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Free Orthopedics Review | Dr Hutaif General Orthopedics -...

27 Apr 2026 143 min read 148 Views
Illustration of bone marrow transplantation - Dr. Mohammed Hutaif

Key Takeaway

Here are the crucial details you must know about FREE Orthopedics MCQS 2022 1851-1900.. Bone marrow transplantation is a medical procedure replacing unhealthy bone marrow with healthy stem cells. It treats various blood cancers like leukemia and lymphoma, aplastic anemia, and certain immune deficiency disorders. The process can involve autologous (patient's own) or allogeneic (donor) stem cells to restore the body's ability to produce blood cells.

ORTHOPEDIC MCQS BANK HAND AND WRIST 1C

Comprehensive 100-Question Exam


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Question 1

A 35-year-old man with a chronic high radial nerve palsy undergoes functional tendon transfers. The surgeon transfers the pronator teres (PT) to the extensor carpi radialis brevis (ECRB) to restore wrist extension, and the flexor carpi ulnaris (FCU) to the extensor digitorum communis (EDC) to restore finger extension. Which of the following is the most appropriate transfer to restore thumb extension in this patient?





Explanation

In a high radial nerve palsy, the palmaris longus (PL) to extensor pollicis longus (EPL) transfer is the gold standard for restoring thumb extension. The extensor indicis proprius (EIP) to EPL transfer is commonly used for spontaneous EPL ruptures, but it cannot be used in a radial nerve palsy because the EIP is innervated by the posterior interosseous nerve (PIN), which is nonfunctional in this scenario.

Question 2

A 55-year-old male presents with severe wrist pain and is diagnosed with Stage III Scapholunate Advanced Collapse (SLAC). The surgeon is debating between a proximal row carpectomy (PRC) and a four-corner fusion. Which of the following findings is an absolute contraindication to performing a proximal row carpectomy?





Explanation

Proximal row carpectomy (PRC) relies on a healthy articulation between the head of the capitate and the lunate fossa of the distal radius. Therefore, significant degenerative arthritis of the proximal capitate articular surface (capitolunate arthritis) is a strict contraindication to a PRC. In such cases, a four-corner fusion with scaphoid excision is the preferred motion-preserving alternative.

Question 3

A 35-year-old man underwent primary repair of a zone III flexor digitorum profundus (FDP) laceration. Postoperatively, he notes that when he attempts to forcefully flex his fingers into a full fist, the PIP joint of the affected finger paradoxically extends. What is the most likely cause of this phenomenon?





Explanation

This patient is demonstrating a 'lumbrical plus' finger. This occurs when the FDP tendon is divided or ruptures distal to the origin of the lumbrical muscle, or if an FDP graft is left too long. When the patient attempts to flex the finger, the proximal retraction of the FDP pulls the lumbrical muscle proximally, which translates force through the lateral bands to cause paradoxical extension of the PIP and DIP joints.

Question 4

A patient with a traumatic ulnar nerve transection at the wrist (low ulnar nerve injury) demonstrates significantly more severe clawing of the ring and small fingers compared to a patient with an ulnar nerve transection at the elbow (high ulnar nerve injury). Which intact muscle is responsible for exacerbating the claw deformity in the low ulnar nerve injury?





Explanation

This describes the 'Ulnar Paradox.' In a high ulnar nerve injury, the flexor digitorum profundus (FDP) to the ring and small fingers is denervated, so there is less active flexion force at the DIP joint. In a low ulnar nerve injury, the FDP remains innervated (by branches given off in the proximal forearm), leading to unopposed flexion of the DIP joints, which drastically accentuates the classic claw hand posture.

Question 5

During a partial fasciectomy for severe Dupuytren's contracture of the ring finger, the surgeon notes that the digital neurovascular bundle is displaced superficially and toward the midline of the digit. Involvement of which of the following fascial cords is the primary cause of this specific anatomical distortion?





Explanation

The spiral cord is responsible for proximal interphalangeal (PIP) joint contractures and classically displaces the digital neurovascular bundle centrally, superficially, and proximally. This distortion places the neurovascular bundle at high risk of iatrogenic injury during surgical excision. The spiral cord is formed by the pretendinous band, spiral band, lateral digital sheet, and Grayson's ligament.

Question 6

A 28-year-old man sustains a severe laceration at the level of the proximal wrist crease, completely transecting the median nerve. Six months later, despite complete absence of median nerve sensation in the hand, he demonstrates surprisingly preserved strength in thumb opposition and a normal thenar eminence. Which of the following neural anomalies best explains this physical finding?





Explanation

The Riche-Cannieu anastomosis is an anomalous neural connection between the deep branch of the ulnar nerve and the recurrent motor branch of the median nerve in the palm. When present, it allows ulnar nerve innervation of the thenar muscles, preserving thumb opposition even if the median nerve is transected proximal to the wrist. The Martin-Gruber anastomosis occurs in the forearm.

Question 7

In the pathogenesis of primary osteoarthritis of the trapeziometacarpal (thumb CMC) joint, attenuation of which specific ligament is classically considered the primary initiating event leading to dorsal-radial subluxation of the metacarpal base?





Explanation

The anterior oblique ligament (AOL), also known as the beak ligament, originates on the palmar tubercle of the trapezium and inserts on the palmar beak of the first metacarpal. It has historically been considered the primary static stabilizer of the trapeziometacarpal joint. Attenuation of the AOL allows dorsal-radial subluxation of the metacarpal base, accelerating joint degeneration.

Question 8

A 45-year-old woman presents with severe, excruciating pain at the tip of her left index finger. The pain is exacerbated by cold weather. On examination, point tenderness is elicited with a pinhead, and the pain resolves temporarily when a tourniquet is inflated around the base of the finger. Histological examination of the excised lesion would most likely reveal:





Explanation

The clinical presentation is classic for a glomus tumor, characterized by the triad of paroxysmal pain, point tenderness (Love's pin test), and cold sensitivity. Pain relief with ischemia is known as Hildreth's sign. Histologically, glomus tumors present as sheets of uniform, round-to-oval cells (glomus cells) surrounding fine vascular channels.

Question 9

A 24-year-old gymnast presents with chronic ulnar-sided wrist pain after a twisting injury. MRI arthrography reveals a tear of the triangular fibrocartilage complex (TFCC) directly at its radial attachment to the sigmoid notch of the radius. According to the Palmer classification system, how is this tear classified?





Explanation

The Palmer classification categorizes TFCC tears into traumatic (Class 1) and degenerative (Class 2). Palmer 1A is a central perforation; 1B is an ulnar avulsion (with or without ulnar styloid fracture); 1C is a distal avulsion (involving the ulnocarpal ligaments); and 1D is a radial avulsion from the sigmoid notch of the radius.

