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7. Hand and Wrist MCQs

Practice Set 97 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 1921

Topic: 7. Hand and Wrist

A patient suffers a knife laceration to the volar aspect of the hand, resulting in an inability to flex the proximal and distal interphalangeal joints of the middle finger. The injury is classified as a Zone II flexor tendon injury. What are the precise anatomic boundaries of flexor tendon Zone II?

. From the carpal tunnel to the A1 pulley
. From the A1 pulley to the insertion of the flexor digitorum superficialis (FDS)
. From the insertion of the FDS to the insertion of the flexor digitorum profundus (FDP)
. From the musculotendinous junction to the distal wrist crease
. From the A2 pulley to the A4 pulley

Correct Answer & Explanation

. From the A1 pulley to the insertion of the flexor digitorum superficialis (FDS)

Explanation

Verdan's classification divides the flexor tendons into five zones. Zone II, historically known as "no man's land" due to historically poor surgical outcomes, extends from the proximal edge of the A1 pulley (distal palmar crease) to the insertion of the flexor digitorum superficialis (FDS) tendon on the middle phalanx. In this zone, both the FDS and FDP tendons travel together in a tight fibro-osseous sheath.

Question 1922

Topic: 7. Hand and Wrist
A patient sustains a deep glass laceration over the volar aspect of the proximal phalanx of the ring finger, completely transecting both the flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) tendons. This anatomical location corresponds to which flexor tendon zone?
. Zone I
. Zone II
. Zone III
. Zone IV
. Zone V

Correct Answer & Explanation

. Zone II

Explanation

Zone II (historically known as Bunnell's 'no man's land') extends from the distal palmar crease (the proximal edge of the A1 pulley) to the insertion of the FDS tendon on the middle phalanx. It contains both the FDS and FDP tendons within a tight fibro-osseous sheath, making repair challenging and prone to adhesions.

Question 1923

Topic: Nerve & Tendon

A 24-year-old male sustains a severe traction injury to his brachial plexus, resulting in a C5-C6 root avulsion. An Oberlin transfer is planned to restore active elbow flexion. Which donor nerve fascicle is classically utilized in this procedure to transfer to the biceps motor branch of the musculocutaneous nerve?

. A redundant fascicle from the ulnar nerve
. The thoracodorsal nerve
. The medial pectoral nerve
. A fascicle from the median nerve (FCR branch)
. The intercostobrachial nerve

Correct Answer & Explanation

. A redundant fascicle from the ulnar nerve

Explanation

The classic Oberlin transfer utilizes a redundant fascicle from the ulnar nerve (usually one supplying the flexor carpi ulnaris) and transfers it directly to the motor branch of the biceps (part of the musculocutaneous nerve) to restore elbow flexion in patients with upper trunk (C5-C6) brachial plexus injuries.

Question 1924

Topic: Wrist & Carpus



A 41-year-old female develops a widespread eczematous skin rash overlying her forearm three weeks after open reduction and internal fixation of a distal radius fracture utilizing a standard 316L stainless steel volar locking plate. Dermatology consultation confirms a metal allergy via patch testing. Which specific element within the stainless steel alloy is most commonly responsible for this type IV hypersensitivity reaction?

. Titanium
. Cobalt
. Chromium
. Nickel
. Molybdenum

Correct Answer & Explanation

. Nickel

Explanation

Nickel is the most common metal sensitizer in the general population, accounting for the vast majority of Type IV hypersensitivity (allergic contact dermatitis) reactions to metallic orthopedic implants. Medical-grade 316L stainless steel contains approximately 10-14% nickel, making it a frequent culprit in sensitive individuals, often necessitating hardware removal or revision to a titanium implant.

Question 1925

Topic: 7. Hand and Wrist

A 45-year-old manual laborer presents with chronic radial-sided wrist pain, recalling a fall on an outstretched hand 5 years ago. Imaging shows a scaphoid nonunion with radioscaphoid and capitolunate arthritis, but the radiolunate joint remains completely preserved.

This describes which stage of Scaphoid Nonunion Advanced Collapse (SNAC), and what is a standard surgical option?

. SNAC Stage 1; Radial styloidectomy
. SNAC Stage 2; Proximal row carpectomy (PRC)
. SNAC Stage 3; Four-corner fusion with scaphoid excision
. SNAC Stage 4; Total wrist arthrodesis
. SNAC Stage 3; Scaphoid open reduction internal fixation with vascularized bone graft

Correct Answer & Explanation

. SNAC Stage 3; Four-corner fusion with scaphoid excision

Explanation

The progression of SNAC wrist is predictable. Stage 1 involves arthritis at the radial styloid; Stage 2 involves the entire radioscaphoid joint; Stage 3 involves the capitolunate joint; Stage 4 involves the radiolunate and/or entire carpus. Because the radiolunate joint is preserved in Stage 3, a four-corner fusion (capitate, hamate, lunate, triquetrum) with scaphoid excision is the standard salvage procedure. Proximal row carpectomy is contraindicated due to capitolunate arthritis.

