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7. Hand and Wrist MCQs

Practice Set 99 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 1961

Topic: 7. Hand and Wrist

A 48-year-old female secretary presents with numbness and tingling in her thumb, index, and middle fingers that wakes her up at night. She has noted weakness in her grip and visible flattening of her thenar eminence. She is diagnosed with severe carpal tunnel syndrome. Which of the following thenar muscles is NOT innervated by the median nerve and would therefore be spared in this condition?

. Abductor pollicis brevis
. Opponens pollicis
. Superficial head of flexor pollicis brevis
. Adductor pollicis
. First lumbrical

Correct Answer & Explanation

. Adductor pollicis

Explanation

The recurrent motor branch of the median nerve innervates the 'OAF' muscles of the thenar eminence: Opponens pollicis, Abductor pollicis brevis, and the superficial head of the Flexor pollicis brevis. The Adductor pollicis, along with the deep head of the flexor pollicis brevis, is innervated by the deep branch of the ulnar nerve and is spared in carpal tunnel syndrome.

Question 1962

Topic: 7. Hand and Wrist

A 20-year-old college student falls onto an outstretched hand and presents with anatomic snuffbox tenderness. Initial radiographs are negative, but an MRI obtained 3 days later confirms a non-displaced fracture of the proximal pole of the scaphoid. The patient is at high risk for avascular necrosis due to the scaphoid's retrograde blood supply. Which of the following vessels provides the primary blood supply to the proximal pole of the scaphoid?

. 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 primary blood supply to the scaphoid comes from the dorsal carpal branch of the radial artery, which enters the scaphoid near the waist in a distal-to-proximal (retrograde) fashion. Because the proximal pole relies entirely on this retrograde flow, fractures at the waist or proximal pole put the proximal segment at significant risk of avascular necrosis and nonunion.

Question 1963

Topic: Wrist & Carpus

A 60-year-old woman presents 4 weeks after sustaining a nondisplaced distal radius fracture, which was managed in a short arm cast. She now complains of a sudden inability to actively extend the interphalangeal joint of her thumb. Which of the following represents the most likely etiology of this complication?

. Injury to the posterior interosseous nerve
. Attritional rupture of the extensor pollicis longus tendon over Lister's tubercle
. Volar subluxation of the distal radioulnar joint
. Adhesion of the flexor pollicis longus tendon
. Ischemic contracture of the forearm musculature

Correct Answer & Explanation

. Attritional rupture of the extensor pollicis longus tendon over Lister's tubercle

Explanation

Extensor pollicis longus (EPL) tendon rupture is a known complication following distal radius fractures, peculiarly most often associated with non-displaced or minimally displaced fractures. It occurs due to attritional wear as the tendon glides over the fracture callus near Lister's tubercle, combined with focal ischemia within the third dorsal compartment. The classic presentation is a sudden inability to extend the IP joint of the thumb a few weeks post-injury. Treatment is typically an extensor indicis proprius (EIP) to EPL tendon transfer.

Question 1964

Topic: Nerve & Tendon

A patient with a chronic high median nerve palsy requires tendon transfers to restore function. Which of the following combinations of tendon transfers is most appropriate to restore thumb flexion, thumb opposition, and index/long finger flexion?

. Brachioradialis (BR) to FPL, ECRL to FDP, EIP to APB
. ECRL to FPL, FCU to FDP, ADM to APB
. ECU to FPL, ECRB to FDP, PL to APB
. BR to FPL, ECU to FDP, EIP to APB
. ECRL to FPL, BR to FDP, EDM to APB

Correct Answer & Explanation

. Brachioradialis (BR) to FPL, ECRL to FDP, EIP to APB

Explanation

In a high median nerve palsy, there is loss of thumb flexion (FPL), index/long finger flexion (FDP), and thumb opposition (APB). A common set of transfers includes the Brachioradialis (BR) to the Flexor Pollicis Longus (FPL) to restore thumb flexion, the Extensor Carpi Radialis Longus (ECRL) to the FDP of the index and long fingers to restore finger flexion, and the Extensor Indicis Proprius (EIP) to the Abductor Pollicis Brevis (APB) (Burkhalter transfer) to restore opposition.