Question 10

A 32-year-old manual laborer presents with dorsal wrist pain. Radiographs reveal sclerosis of the lunate without collapse, and an ulnar variance of minus 3 mm. MRI confirms avascular necrosis of the lunate. Which of the following is the most appropriate initial surgical intervention?





Explanation

This patient has Stage II Kienböck's disease (sclerosis of the lunate, normal architecture without collapse) combined with negative ulnar variance. The standard of care to decompress the lunate in the setting of negative ulnar variance is a joint leveling procedure. Radial shortening osteotomy is biomechanically superior and has a lower complication rate compared to ulnar lengthening.

Question 11

A term newborn is noted to have fused digits on bilateral hands. The fusion involves the long and ring fingers, with soft tissue connection extending only to the proximal interphalangeal joint, and no bony fusion is present. Which of the following best describes the most common classification and genetic inheritance pattern if this were a familial trait?





Explanation

Simple syndactyly involves only soft tissue fusion, whereas complex implies bony fusion. Incomplete means it does not extend to the fingertips. Simple incomplete syndactyly between the 3rd and 4th digits (long and ring fingers) is the most common presentation. When familial, isolated syndactyly typically follows an autosomal dominant inheritance pattern with variable penetrance.

Question 12

A 50-year-old woman complains of burning pain and numbness over the dorsoradial aspect of her right hand, which worsens when she wears tightly cuffed shirts. Examination reveals a positive Tinel's sign over the distal forearm, approximately 8 cm proximal to the radial styloid. Finkelstein's test is negative. Compression of the involved nerve typically occurs between which two structures during forearm pronation?





Explanation

The clinical picture describes Wartenberg's syndrome, an entrapment neuropathy of the superficial sensory branch of the radial nerve. Compression most classically occurs at the junction of the middle and distal thirds of the forearm, where the nerve emerges from its subfascial location between the brachioradialis and ECRL tendons. This compression is exacerbated during forearm pronation.

Question 13

A 41-year-old mechanic presents with an inability to form an 'OK' sign with his thumb and index finger, noting that the distal phalanges remain extended during the attempt. Sensation over the entire hand is completely normal. Which of the following anatomical variants is most classically associated with compression of the affected nerve?





Explanation

The patient has Anterior Interosseous Nerve (AIN) syndrome, demonstrated by the inability to flex the IP joint of the thumb (FPL) and the DIP joint of the index finger (FDP). The AIN has no cutaneous sensory innervation. Gantzer's muscle, which is an accessory head of the flexor pollicis longus (FPL), is a well-known anatomical variant and a classic cause of AIN compression.

Question 14

Following a neglected central slip rupture, a patient develops a chronic Boutonniere deformity. In the pathogenesis of this established deformity, which anatomical structure becomes attenuated, allowing the lateral bands to subluxate volar to the axis of rotation of the proximal interphalangeal (PIP) joint?





Explanation

In a Boutonniere deformity, disruption of the central slip eliminates primary PIP extension. Over time, the triangular ligament (which normally holds the lateral bands dorsal to the PIP joint axis) attenuates. This allows the lateral bands to slide volarly, turning them into PIP joint flexors and causing secondary hyperextension of the DIP joint.

Question 15

A 38-year-old avid cyclist presents with profound weakness of the interossei and adductor pollicis muscles, resulting in a positive Froment's sign. He has normal sensation over the volar and dorsal aspects of the small finger and the ulnar half of the ring finger. Hypothenar muscle function is also preserved. Based on this isolated clinical presentation, compression of the ulnar nerve is most likely occurring in which zone of Guyon's canal?





Explanation

Guyon's canal is divided into three zones. Zone 1 is proximal to the bifurcation (mixed motor and sensory). Zone 2 encompasses the deep motor branch (motor only). Zone 3 encompasses the superficial sensory branch (sensory only). Isolated motor deficits without sensory loss indicate a Zone 2 lesion. Sparing of the hypothenar muscles specifically implies compression in distal Zone 2, after the hypothenar motor branches have taken off.

Question 16

A 20-year-old collegiate football player grabs an opponent's jersey and sustains a forced hyperextension injury to his ring finger while actively flexing. He is unable to actively flex the distal interphalangeal (DIP) joint. Radiographs demonstrate no fracture. Ultrasound reveals the proximal stump of the flexor digitorum profundus (FDP) tendon is retracted into the palm. According to the Leddy-Packer classification, what type of injury is this, and what is the status of the vincula?





Explanation

A Leddy-Packer Type I Jersey finger involves avulsion of the FDP tendon with proximal retraction all the way into the palm. For the tendon to retract this far, both the vinculum breve and vinculum longum must be ruptured. This severely compromises the tendon's blood supply, requiring urgent surgical repair within 7-10 days to avoid permanent retraction and necrosis.

Question 17

A 55-year-old woman sustains a volar shearing fracture of the distal radius (volar Barton's fracture). The carpus subluxates volarly with the fracture fragment. Which of the following intrinsic/extrinsic carpal ligaments remains firmly attached to this volar fragment, pulling the carpus with it?





Explanation

In a volar Barton's fracture, the volar marginal rim of the distal radius shears off. The strong volar radiocarpal ligaments, specifically the radioscaphocapitate (RSC) and the long radiolunate (LRL) ligaments, remain firmly attached to this fragment. As the fragment displaces volarly, the intact ligaments pull the entire carpus along with it, leading to the characteristic radiocarpal subluxation.

Question 18

A 27-year-old carpenter presents with a swollen, painful index finger 3 days after a puncture wound. Upon examination, he exhibits all four of Kanavel's cardinal signs for suppurative flexor tenosynovitis. Which of these four signs is considered the earliest and most sensitive indicator of this condition?





Explanation

Kanavel's four cardinal signs of purulent flexor tenosynovitis are: 1) fusiform (sausage-like) swelling, 2) flexed resting posture of the digit, 3) exquisite tenderness along the entire course of the flexor tendon sheath, and 4) excruciating pain with passive extension of the digit. Pain with passive extension is historically and clinically considered the earliest and most sensitive sign of the condition.

Question 19

Which of the following scenarios represents an absolute contraindication to replantation of an amputated body part?





Explanation

Replantation of 'macroamputations' (amputations proximal to the radiocarpal joint containing significant muscle mass) is absolutely contraindicated if warm ischemia time exceeds 6 hours. Prolonged ischemia of skeletal muscle leads to irreversible necrosis. Reperfusion after 6 hours of warm ischemia can release massive amounts of myoglobin, potassium, and lactic acid, potentially causing fatal renal failure or arrhythmias. Digits lack muscle bellies and can tolerate up to 12 hours of warm ischemia.

Question 20

A neonate is evaluated for bilateral radial deviation of the hands. Radiographs reveal complete absence of the radii bilaterally. However, the child has well-formed, pentadactyl hands with fully functional thumbs bilaterally. Laboratory evaluation is notable for a profoundly low platelet count. This clinical picture is pathognomonic for which of the following syndromes?