Question 1926

Topic: 7. Hand and Wrist

A 28-year-old chef accidentally lacerates the volar aspect of his index finger proximal phalanx (Zone II), resulting in a loss of PIP and DIP joint active flexion. He undergoes primary flexor tendon repair. To optimize the biomechanical strength of the tendon repair and minimize gap formation to allow for an early active motion protocol, what is the current gold standard core suture construct?

. Traditional 2-strand repair with 4-0 nonabsorbable suture
. 4-strand or 6-strand core repair augmented with a peripheral running epitendinous suture
. Barbed suture knotless repair without the need for epitendinous augmentation
. Figure-of-eight 2-strand repair using heavy 2-0 suture
. Multiple superficial horizontal mattress sutures exclusively

Correct Answer & Explanation

. 4-strand or 6-strand core repair augmented with a peripheral running epitendinous suture

Explanation

In flexor tendon repairs, particularly in Zone II, the goal is to achieve sufficient mechanical strength to withstand early active motion protocols, which are crucial for preventing adhesion formation and optimizing glide. A multi-strand core repair (4-strand or 6-strand) using robust suture (e.g., 3-0 or 4-0) combined with a peripheral running epitendinous suture provides substantially greater tensile strength and resistance to gap formation than a traditional 2-strand repair. The epitendinous suture adds strength and smooths the repair site to facilitate gliding.

Question 1927

Topic: 7. Hand and Wrist
A 28-year-old carpenter sustains a sharp knife laceration to the volar aspect of his index finger at the level of the proximal phalanx. He is unable to flex the DIP and PIP joints. Which zone of flexor tendon injury does this represent, and what is its anatomic definition?
. Zone I; insertion of FDS to the insertion of FDP
. Zone II; from the distal palmar crease (A1 pulley) to the mid-middle phalanx (FDS insertion)
. Zone III; lumbrical origin in the palm
. Zone IV; within the carpal tunnel
. Zone V; proximal to the carpal tunnel

Correct Answer & Explanation

. Zone II; from the distal palmar crease (A1 pulley) to the mid-middle phalanx (FDS insertion)

Explanation

Zone II flexor tendon injuries occur between the distal palmar crease (the proximal edge of the A1 pulley) and the insertion of the flexor digitorum superficialis (FDS) on the middle phalanx. Historically termed 'no man's land' by Bunnell, this zone contains both the FDS and FDP tendons tightly enclosed within the flexor tendon sheath, making repair prone to adhesions.

Question 1928

Topic: 7. Hand and Wrist

A 45-year-old manual laborer presents with chronic, activity-related wrist pain.

Radiographs demonstrate a scaphoid nonunion advanced collapse (SNAC) pattern. According to the predictable and sequential pattern of arthrosis in a SNAC wrist, which articulation is characteristically preserved until the terminal stages of the disease process?

. Radioscaphoid joint
. Capitolunate joint
. Scaphocapitate joint
. Radiolunate joint
. Scaphotrapezial joint

Correct Answer & Explanation

. Radiolunate joint

Explanation

In both Scaphoid Nonunion Advanced Collapse (SNAC) and Scapholunate Advanced Collapse (SLAC) wrists, the radiolunate joint is characteristically spared from degenerative changes until very late. This sparing occurs because the proximal articular surface of the lunate maintains a concentric, conformal geometry with the spherical lunate fossa of the radius, preserving normal contact pressures despite profound carpal instability.

Question 1929

Topic: 7. Hand and Wrist

A 35-year-old volleyball player presents with the inability to actively extend the distal interphalangeal (DIP) joint of her long finger after a jamming injury.

This classic mallet finger deformity represents a disruption of the terminal extensor tendon. If left untreated, what secondary digit deformity is most likely to develop over time?

. Boutonniere deformity
. Swan neck deformity
. Pseudoboutonniere deformity
. Intrinsic plus hand
. Lumbrical plus deformity

Correct Answer & Explanation

. Swan neck deformity

Explanation

A mallet finger results from the avulsion or rupture of the terminal extensor tendon at the base of the distal phalanx. If left untreated, the extensor mechanism retracts proximally, concentrating extensor forces at the central slip over the proximal interphalangeal (PIP) joint. This chronic imbalance leads to progressive hyperextension of the PIP joint combined with flexion of the DIP joint, clinically recognized as a swan neck deformity.