Question 1965

Topic: 7. Hand and Wrist
A 32-year-old manual laborer presents with dorsal wrist pain and decreased grip strength. Radiographs show sclerosis and fragmentation of the lunate, with proximal migration of the capitate and a loss of carpal height. There is no evidence of radiocarpal or midcarpal osteoarthritis. What is the Lichtman classification stage of this patient's Kienböck's disease?
. Stage I
. Stage II
. Stage IIIA
. Stage IIIB
. Stage IV

Correct Answer & Explanation

. Stage IIIB

Explanation

The Lichtman classification for Kienböck's disease (avascular necrosis of the lunate): Stage I has normal x-rays (changes seen only on MRI). Stage II shows lunate sclerosis without collapse. Stage IIIA shows lunate collapse without fixed scaphoid rotation or carpal height loss. Stage IIIB shows lunate collapse with fixed scaphoid flexion, proximal migration of the capitate, and loss of carpal height, but no osteoarthritis. Stage IV includes secondary radiocarpal or midcarpal osteoarthritis.

Question 1966

Topic: 7. Hand and Wrist

A 62-year-old female underwent volar locked plating for a comminuted distal radius fracture 3 months ago. She now presents with a sudden inability to actively flex the interphalangeal joint of her thumb. Which of the following factors most likely contributed to this complication?

. Extensor pollicis longus (EPL) attrition from dorsal screw penetration
. Flexor pollicis longus (FPL) rupture secondary to plate prominence at the watershed line
. Iatrogenic transection of the anterior interosseous nerve during exposure
. Flexor digitorum profundus (FDP) rupture from overly long distal screws
. Adhesions of the flexor tendons within the carpal tunnel

Correct Answer & Explanation

. Flexor pollicis longus (FPL) rupture secondary to plate prominence at the watershed line

Explanation

The patient has experienced a spontaneous rupture of the Flexor Pollicis Longus (FPL) tendon. This is a well-known complication of volar locked plating of distal radius fractures, most commonly caused by placing the plate too far distally so that it extends past the watershed line of the distal radius. The prominent distal edge of the plate causes attritional wear and eventual rupture of the overlying FPL tendon.

Question 1967

Topic: 7. Hand and Wrist
A 28-year-old chef sustains a knife laceration over the palmar aspect of his proximal phalanx of the ring finger. Examination reveals an inability to actively flex both the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints of the ring finger. In which flexor tendon zone did this injury occur?
. Zone I
. Zone II
. Zone III
. Zone IV
. Zone V

Correct Answer & Explanation

. Zone II

Explanation

Flexor tendon Zone II, historically known as 'no man's land,' extends from the proximal edge of the A1 pulley (at the metacarpal neck) to the insertion of the Flexor Digitorum Superficialis (FDS) at the middle phalanx. An injury over the palmar aspect of the proximal phalanx occurs within Zone II. Lacerations here typically involve both the FDS and FDP tendons. Zone I is distal to the FDS insertion (FDP only). Zone III is in the palm. Zone IV is within the carpal tunnel.

Question 1968

Topic: Wrist & Carpus
A 45-year-old manual laborer presents with chronic wrist pain and stiffness. Radiographs demonstrate Scaphoid Nonunion Advanced Collapse (SNAC) Stage III. Which of the following joint involvement patterns correctly describes SNAC Stage III, making Proximal Row Carpectomy (PRC) contraindicated?
. Isolated radioscaphoid arthritis
. Capitolunate arthritis
. Scaphocapitate arthritis
. Pancarpal arthritis
. Radiolunate arthritis

Correct Answer & Explanation

. Capitolunate arthritis

Explanation

SNAC staging progresses as follows: Stage I involves the radioscaphoid joint (specifically the radial styloid); Stage II involves the scaphocapitate joint; Stage III involves the capitolunate joint; and Stage IV is pancarpal arthritis. Proximal row carpectomy (PRC) relies on a preserved proximal capitate head articulating with the lunate fossa of the radius. Because SNAC III involves degenerative changes at the capitolunate joint (including the capitate head), PRC is contraindicated, and a four-corner arthrodesis is the preferred motion-preserving salvage procedure.