Explanation

TAR (Thrombocytopenia-Absent Radius) syndrome is classically characterized by bilateral absence of the radius combined with thrombocytopenia. A pathognomonic and differentiating feature of TAR syndrome is that the thumb is uniformly present and often functional, unlike other radial longitudinal deficiencies (such as Fanconi anemia, Holt-Oram syndrome, and VACTERL association) where the thumb is typically absent or severely hypoplastic.

Question 21

A 35-year-old male presents with a persistent radial nerve palsy following a humerus fracture sustained 12 months ago. He has failed conservative management and is scheduled for tendon transfer surgery. Which of the following describes the most appropriate standard set of tendon transfers to restore wrist, finger, and thumb extension?





Explanation

The classic set of transfers for radial nerve palsy is the Pronator Teres (PT) to Extensor Carpi Radialis Brevis (ECRB) for wrist extension, Flexor Carpi Radialis (FCR) to Extensor Digitorum Communis (EDC) for finger extension, and Palmaris Longus (PL) to Extensor Pollicis Longus (EPL) for thumb extension. Transferring PT to ECRB rather than ECRL is preferred to prevent a radial deviation moment with wrist extension. FCR is often preferred over FCU for finger extension as preserving the FCU provides better ulnar-sided wrist stability, especially in power grip.

Question 22

A newborn is evaluated for a right radial clubhand and an absent thumb. To rule out the most life-threatening associated condition in this patient, which of the following screening tests MUST be obtained?





Explanation

Radial longitudinal deficiency is associated with several syndromes, including VATER/VACTERL, Holt-Oram, TAR, and Fanconi anemia. Fanconi anemia is the most life-threatening of these due to its high risk of aplastic anemia and leukemia. It is diagnosed via chromosomal breakage testing induced by diepoxybutane (DEB) or mitomycin C. While echocardiogram and renal ultrasounds are also part of the workup for VACTERL and Holt-Oram, ruling out Fanconi anemia is paramount.

Question 23

A 28-year-old laborer presents with dorsal wrist pain. Radiographs reveal sclerosis and fragmentation of the lunate, normal carpal height, and an ulnar variance of -3 mm. There is no evidence of fixed scaphoid rotary subluxation. What is the most appropriate surgical treatment?





Explanation

The patient has Lichtman Stage IIIA Kienböck's disease (lunate fragmentation/collapse, normal carpal height, no fixed scaphoid rotary subluxation). In the presence of ulnar negative variance, a joint-leveling procedure such as a radial shortening osteotomy is the treatment of choice to unload the lunate and halt disease progression. Proximal row carpectomy or limited carpal fusions are reserved for Stage IIIB (fixed scaphoid subluxation) or Stage IV (pancarpal arthritis).

Question 24

A 42-year-old female presents with severe pain in her right ring finger exacerbated by exposure to cold. On exam, she has exquisite pinpoint tenderness over the nail bed. Application of a tourniquet to the base of the digit completely abolishes her pain. What is the most likely diagnosis?





Explanation

The clinical scenario describes the classic triad of a glomus tumor: severe paroxysmal pain, point tenderness (Love's pin test), and cold intolerance. The abolition of pain with tourniquet ischemia is known as Hildreth's sign, which is highly specific for a glomus tumor. These are benign hamartomas of the neuromyoarterial glomus body.

Question 25

In a patient with rheumatoid arthritis, which of the following is the primary initiating anatomic event in the pathogenesis of a classic Type I swan neck deformity?





Explanation

A swan neck deformity is characterized by PIP joint hyperextension and DIP joint flexion. In rheumatoid arthritis, the initiating event is typically synovitis of the PIP joint leading to attenuation of the volar plate and transverse retinacular ligament. This allows the lateral bands to subluxate dorsally, leading to PIP hyperextension, which subsequently causes passive stretching and eventual flexion of the DIP joint. Central slip rupture causes a boutonniere deformity.

Question 26

A 24-year-old male sustained a C5-C6 brachial plexus root avulsion injury 4 months ago. He has no elbow flexion but normal hand and wrist function. An Oberlin transfer is planned. Which of the following describes the donor and recipient nerves in this procedure?





Explanation

The classic Oberlin transfer involves taking redundant fascicles from the ulnar nerve (typically those supplying the FCU) and coapting them directly to the motor branch of the biceps (from the musculocutaneous nerve) to restore elbow flexion in upper trunk brachial plexus injuries. A double fascicular transfer (Mackinnon) adds median nerve fascicles to the brachialis branch.

Question 27

A 45-year-old mechanic presents with cold intolerance, pain, and ischemic changes in his right ring and small fingers. He frequently uses the heel of his hand to strike objects at work. Angiography reveals occlusion of the ulnar artery at the level of the wrist. The arterial injury is most likely occurring adjacent to which of the following osseous structures?





Explanation

This patient has hypothenar hammer syndrome, caused by repetitive blunt trauma to the hypothenar eminence. The ulnar artery (superficial palmar arch) is vulnerable to crushing against the hook of the hamate as it exits Guyon's canal, leading to thrombosis, aneurysm formation, and distal embolization.

Question 28

A 32-year-old diabetic patient presents with a purulent flexor tenosynovitis of the small finger. Two days later, despite antibiotics, he develops swelling, pain, and tenderness along the flexor tendon sheath of the thumb. The infection most likely spread from the small finger to the thumb via which of the following anatomic spaces?





Explanation

The patient has developed a 'horseshoe abscess.' The flexor tendon sheath of the small finger communicates with the ulnar bursa, and the flexor sheath of the thumb communicates with the radial bursa. In the distal forearm, the radial and ulnar bursae communicate via the Space of Parona, which lies deep to the flexor tendons and superficial to the pronator quadratus.

Question 29

A 30-year-old cyclist presents with profound weakness of the dorsal and volar interossei, lumbricals to the ring and small fingers, and adductor pollicis in his right hand. He has completely normal sensation over the entire hand, including the hypothenar eminence and the small finger. A compressive lesion in Guyon's canal is suspected. In which zone of Guyon's canal is the compression most likely located?





Explanation

Guyon's canal is divided into three zones. Zone 1 is proximal to the bifurcation and contains both motor and sensory fibers; compression here causes mixed deficits. Zone 2 contains only the deep motor branch; compression here causes isolated motor deficits (interossei, lumbricals 3/4, adductor pollicis), which matches this patient's presentation. Zone 3 contains the superficial sensory branch; compression here causes isolated sensory deficits.

Question 30

A 45-year-old man presents with chronic wrist pain. Radiographs reveal a scaphoid nonunion with arthritic changes involving the radioscaphoid joint and the capitolunate joint. The radiolunate joint is spared. The proximal pole of the capitate demonstrates severe eburnation. Which of the following is the most appropriate surgical treatment?