Question 1930

Topic: 7. Hand and Wrist

A 22-year-old male falls onto an outstretched hand and sustains a displaced fracture through the proximal pole of the scaphoid. Avascular necrosis of the proximal pole is highly likely due to the disruption of its primary vascular supply. Which vessel provides this critical retrograde perfusion?

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

Correct Answer & Explanation

. Dorsal carpal branch of the radial artery

Explanation

The primary blood supply to the scaphoid is from the dorsal carpal branch of the radial artery, which enters the dorsal ridge of the scaphoid at the waist and courses proximally. This retrograde blood flow makes proximal pole fractures highly susceptible to avascular necrosis and nonunion. The superficial palmar branch provides a minor supply (about 20%) to the distal pole.

Question 1931

Topic: Hand Trauma & Infection
A 40-year-old diabetic male presents with a swollen, painful right index finger after a puncture wound. You suspect pyogenic flexor tenosynovitis. Kanavel's classical cardinal signs for this condition include all of the following EXCEPT:
. Fusiform swelling of the entire digit
. Pain with passive extension of the digit
. Flexed resting posture of the digit
. Erythema extending proximally into the mid-palm
. Tenderness to palpation along the flexor tendon sheath

Correct Answer & Explanation

. Erythema extending proximally into the mid-palm

Explanation

Kanavel's four cardinal signs of flexor tenosynovitis are: 1) fusiform (sausage-like) swelling of the digit, 2) severe pain with passive extension, 3) a flexed resting posture of the digit, and 4) tenderness along the entire course of the flexor tendon sheath. Erythema extending to the mid-palm is not one of Kanavel's specific signs, though localized erythema may be present.

Question 1932

Topic: 7. Hand and Wrist
A 45-year-old manual laborer complains of chronic radial-sided wrist pain. He recalls a severe 'sprain' 10 years ago. Radiographs demonstrate scapholunate dissociation with advanced radioscaphoid arthritis. MRI confirms the radiolunate joint is spared, but the proximal capitate shows severe, full-thickness chondral wear. Which of the following procedures is most appropriate to provide durable pain relief while preserving motion?
. Proximal row carpectomy (PRC)
. Scaphoid excision and four-corner fusion
. Total wrist arthroplasty
. Scapholunate ligament reconstruction using a tendon graft
. Radial styloidectomy and posterior interosseous nerve neurectomy

Correct Answer & Explanation

. Scaphoid excision and four-corner fusion

Explanation

The patient has Scapholunate Advanced Collapse (SLAC) pattern of the wrist. Stage III SLAC involves the capitolunate joint, while the radiolunate joint characteristically remains spared. Because the capitate head is severely arthritic, Proximal Row Carpectomy (PRC) is contraindicated, as it relies on a healthy cartilage interface between the capitate and the lunate fossa. Scaphoid excision with four-corner fusion (capitate, hamate, lunate, triquetrum) is the procedure of choice.

Question 1933

Topic: Nerve & Tendon
A 28-year-old rugby player presents unable to actively flex the distal interphalangeal (DIP) joint of his ring finger after grabbing an opponent's jersey. Radiographs reveal a small bony avulsion fragment located at the level of the proximal interphalangeal (PIP) joint. According to the Leddy and Packer classification, what type of injury is this?
. Type I
. Type II
. Type III
. Type IV
. Type V

Correct Answer & Explanation

. Type II

Explanation

Jersey finger represents an avulsion of the flexor digitorum profundus (FDP) tendon. Leddy and Packer classification: Type I involves retraction to the palm, both vincula ruptured (high risk of ischemia, requires urgent repair). Type II involves retraction to the PIP joint level, where it is held by the intact vinculum longus; a small bony fragment may be seen at this level. Type III involves a large bony avulsion that is caught at the A4 pulley (DIP joint level). This patient has a Type II injury.

Question 1934

Topic: 7. Hand and Wrist

A 40-year-old carpenter presents with the inability to form an 'OK' sign with his thumb and index finger; instead, he forms a flat pinch. Sensation in the hand, fingers, and forearm is completely normal. Which of the following muscles is most likely affected by this isolated nerve lesion?

. Flexor digitorum superficialis to the index finger
. Flexor pollicis brevis
. Flexor digitorum profundus to the index finger
. Abductor pollicis brevis
. Opponens pollicis

Correct Answer & Explanation

. Flexor digitorum profundus to the index finger

Explanation

The patient is exhibiting the classic 'OK sign' deficit, which is pathognomonic for Anterior Interosseous Nerve (AIN) syndrome. The AIN is a pure motor branch of the median nerve (hence the normal sensation) that innervates the Flexor Pollicis Longus (FPL), the Flexor Digitorum Profundus (FDP) to the index and middle fingers, and the Pronator Quadratus. The inability to flex the DIP joint of the index finger (FDP) and the IP joint of the thumb (FPL) results in a flat pinch rather than a rounded 'OK' sign.