Question 1969

Topic: 7. Hand and Wrist

A 60-year-old female undergoes open reduction and internal fixation of a distal radius fracture with a volar locking plate. Three months postoperatively, she suddenly loses the ability to actively flex the interphalangeal joint of her thumb. Which technical error during the initial surgery is the most likely cause of this complication?

. Placement of the plate prominent to the volar watershed line
. Penetration of a dorsal screw into the third extensor compartment
. Failure to release the brachioradialis tendon
. Over-reduction of the volar tilt leading to median nerve compression
. Placement of a screw excessively deep into the distal radioulnar joint

Correct Answer & Explanation

. Placement of the plate prominent to the volar watershed line

Explanation

Attritional rupture of the flexor pollicis longus (FPL) tendon is a well-documented complication of volar locking plate fixation for distal radius fractures. It most commonly occurs when the plate is placed distal to the 'watershed line' (Soong Grade 2), causing the FPL tendon to rub directly against the prominent distal edge of the plate during wrist motion.

Question 1970

Topic: 7. Hand and Wrist

A 25-year-old manual laborer presents with 6 months of radial-sided wrist pain. He recalls a fall on an outstretched hand approximately one year ago but did not seek medical attention at the time. Radiographs demonstrate a scaphoid waist nonunion with sclerosis and cystic changes, but there is no evidence of radioscaphoid or midcarpal arthritis. What is the most appropriate surgical treatment?

. Four-corner fusion
. Proximal row carpectomy
. Scaphoid excision and four-corner fusion
. Open reduction internal fixation with bone grafting
. Total wrist arthrodesis

Correct Answer & Explanation

. Open reduction internal fixation with bone grafting

Explanation

The patient has a scaphoid nonunion but lacks degenerative arthritic changes (this is pre-SNAC or SNAC stage 0). In the absence of arthritis, the goal is to obtain union of the scaphoid to prevent the progression of carpal collapse and arthritis. This is best achieved via ORIF with bone grafting (non-vascularized or vascularized, depending on proximal pole viability). Salvage procedures like four-corner fusion or PRC are reserved for established SNAC arthritis.

Question 1971

Topic: 7. Hand and Wrist

Flexor tendon Zone II in the hand, historically referred to as 'no man's land' due to the poor outcomes associated with primary repair, is defined anatomically by which of the following boundaries?

. From the distal insertion of the FDS to the distal insertion of the FDP
. From the proximal margin of the A1 pulley to the insertion of the FDS
. From the distal edge of the carpal tunnel to the proximal margin of the A1 pulley
. From the musculotendinous junction to the proximal edge of the carpal tunnel
. From the distal edge of the A4 pulley to the insertion of the FDP

Correct Answer & Explanation

. From the proximal margin of the A1 pulley to the insertion of the FDS

Explanation

Flexor tendon Zone II extends from the proximal aspect of the A1 pulley to the insertion of the Flexor Digitorum Superficialis (FDS) tendon on the middle phalanx. Within this zone, both the FDS and the Flexor Digitorum Profundus (FDP) tendons run tightly together within the fibro-osseous digital sheath. Adhesions are common after repair here, which originally led Bunnell to term it 'no man's land'.

Question 1972

Topic: Wrist & Carpus



A 65-year-old female underwent volar locked plating for a comminuted distal radius fracture 6 months ago. The fracture has healed uneventfully. However, she now presents to the clinic with a sudden inability to actively flex the interphalangeal (IP) joint of her thumb. Which of the following technical errors during the index surgery most likely caused this complication?