Explanation

This patient has Scaphoid Nonunion Advanced Collapse (SNAC) Stage III (involving the radioscaphoid and capitolunate joints). Proximal row carpectomy (PRC) relies on a healthy articulation between the lunate fossa of the radius and the proximal capitate. Because the capitate head demonstrates severe eburnation (arthritis), PRC is contraindicated. Therefore, scaphoid excision and four-corner fusion (capitate, hamate, lunate, triquetrum) is the treatment of choice, as the radiolunate joint is spared.

Question 31

A 22-year-old rugby player cannot actively flex his ring finger DIP joint after grabbing an opponent's jersey. Radiographs show no fractures. On examination, the avulsed flexor digitorum profundus (FDP) tendon is palpable in the palm. Which of the following statements regarding this specific injury pattern is true?





Explanation

This is a Leddy and Packer Type I Jersey finger, characterized by retraction of the FDP tendon into the palm. This extensive retraction ruptures both the vincula brevis and longus, severely compromising the blood supply to the tendon. Because of the ischemia and rapid contracture, primary repair must be performed early, ideally within 7 to 10 days. Type II retracts to the PIP level (vincula longus intact), and Type III is a large bony avulsion caught at the A4 pulley.

Question 32

A 25-year-old gymnast presents with ulnar-sided wrist pain after a fall on an extended, pronated wrist. MRI demonstrates a peripheral tear of the triangular fibrocartilage complex (TFCC) at its insertion onto the fovea of the ulnar styloid. According to the Palmer classification, what type of injury is this?





Explanation

The Palmer classification divides TFCC tears into traumatic (Class 1) and degenerative (Class 2). Class 1A is a central perforation. Class 1B is an ulnar avulsion (with or without ulnar styloid fracture), which occurs in the vascular zone and is amenable to repair. Class 1C is a distal avulsion (carpal attachment). Class 1D is a radial avulsion.

Question 33

During a flexor tenolysis procedure in a manual laborer, the surgeon notes significant scarring of the annular pulley system. To prevent bowstringing of the flexor tendons and significant loss of digital flexion mechanics, which two annular pulleys are mechanically the most important to preserve or reconstruct?





Explanation

The A2 (located over the proximal phalanx) and A4 (located over the middle phalanx) pulleys are the most robust and mechanically critical pulleys in the digit. Their preservation or reconstruction is vital to prevent bowstringing of the flexor tendons, which would result in a substantial loss of active motion and mechanical disadvantage.

Question 34

A 65-year-old man undergoes fasciectomy for severe Dupuytren's contracture. The surgeon dissects diseased fascia causing a 60-degree flexion contracture of the PIP joint of the small finger. The neurovascular bundle is found displaced centrally, proximally, and superficially. Which of the following fascial cords is primarily responsible for both the PIP joint contracture and this characteristic displacement of the neurovascular bundle?





Explanation

The spiral cord in Dupuytren's disease is formed from the continuation of the pretendinous band, spiral band, lateral digital sheet, and Grayson's ligament. As it contracts, it causes PIP joint flexion and characteristically pulls the neurovascular bundle toward the midline (centrally), proximally, and superficially, placing it at high risk for iatrogenic injury during surgical excision.

Question 35

A 42-year-old male presents with inability to flex the IP joint of his right thumb and the DIP joint of his right index finger. He cannot make an 'OK' sign. To clinically differentiate between an Anterior Interosseous Nerve (AIN) palsy and a closed spontaneous rupture of the flexor tendons, which of the following physical examination maneuvers is most useful?





Explanation

The inability to make the 'OK' sign indicates loss of FPL and FDP to the index finger. This can be due to an AIN palsy or tendon ruptures (e.g., in rheumatoid arthritis or Mannerfelt syndrome). The passive tenodesis test differentiates the two: passively extending the wrist will cause spontaneous flexion of the digits if the tendons are intact (AIN palsy). If the tendons are ruptured, the digits will remain extended during passive wrist extension.

Question 36

A 28-year-old man sustains a Bennett fracture-dislocation of his right thumb. The volar ulnar fragment of the metacarpal base remains anatomically reduced due to its strong ligamentous attachment, while the metacarpal shaft displaces proximally, radially, and dorsally. Which muscle is primarily responsible for the proximal and dorsal displacement of the metacarpal shaft?





Explanation

In a Bennett fracture, the small volar ulnar fragment is held in place by the anterior oblique ligament. The metacarpal shaft is pulled proximally, dorsally, and radially by the deforming force of the Abductor Pollicis Longus (APL), which inserts on the base of the first metacarpal. The Adductor Pollicis pulls the metacarpal head medially, creating a supination deformity.

Question 37

A 60-year-old female presents with base of thumb pain. Radiographs demonstrate severe joint space narrowing, subchondral sclerosis, and osteophytes larger than 2 mm at the trapeziometacarpal joint. Additionally, there is complete loss of joint space at the scaphotrapezial-trapezoid (STT) joint. According to the Eaton-Littler classification, what stage is this disease, and what specific surgical option is relatively contraindicated compared to earlier stages?





Explanation

The patient has pantrapezial arthritis (involving both the CMC and STT joints), which is Eaton-Littler Stage IV. An isolated trapeziometacarpal (CMC) arthrodesis or hemiarthroplasty that retains the trapezium is contraindicated in Stage IV because the patient will continue to experience pain from the arthritic STT joint. Procedures that excise the trapezium (like LRTI or hematoma distraction arthroplasty) address both areas and are indicated.

Question 38

A 35-year-old woman complains of pain, tingling, and numbness over the dorsoradial aspect of her right hand, worsened by tight watchbands and pronation. Tinel's sign is positive over the radial aspect of the mid-forearm. Motor examination is normal. Which two muscles typically compress the involved nerve in this syndrome?





Explanation

The patient has Wartenberg's syndrome, which is compression of the superficial sensory branch of the radial nerve. The nerve is most commonly compressed as it emerges from beneath the deep fascia between the Brachioradialis (BR) and the Extensor Carpi Radialis Longus (ECRL), especially during pronation, which causes these tendons to scissor together.

Question 39

A 30-year-old woodworker amputates his left index finger at the proximal phalanx. The amputated part is properly wrapped in saline-moistened gauze, sealed in a plastic bag, and placed on ice. What is the generally accepted maximum cold ischemia time for a clean, sharp amputation of a digit at this level to remain viable for replantation?





Explanation

Digits do not contain muscle belly, which makes them highly tolerant of ischemia compared to major limb amputations. A properly cooled digit can tolerate cold ischemia for up to 24 hours (and sometimes longer) and still be viable for replantation. In contrast, major limb amputations (proximal to the radiocarpal joint, containing muscle) tolerate only about 6 hours of warm ischemia or 12 hours of cold ischemia before irreversible muscle necrosis occurs.

Question 40

A 6-month-old infant is evaluated for congenital syndactyly of the hands. The parents are inquiring about the planned surgical management. Which of the following principles regarding congenital syndactyly and its surgical reconstruction is correct?