Question 1935

Topic: Nerve & Tendon

A 30-year-old carpenter sustains a sharp laceration over the dorsal aspect of his proximal interphalangeal (PIP) joint, completely severing the central slip of the extensor mechanism. If this injury is misdiagnosed and left untreated, what classic finger deformity will predictably develop over the ensuing weeks?

. Swan neck deformity
. Boutonniere deformity
. Mallet finger
. Pseudo-boutonniere deformity
. Intrinsic plus hand

Correct Answer & Explanation

. Boutonniere deformity

Explanation

Disruption of the central slip at the PIP joint initially results in a subtle extension lag. Over time, the lateral bands subluxate volarly. Once the lateral bands fall volar to the axis of rotation of the PIP joint, they act as flexors of the PIP joint and hyperextensors of the DIP joint, creating the classic Boutonniere deformity.

Question 1936

Topic: 7. Hand and Wrist

A 24-year-old man falls on an outstretched hand and sustains a proximal pole scaphoid fracture.

Which of the following vascular supplies is most directly responsible for the high rate of nonunion and avascular necrosis in this specific fracture location?

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

Correct Answer & Explanation

. Dorsal carpal branch of the radial artery

Explanation

The major blood supply to the scaphoid enters distally at the dorsal ridge via the dorsal carpal branch of the radial artery and flows retrogradely to the proximal pole. Fractures at the proximal pole disrupt this retrograde supply, leading to high rates of avascular necrosis and nonunion.

Question 1937

Topic: Nerve & Tendon

A 6-year-old girl falls off the monkey bars and sustains a displaced extension-type supracondylar humerus fracture. On examination, she is unable to make an 'A-OK' sign, instead demonstrating a pinch with the pulps of her index finger and thumb. Which nerve is most likely injured?

. Radial nerve
. Ulnar nerve
. Anterior interosseous nerve
. Posterior interosseous nerve
. Musculocutaneous nerve

Correct Answer & Explanation

. Anterior interosseous nerve

Explanation

The anterior interosseous nerve (AIN), a branch of the median nerve, is the most commonly injured nerve in extension-type supracondylar humerus fractures. It innervates the flexor pollicis longus and flexor digitorum profundus to the index finger; an injury results in an inability to flex the IP joint of the thumb and DIP joint of the index finger (positive 'A-OK' or 'pinch' test).

Question 1938

Topic: 7. Hand and Wrist
A laceration to the volar surface of the hand occurs between the distal palmar crease and the proximal interphalangeal joint. Both the flexor digitorum superficialis (FDS) and profundus (FDP) tendons are severed. This injury is located in which flexor tendon zone?
. Zone I
. Zone II
. Zone III
. Zone IV
. Zone V

Correct Answer & Explanation

. Zone II

Explanation

Zone II (historically known as 'no man's land') extends from the A1 pulley (at the level of the distal palmar crease) to the insertion of the FDS tendon (middle phalanx). Injuries here involve both the FDS and FDP within the tight fibro-osseous sheath, making repair challenging due to adhesion formation.

Question 1939

Topic: 7. Hand and Wrist
A 45-year-old male presents with chronic wrist pain. Radiographs demonstrate scapholunate advanced collapse (SLAC). In a Stage II SLAC wrist, the degenerative changes involve which of the following articulations?
. Radial styloid and scaphoid alone
. Entire radioscaphoid joint
. Radioscaphoid and capitolunate joints
. Capitolunate and lunotriquetral joints
. Radiolunate joint

Correct Answer & Explanation

. Entire radioscaphoid joint

Explanation

SLAC wrist progression: Stage I involves the radial styloid-scaphoid articulation. Stage II involves the entire radioscaphoid facet. Stage III involves the capitolunate joint. The radiolunate joint is characteristically spared.

Question 1940

Topic: Wrist & Carpus

A 60-year-old female undergoes volar locked plating for a displaced distal radius fracture. Eight weeks post-operatively, she returns complaining of the sudden inability to actively flex the interphalangeal joint of her thumb. Which of the following surgical errors most likely led to this complication?

. Plate placed distal to the watershed line
. Dorsal screw penetration
. Unrecognized scapholunate ligament tear
. Failure to repair the pronator quadratus
. Over-distraction of the radiocarpal joint

Correct Answer & Explanation

. Plate placed distal to the watershed line

Explanation

Flexor pollicis longus (FPL) tendon rupture is a known complication of volar plating of the distal radius. It is typically caused by placement of the plate distal to the watershed line, allowing the FPL tendon to rub against the prominent distal edge of the plate.

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