. Over-penetration of the dorsal cortex with locking screws
. Placement of the volar plate distal to the watershed line
. Failure to repair the pronator quadratus over the plate
. Iatrogenic injury to the radial artery during the Henry approach
. Excessive volar tilt correction during reduction

Correct Answer & Explanation

. Placement of the volar plate distal to the watershed line

Explanation

The patient is presenting with a spontaneous rupture of the Flexor Pollicis Longus (FPL) tendon, which is a well-documented complication of volar plating of the distal radius. It is most commonly caused by iatrogenic plate prominence due to placement of the plate distal to the 'watershed line'. This creates attrition and friction on the FPL tendon as it glides over the prominent hardware, eventually leading to rupture. Prominent dorsal screws would endanger the extensor tendons (e.g., EPL).

Question 1973

Topic: 7. Hand and Wrist

A 32-year-old carpenter sustains a laceration to the volar aspect of his index finger proximal phalanx, cutting the flexor digitorum profundus (FDP) and superficialis (FDS) tendons in Zone II.

To permit an early active motion protocol safely, biomechanical studies suggest the core suture repair of the FDP tendon should consist of at least how many strands?

. 2 strands
. 4 strands
. 6 strands
. 8 strands
. Strand count is irrelevant if an epitendinous suture is used

Correct Answer & Explanation

. 4 strands

Explanation

In flexor tendon repairs, biomechanical strength is directly proportional to the number of core suture strands crossing the repair site. Studies have demonstrated that a 2-strand repair is generally only strong enough for passive motion protocols. A minimum of a 4-strand core repair is required to withstand the forces generated during an early active motion protocol and reduce the risk of gap formation or rupture.

Question 1974

Topic: 7. Hand and Wrist

During an open carpal tunnel release, the surgeon carefully incises the transverse carpal ligament, mindful of the recurrent motor branch of the median nerve to the thenar muscles.

According to anatomic studies (e.g., Lanz's classification), what is the most common path of the recurrent motor branch?

. Extraligamentous, branching distal to the transverse carpal ligament and recurring to the thenar muscles
. Subligamentous, branching deep to the transverse carpal ligament
. Transligamentous, piercing directly through the transverse carpal ligament
. Branching from the ulnar aspect of the median nerve
. Passing dorsal to the flexor tendons before entering the thenar musculature

Correct Answer & Explanation

. Extraligamentous, branching distal to the transverse carpal ligament and recurring to the thenar muscles

Explanation

According to Lanz's anatomic classification of the median nerve in the carpal tunnel, the extraligamentous variation is the most common (found in roughly 50-80% of cases). In this pattern, the recurrent motor branch arises distal to the transverse carpal ligament and recurves over its distal edge to innervate the thenar muscles. Transligamentous, subligamentous, and ulnar-sided branches are less common variants.

Question 1975

Topic: Nerve & Tendon
A 28-year-old carpenter sustains a deep laceration to his volar palm, exactly at the proximal edge of the A1 pulley, resulting in an inability to flex his digits. In which flexor tendon zone did this injury occur?
. Zone I
. Zone II
. Zone III
. Zone IV
. Zone V

Correct Answer & Explanation

. Zone II

Explanation

Zone II (historically termed 'no man's land' by Bunnell due to historically poor surgical outcomes) extends from the proximal aspect of the A1 pulley to the insertion of the flexor digitorum superficialis (FDS) on the middle phalanx. Both FDS and FDP tendons run tightly together in the fibro-osseous sheath in this zone, making repair technically demanding.

Question 1976

Topic: 7. Hand and Wrist
A 35-year-old manual laborer presents with chronic dorsal wrist pain and decreased grip strength. Radiographs demonstrate sclerosis and early collapse of the lunate, accompanied by ulnar minus (negative) variance. Which of the following is the most appropriate initial surgical management for this early-stage (Stage II or IIIA) Kienböck's disease?
. Proximal row carpectomy
. Total wrist arthrodesis
. Radial shortening osteotomy
. Lunate excision and silastic replacement
. Ulnar shortening osteotomy

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

In early stages of Kienböck's disease (avascular necrosis of the lunate) where the lunate has not severely collapsed or fragmented (Stage I, II, or IIIA) and there is negative ulnar variance, joint leveling procedures are indicated. A radial shortening osteotomy (or ulnar lengthening) shifts load off the radiolunate joint onto the ulnocarpal joint, allowing lunate revascularization. Proximal row carpectomy or arthrodesis are salvage procedures for advanced disease (Stage IIIB/IV).