Explanation

Syndactyly of border digits (first webspace: thumb-index; fourth webspace: ring-small) involves fingers with significantly different growth rates. If left tethered, the longer digit will develop a severe flexion and angular deformity. Therefore, border digits are released early, typically at 6 months. The 3rd webspace is most commonly involved. Complex syndactyly involves bony fusion. Full-thickness skin grafts are almost always required to cover the resultant defects.

Question 41

A 32-year-old professional boxer presents with pain over the long finger MCP joint after a punch. He cannot actively extend the MCP joint from a flexed position but can maintain extension if passively placed in that position. On examination, the extensor tendon subluxates ulnarly during active flexion. Assuming this is an acute injury (2 days old), what is the most appropriate initial management?





Explanation

Acute sagittal band ruptures (within 3 weeks) are effectively treated non-operatively with an extension splint for the MCP joint for 4-6 weeks, leaving the PIP joint free. The radial sagittal band is most commonly injured, leading to ulnar subluxation of the extensor tendon. Surgical repair is indicated for chronic injuries or failed conservative management.

Question 42

A 25-year-old rugby player presents 4 days after grabbing an opponent's jersey. He cannot actively flex the DIP joint of his ring finger. Radiographs show no fractures. On ultrasound, the flexor digitorum profundus (FDP) tendon stump is identified at the level of the proximal interphalangeal (PIP) joint. According to the Leddy-Packer classification, what is the type of this injury and the status of the vincula?





Explanation

Leddy-Packer Type II 'jersey finger' involves the tendon retracting to the level of the PIP joint. The long vinculum remains intact, preventing further proximal retraction into the palm, which preserves some of its blood supply. Type I retracts to the palm (vincula ruptured). Type III involves a large bony fragment trapped at the A4 pulley.

Question 43

A 45-year-old gymnast complains of chronic ulnar-sided wrist pain that worsens with pronation and ulnar deviation. Radiographs reveal ulnar positive variance and cystic changes in the lunate and triquetrum. MRI confirms tears of the central TFCC articular disc but demonstrates that the distal radioulnar joint (DRUJ) is perfectly congruent without arthritic changes. Which of the following surgical procedures is most appropriate?





Explanation

Ulnar shortening osteotomy is the treatment of choice for ulnar impaction syndrome in patients with positive ulnar variance and a congruent, non-arthritic DRUJ. It effectively unloads the ulnocarpal joint and tightens the ulnocarpal ligaments. If significant DRUJ arthritis were present, a salvage procedure like a Sauve-Kapandji or Darrach procedure would be considered instead.

Question 44

A 50-year-old manual laborer presents with chronic progressive wrist pain years after an untreated scapholunate ligament tear. Radiographs reveal advanced arthritis involving the radioscaphoid joint and the capitolunate joint. The radiolunate joint is characteristically spared. What is the Watson stage of this patient's wrist, and what is the preferred salvage procedure?





Explanation

Scapholunate advanced collapse (SLAC) Stage III involves arthritis of the radioscaphoid and capitolunate joints, while the radiolunate joint is spared. Because the capitate head is arthritic, a proximal row carpectomy (PRC) is contraindicated (as the arthritic capitate would articulate with the lunate fossa). Scaphoid excision and four-corner fusion is the preferred salvage procedure for Stage III SLAC.

Question 45

A 55-year-old woman with base of thumb pain has radiographs showing thumb CMC joint space narrowing, subchondral sclerosis, and a 3 mm radial osteophyte. The scaphotrapezial (STT) joint appears completely normal. According to the Eaton-Littler classification, what is the stage of her disease?





Explanation

The Eaton-Littler classification stages thumb CMC arthritis: Stage I has normal joint space with possible capsular widening. Stage II has mild narrowing and osteophytes < 2 mm. Stage III is characterized by advanced CMC joint degeneration (sclerosis, joint space narrowing) and osteophytes > 2 mm, while the STT joint remains normal. Stage IV involves pantrapezial arthritis (including the STT joint).

Question 46

A 38-year-old female presents with severe, episodic pain in her left index finger, exquisitely sensitive to cold. Physical exam reveals point tenderness over the nail bed. The pain is relieved by inflating a blood pressure cuff on the ipsilateral arm. What is the name of the clinical test described that relieves the patient's pain?





Explanation

Hildreth's test is the relief of pain from a glomus tumor when a tourniquet (or blood pressure cuff) is inflated proximal to the lesion. Glomus tumors are benign hamartomas presenting with a classic triad of cold hypersensitivity, paroxysmal pain, and pinpoint tenderness. Love's pin test involves eliciting severe localized pain using the head of a pin directly over the lesion.

Question 47

A 30-year-old mechanic presents with dorsal wrist pain. X-rays show sclerosis of the lunate with coronal fracturing and fragmentation, but carpal height is maintained and the scaphoid does not demonstrate a fixed ring sign. Ulnar variance is negative. What is the Lichtman stage of this disease, and what is a widely accepted initial surgical option?





Explanation

Lichtman Stage IIIA is defined by lunate collapse/fragmentation without fixed scaphoid rotation or carpal collapse. Because the patient has negative ulnar variance, a joint-leveling procedure such as a radial shortening osteotomy is indicated. It effectively unloads the lunate to halt progression of Kienbock's disease. Stage IIIB (fixed scaphoid rotation/carpal collapse) typically requires salvage procedures like PRC or STT fusion.

Question 48

In the context of digital amputations, which of the following scenarios represents a generally accepted absolute contraindication to attempted microvascular replantation?





Explanation

Multiple level (segmental) amputations in the same digit is considered an absolute contraindication to replantation because of the inability to restore adequate vascularity and the guarantee of extremely poor functional outcomes. Single digit amputation in Zone II is a relative contraindication (except in children). Thumb replantation is almost always indicated regardless of age if feasible. Up to 12 hours of warm ischemia time is tolerated for digits.

Question 49

A 28-year-old male sustains a midshaft radius fracture. After open reduction and internal fixation of the radius, the distal radioulnar joint (DRUJ) remains dorsally dislocated and is irreducible despite anatomic restoration of the radius. What is the most common anatomic structure blocking reduction of the DRUJ in this Galeazzi fracture-dislocation?





Explanation

In a Galeazzi fracture-dislocation, if the DRUJ is irreducible after anatomic fixation of the radius, an interposed soft tissue structure must be suspected. The most common structure blocking reduction is the Extensor Carpi Ulnaris (ECU) tendon. The ECU tendon can subluxate and become trapped in the DRUJ. The EDM tendon or median nerve can also block reduction, but the ECU is the most frequent offender.

Question 50

To distinguish between intrinsic muscle tightness and joint capsule contracture in a patient with a suspected intrinsic-plus hand, the examiner performs the Bunnell-Littler test. The PIP joint has 30 degrees of flexion when the MCP joint is held in full extension. When the MCP joint is flexed to 90 degrees, the PIP joint can now flex to 90 degrees. What do these findings indicate?





