presents with numbness in the small and ring fingers.

Which of the following clinical findings best differentiates ulnar nerve compression at the cubital tunnel from compression at Guyon's canal?

. Weakness of the adductor pollicis
. Decreased sensation over the dorsal ulnar aspect of the hand
. Positive Froment's sign
. Wasting of the first dorsal interosseous muscle
. Clawing of the small and ring fingers

Correct Answer & Explanation

. Decreased sensation over the dorsal ulnar aspect of the hand

Explanation

The dorsal ulnar cutaneous nerve (DUCN) branches off the ulnar nerve approximately 5-8 cm proximal to the wrist and supplies sensation to the dorsal ulnar aspect of the hand. A lesion at Guyon's canal (at the wrist) spares the DUCN, meaning dorsal sensation will be intact. A lesion at the elbow (cubital tunnel) affects the entire ulnar nerve, including the DUCN, resulting in decreased sensation over the dorsal ulnar hand.

Question 1920

Topic: Nerve & Tendon

A 7-year-old boy sustains a displaced lateral condyle fracture of the humerus.

The family refuses surgery, and the fracture goes on to a nonunion. Years later, which of the following is the most likely late complication to develop?

. Median nerve palsy
. Anterior interosseous nerve syndrome
. Radial nerve palsy
. Tardy ulnar nerve palsy
. Posterior interosseous nerve entrapment

Correct Answer & Explanation

. Tardy ulnar nerve palsy

Explanation

A nonunion of a lateral condyle fracture typically leads to a progressive cubitus valgus deformity due to the failure of the lateral column of the distal humerus to support the elbow joint properly. Over time, this valgus deformity stretches the ulnar nerve behind the medial epicondyle, resulting in a tardy ulnar nerve palsy years or even decades after the initial injury.

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