Question 1977

Topic: Nerve & Tendon

The recurrent motor branch of the median nerve provides critical motor innervation to the thenar eminence. Which of the following muscles is typically NOT innervated by the recurrent motor branch of the median nerve?

. Abductor pollicis brevis
. Opponens pollicis
. Superficial head of the flexor pollicis brevis
. Deep head of the flexor pollicis brevis
. None of the above; all are innervated by the recurrent median nerve.

Correct Answer & Explanation

. Deep head of the flexor pollicis brevis

Explanation

The thenar muscles include the abductor pollicis brevis (APB), opponens pollicis (OP), and flexor pollicis brevis (FPB). The recurrent motor branch of the median nerve innervates the APB, OP, and the superficial head of the FPB. The deep head of the FPB is typically innervated by the deep branch of the ulnar nerve (though dual innervation can occur). The adductor pollicis is also innervated by the ulnar nerve.

Question 1978

Topic: 7. Hand and Wrist
A 35-year-old male presents with chronic wrist pain. Radiographs reveal a scaphoid nonunion with radioscaphoid arthritis. The capitolunate and radiolunate joints are radiographically preserved. What stage of Scaphoid Nonunion Advanced Collapse (SNAC) is this, and what is the most appropriate surgical treatment?
. Stage I: Radial styloidectomy and scaphoid fixation
. Stage II: Proximal row carpectomy or four-corner fusion
. Stage III: Total wrist arthrodesis
. Stage IV: Total wrist arthroplasty
. Stage II: Scaphoid fixation with vascularized bone graft

Correct Answer & Explanation

. Stage II: Proximal row carpectomy or four-corner fusion

Explanation

This is SNAC Stage II. Stage I involves arthritis isolated to the radial styloid. Stage II involves the entire radioscaphoid joint. Stage III involves the capitolunate joint. The radiolunate joint is typically spared. Stage II is appropriately treated with proximal row carpectomy (PRC) or 4-corner fusion.

Question 1979

Topic: 7. Hand and Wrist
A patient sustains a deep laceration over the volar aspect of the proximal phalanx of the index finger. Surgical exploration reveals complete transection of both the flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP). What flexor tendon zone is this injury located in?
. Zone I
. Zone II
. Zone III
. Zone IV
. Zone V

Correct Answer & Explanation

. Zone II

Explanation

Zone II (historically called 'no man's land') extends from the A1 pulley (distal palmar crease) to the insertion of the FDS on the middle phalanx. It contains both the FDS and FDP tendons within the narrow fibro-osseous sheath.

Question 1980

Topic: 7. Hand and Wrist

A 62-year-old female presents with a painful mass over the dorsal aspect of her right index finger distal interphalangeal (DIP) joint, accompanied by a longitudinal groove in her nail plate.

She undergoes surgical excision of the lesion. To minimize the highest risk of recurrence, which of the following must be performed during the procedure?

. Wide excision of the overlying skin with a rotation flap
. Marginal excision of the associated distal phalanx osteophyte
. Arthrodesis of the DIP joint
. Complete resection of the extensor tendon insertion
. Cauterization of the nail matrix

Correct Answer & Explanation

. Marginal excision of the associated distal phalanx osteophyte

Explanation

The clinical scenario and image refer to a mucous cyst of the DIP joint, which is a ganglion cyst associated with underlying osteoarthritis (Heberden's nodes). The highest rate of recurrence of a mucous cyst occurs if the surgeon fails to identify and debride the underlying marginal osteophyte from the DIP joint. Excision of the cyst stalk and meticulous osteophyte debridement reduces the recurrence rate to less than 5%.

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