Explanation

The Bunnell-Littler test assesses intrinsic tightness. When the MCP joint is extended, the intrinsic muscles are put on stretch; if PIP flexion is limited in this position but improves when the MCP joint is flexed (which relaxes the intrinsics), intrinsic tightness is confirmed. If PIP flexion was restricted equally regardless of MCP position, it would indicate a fixed joint capsular contracture.

Question 51

A newborn is evaluated for a right radial longitudinal deficiency. Physical exam shows an absent right thumb and radius. Complete blood counts are entirely normal at birth, but the pediatrician is concerned about a condition that commonly presents with aplastic anemia later in childhood. Which of the following tests is used to definitively diagnose this genetic condition?





Explanation

The patient is suspected of having Fanconi anemia, an autosomal recessive disorder characterized by radial ray anomalies (absent radius and thumb) and progressive bone marrow failure. The definitive diagnostic test is chromosomal breakage analysis using clastogenic agents like diepoxybutane (DEB) or mitomycin C. Normal complete blood counts at birth are common, as pancytopenia typically develops between ages 5 and 10.

Question 52

A 25-year-old male presents with a complex dorsal dislocation of the index finger MCP joint. Pucker sign is visible in the distal palmar crease. Closed reduction fails. During an open reduction using a volar approach, which of the following structures is most at risk of iatrogenic transection because it is displaced and stretched tightly just deep to the skin over the prominent metacarpal head?





Explanation

In a complex dorsal dislocation of the index MCP joint, the metacarpal head buttonholes through the volar structures (between the lumbrical radially and the flexor tendons ulnarly). The radial digital nerve is displaced volarly and stretched tightly directly over the prominent metacarpal head just beneath the skin. A volar surgical approach places this nerve at exceedingly high risk of transection during the initial skin incision.

Question 53

A 42-year-old male sustains a severe bite to his hand while breaking up a dog fight. Examination shows a deep puncture wound over the thenar eminence. He has no drug allergies. What is the most common pathogen involved in this specific injury, and what is the empiric oral antibiotic of choice?





Explanation

The most common pathogen isolated from dog and cat bites is Pasteurella multocida. The empiric oral antibiotic of choice for animal bites to the hand is Amoxicillin-clavulanate (Augmentin), which provides excellent coverage for Pasteurella, anaerobes, and Staphylococcus species. Eikenella corrodens is the classic pathogen associated with human 'fight bite' injuries.

Question 54

A 32-year-old competitive rower presents with pain, swelling, and crepitus on the dorsal radial aspect of the distal forearm, approximately 4-5 cm proximal to the radiocarpal joint. The pain is exacerbated by resisted wrist extension and thumb extension. This condition is caused by friction at the intersection of which two extensor compartments?





Explanation

Intersection syndrome is an inflammatory tenosynovitis occurring at the friction point where the muscle bellies of the first dorsal extensor compartment (abductor pollicis longus and extensor pollicis brevis) cross obliquely over the tendons of the second dorsal extensor compartment (extensor carpi radialis longus and extensor carpi radialis brevis). It typically presents 4-5 cm proximal to the wrist joint.

Question 55

A pediatric patient is evaluated for an extra thumb on the right hand. Radiographs show a complete duplication of the proximal and distal phalanges of the thumb, with a single normal-appearing metacarpal. Both proximal phalanges articulate with the single metacarpal head. According to the Wassel classification of radial polydactyly, what type is this?





Explanation

The Wassel classification describes thumb duplication (radial polydactyly). Type IV involves a duplicated proximal and distal phalanx sitting on a single metacarpal. It is the most common type, accounting for roughly 40-50% of cases. Type I is a bifid distal phalanx, Type II is a duplicated distal phalanx, and Type III is a bifid proximal phalanx.

Question 56

A 40-year-old carpenter presents with severe pain, swelling, and erythema along the volar small finger extending into the palm and distal forearm following a puncture wound. He has pain with passive extension of the small finger. The infection is confirmed as pyogenic flexor tenosynovitis of the small finger. Into which space does the ulnar bursa most commonly communicate, potentially leading to a 'horseshoe abscess'?





Explanation

A 'horseshoe abscess' occurs when an infection spreads from the ulnar bursa (which envelops the flexor tendons of the small finger) directly to the radial bursa (which envelops the flexor pollicis longus tendon), or vice versa. These two bursae communicate in the proximal palm/carpal tunnel region in approximately 50-80% of individuals.

Question 57

A 24-year-old male sustained a C6-C7 brachial plexus root avulsion injury 6 months ago. He has absent finger and thumb extension but maintains strong elbow flexion, shoulder abduction, active wrist flexion, and intact median nerve intrinsic function. A nerve transfer is planned to restore thumb and finger extension. Which of the following is the most appropriate nerve transfer for this purpose?





Explanation

In patients with a lower brachial plexus injury or radial nerve palsy who have intact median nerve function, a classic Mackinnon nerve transfer utilizes the redundant branches of the median nerve to the flexor digitorum superficialis (FDS) (or flexor carpi radialis) transferred directly to the posterior interosseous nerve (PIN). This is highly effective for restoring active finger and thumb extension.

Question 58

A 28-year-old skier falls while holding a ski pole, forcibly abducting his right thumb. He presents with pain and 45 degrees of laxity to valgus stress testing at 30 degrees of MCP flexion, with no endpoint. Ultrasound confirms a complete tear of the ulnar collateral ligament (UCL) and a Stener lesion. What defines a Stener lesion anatomically?





Explanation

A Stener lesion occurs when the completely torn ulnar collateral ligament (UCL) of the thumb MCP joint displaces proximally and superficially to the adductor pollicis aponeurosis. The aponeurosis becomes interposed between the torn ends of the UCL and its insertion on the proximal phalanx, preventing spontaneous healing and thus serving as an absolute indication for surgical repair.

Question 59

A 35-year-old mechanic sustains a severe crush injury to his right hand. Examination reveals a tense, swollen hand with the fingers resting in a slightly flexed position. Intracompartmental pressure testing indicates compartment syndrome. How many discrete fascial compartments are recognized in the hand, and which surgical approach effectively releases the interosseous compartments?





Explanation

There are 10 recognized discrete fascial compartments in the hand: 4 dorsal interosseous, 3 volar interosseous, the thenar compartment, the hypothenar compartment, and the adductor pollicis compartment. The seven interosseous compartments can be efficiently decompressed using two dorsal longitudinal incisions placed over the index and ring (2nd and 4th) metacarpals.

Question 60

A 29-year-old butcher sustains a deep laceration to the mid-palm, transecting the superficial palmar arch. Which of the following best describes the primary arterial supply and the typical anatomical location of the superficial palmar arch in the hand?





Explanation

The superficial palmar arch is primarily formed by the main continuation of the ulnar artery, with a variable contribution from the superficial palmar branch of the radial artery. Anatomically, it is located superficial to the flexor tendons and lumbrical muscles, but deep to the palmar aponeurosis. Conversely, the deep palmar arch is primarily formed by the radial artery and lies deep to the flexor tendons.

Question 61

A 6-month-old infant presents with a bilaterally absent thumb and radial deviation of the wrists. Radiographs reveal complete absence of the radius bilaterally. Which of the following laboratory screening tests is essential to rule out a life-threatening condition associated with this deformity?





Explanation

Radial longitudinal deficiency is highly associated with systemic syndromes, particularly Fanconi anemia, Holt-Oram syndrome, TAR (Thrombocytopenia Absent Radius) syndrome, and VACTERL. Fanconi anemia is a fatal aplastic anemia if unrecognized and is diagnosed via the chromosomal breakage test using diepoxybutane (DEB). All patients with radial longitudinal deficiency require a DEB test, echocardiogram (Holt-Oram), and renal ultrasound (VACTERL) to rule out life-threatening anomalies.

Question 62

During a fasciectomy for Dupuytren's disease affecting the ring finger, the surgeon notes that the neurovascular bundle is displaced toward the midline of the digit and superficially into the palm. Which pathological fascial cord is primarily responsible for this specific displacement?





Explanation

The spiral cord is responsible for displacing the neurovascular bundle centrally, superficially, and proximally. It is formed by the confluence of the pretendinous band, spiral band, lateral digital sheet, and Grayson's ligament. This anatomy is critical to understand during fasciectomy to prevent iatrogenic digital nerve injury.

Question 63

A 25-year-old man presents with an infected laceration over the 3rd metacarpophalangeal joint after striking another person in the mouth during an altercation. Wound cultures grow a fastidious Gram-negative rod. Which of the following is the most appropriate empiric antibiotic treatment for this specific pathogen?





Explanation

The scenario describes a classic "clenched fist injury" or human bite. The fastidious Gram-negative rod associated with human bites is Eikenella corrodens. The drug of choice for Eikenella and general human bite prophylaxis/treatment is amoxicillin-clavulanate. Cephalexin and clindamycin have poor coverage against Eikenella.

Question 64

A 35-year-old woman complains of severe, paroxysmal pain in her left index finger, which is exacerbated by cold weather. Examination reveals pinpoint tenderness over the nail bed, and placing a tourniquet at the finger base relieves the pain. Radiographs demonstrate mild scalloping of the dorsal aspect of the distal phalanx. What is the most likely diagnosis?





Explanation

The patient exhibits the classic triad for a glomus tumor: cold sensitivity, paroxysmal pain, and pinpoint tenderness (Love's sign). The relief of pain with ischemia (tourniquet) is known as Hildreth's sign. Glomus tumors are benign hamartomas of the neuromyoarterial glomus body and frequently cause scalloping on the dorsal distal phalanx.

Question 65

A 60-year-old patient with severe, chronic carpal tunnel syndrome presents with isolated profound thenar wasting and complete loss of palmar abduction of the thumb. The surgeon plans a Camitz tendon transfer to restore function. Which muscle-tendon unit is utilized in this specific transfer?





Explanation

The Camitz transfer utilizes the palmaris longus tendon, often harvested with a strip of palmar fascia to increase length, transferred to the abductor pollicis brevis (APB). It is an excellent transfer for restoring palmar abduction (essential in severe median nerve palsy) and is frequently performed concurrently with carpal tunnel release.

Question 66

A 28-year-old tennis player presents with persistent ulnar-sided wrist pain and clicking. MRI reveals an isolated tear of the foveal attachment of the triangular fibrocartilage complex (TFCC). On examination, the distal radioulnar joint (DRUJ) is grossly unstable compared to the contralateral side. What is the most appropriate surgical management?





Explanation

A tear of the foveal attachment (the deep fibers of the radioulnar ligaments) of the TFCC is the primary cause of DRUJ instability (Palmer class 1B). Because the DRUJ is unstable, simple debridement is inadequate. Surgical repair via open or arthroscopic foveal reattachment (e.g., using bone anchors or transosseous sutures) is required to restore DRUJ stability.

Question 67

A 60-year-old woman with severe rheumatoid arthritis presents with a sudden inability to actively extend her ring and small fingers at the metacarpophalangeal (MCP) joints. The tenodesis effect is completely absent. What is the most likely underlying etiology of this condition?





Explanation

The abrupt loss of active finger extension in a rheumatoid patient with absent tenodesis effect is diagnostic of extensor tendon rupture. Vaughan-Jackson syndrome describes the sequential rupture of the extensor tendons, typically starting ulnarly (EDM and EDC to the small finger) and progressing radially. It is caused by attrition over a dorsally subluxated distal ulna (caput ulnae) due to DRUJ destruction.

Question 68

A 30-year-old manual laborer presents with dorsal wrist pain. Radiographs reveal sclerosis and a coronal fracture of the lunate, but the carpal height is strictly maintained and there is no fixed scaphoid rotary subluxation. According to the Lichtman classification of Kienböck's disease, what is the correct stage?





Explanation

In the Lichtman classification for Kienböck's disease: Stage I has normal radiographs (changes on MRI). Stage II shows lunate sclerosis. Stage IIIA shows lunate collapse or fracture, but carpal height is maintained and the scaphoid is normally aligned. Stage IIIB shows lunate collapse with fixed scaphoid rotary subluxation and decreased carpal height. Stage IV involves radiocarpal or midcarpal arthrosis.

Question 69

A 24-year-old man presents with a symptomatic scaphoid proximal pole nonunion recognized 8 months post-injury. MRI demonstrates avascular necrosis (AVN) of the proximal pole. There is no radiocarpal arthritis. Which of the following is the most appropriate surgical treatment?





Explanation

For a scaphoid nonunion with AVN of the proximal pole (without established secondary osteoarthritis), a vascularized bone graft is the treatment of choice to optimize healing. The 1,2 intercompartmental supraretinacular artery (1,2 ICSRA) graft, pedicled from the distal radius, is a standard and high-yield board answer for this scenario.

Question 70

A 30-year-old carpenter sustains a volar oblique fingertip amputation of the index finger. The distal phalanx bone is exposed, and there is significantly more palmar soft tissue loss than dorsal. Which of the following local flaps is most appropriate for providing sensate coverage of this defect?





Explanation

A cross-finger flap is indicated for volar oblique amputations where local advancement flaps (like V-Y Atasoy) lack sufficient tissue. The Atasoy (V-Y) flap is ideal for dorsal oblique or transverse amputations. The Moberg flap is strictly reserved for the thumb due to the robust dorsal blood supply of the thumb allowing dual neurovascular volar advancement.

Question 71

In the setting of crush injuries to the upper extremity, acute compartment syndrome of the hand may necessitate emergent fasciotomy. Anatomically, how many distinct fascial compartments are recognized within the human hand for this procedure?





Explanation

There are 10 recognized compartments in the hand that require decompression in acute compartment syndrome: four dorsal interosseous compartments, three volar interosseous compartments, the thenar compartment, the hypothenar compartment, and the adductor pollicis compartment.

Question 72

Nerve conduction studies for a patient with suspected ulnar neuropathy at the elbow demonstrate preserved motor responses in the first dorsal interosseous (FDI) muscle when the ulnar nerve is stimulated at the wrist, but a markedly decreased amplitude when stimulated at the elbow. A Martin-Gruber anastomosis is suspected. Where does this anomalous neural connection cross from the median to the ulnar nerve?





Explanation

The Martin-Gruber anastomosis is an anomalous connection between the median and ulnar nerves that occurs in the forearm. It typically involves motor fibers from the median nerve (or AIN) crossing over to join the ulnar nerve, eventually innervating intrinsic hand muscles (most commonly the FDI) that are ordinarily ulnar-innervated. This can confound EMG/NCS findings in ulnar neuropathy.

Question 73

A 22-year-old boxer sustains a Y-shaped intra-articular fracture at the base of the first metacarpal (Rolando fracture). Which muscle acts as the primary deforming force, causing proximal, dorsal, and radial displacement of the main metacarpal shaft fragment?





Explanation

In both Bennett and Rolando fractures, the main metacarpal shaft fragment is displaced proximally, dorsally, and radially by the pull of the Abductor Pollicis Longus (APL). The adductor pollicis pulls the distal aspect of the metacarpal towards the palm, creating an apex dorsal angulation.

Question 74

A 45-year-old man presents with a "snapping" sensation over the long finger metacarpophalangeal (MCP) joint. Examination demonstrates that when he makes a fist, the extensor tendon subluxates into the ulnar gutter. The tendon reduces when he actively extends his fingers. Which structure is most likely injured?





Explanation

The sagittal bands centralize the extensor tendon over the MCP joint. The radial sagittal band is injured most commonly (often termed "boxer's knuckle"), allowing the extensor tendon to subluxate or dislocate into the ulnar gutter during flexion. Ulnar sagittal band injuries are rare.

Question 75

During a primary repair of a lacerated flexor digitorum profundus (FDP) tendon in Zone II, the surgeon must vent parts of the flexor sheath to facilitate tendon gliding. However, specific pulleys must be preserved to prevent bowstringing of the tendon. Which two pulleys are biomechanically the most critical and must be maintained?





Explanation

The A2 pulley (located over the proximal phalanx) and the A4 pulley (located over the middle phalanx) are the most biomechanically critical components of the flexor tendon sheath. They are essential to prevent bowstringing of the flexor tendons and must be preserved or reconstructed.

Question 76

A full-term newborn is noted to have a complete simple syndactyly between the middle and ring fingers. To optimize hand function and minimize growth disturbances, at what age is surgical separation typically recommended for this specific web space?





Explanation

Surgical release of syndactyly for central digits (middle/ring fingers) is generally performed between 12-18 months of age. Syndactyly involving border digits (thumb/index or ring/small) creates a larger length discrepancy during growth and is typically released earlier (around 6 months) to prevent progressive angular deformity.

Question 77

Which of the following radiographic parameters is most strongly associated with the biomechanical pathogenesis of Kienböck's disease?





Explanation

Negative ulnar variance (ulna is shorter than the radius) was classically described by Hultén as being strongly associated with Kienböck's disease (avascular necrosis of the lunate). This anatomy increases shear forces and load transmission directly onto the lunate from the radius.

Question 78

In a patient undergoing tendon transfer for a high radial nerve palsy (e.g., standard Jones or Brand transfer), which muscle-tendon unit is universally utilized to restore functional wrist extension?





Explanation

The pronator teres (PT) is universally utilized to restore wrist extension in radial nerve palsy. It is transferred to the extensor carpi radialis brevis (ECRB) because the ECRB is centrally located and provides balanced wrist extension without severe radial or ulnar deviation. The other muscles mentioned are typically utilized to restore finger extension or thumb extension.

Question 79

What is the standard, most widely recommended sequence of structural repair during the microsurgical replantation of a completely amputated digit?





Explanation

The classic and widely taught sequence for digital replantation is: 1) Bone fixation (establishes skeletal stability), 2) Extensor tendon repair, 3) Flexor tendon repair, 4) Arterial anastomosis, 5) Nerve repair, 6) Venous anastomosis, and 7) Skin closure. This is often remembered by the mnemonic BEFANV.

Question 80

A 55-year-old man presents with chronic wrist pain. Radiographs demonstrate narrowing and osteophyte formation at the radioscaphoid joint and the capitolunate joint, accompanied by proximal migration of the capitate. The radiolunate joint is completely spared. What is the correct Watson stage of this Scapholunate Advanced Collapse (SLAC) wrist?





Explanation

The SLAC wrist staging by Watson is progressive: Stage I involves only the radial styloid. Stage II involves the entire radioscaphoid fossa. Stage III involves the capitolunate joint (with capitate proximal migration). Stage IV (in some classifications) involves pancarpal arthritis. The preservation of the radiolunate joint is the hallmark of SLAC/SNAC arthropathy due to its spherical congruency.

Question 81

A neonate is evaluated for bilateral congenital forearm anomalies. Radiographs demonstrate bilateral absent radii, but both thumbs are present and well-formed. Which of the following diagnostic tests is the most urgent next step in the workup of this patient?





Explanation

This presentation is highly characteristic of Thrombocytopenia-Absent Radius (TAR) syndrome. A key distinguishing feature of TAR syndrome compared to Fanconi anemia and Holt-Oram syndrome is that the thumbs are present despite the absent radii. A complete blood count is crucial to evaluate for thrombocytopenia, which can be life-threatening in early infancy. Fanconi anemia (requires chromosomal breakage analysis) presents with absent radii AND absent thumbs. Holt-Oram syndrome (requires echocardiogram) involves heart defects and variable radial/thumb deficiencies.

Question 82

A 35-year-old woman presents with severe, sharp pain in her left ring finger tip, which worsens in cold weather. Exam shows a subtle bluish discoloration beneath the nail plate. The pain is completely abolished when a pneumatic tourniquet is inflated at the base of the finger. What is the most likely diagnosis?





Explanation

A glomus tumor is a benign hamartoma of the glomus body (a neuromyoarterial glomus involved in thermoregulation). The classic clinical triad includes cold hypersensitivity, paroxysmal severe pain, and pinpoint point tenderness (Love's test). The abolition of pain upon inflation of a proximal tourniquet is known as Hildreth's sign, which is highly specific for a glomus tumor.

Question 83

A 60-year-old woman with long-standing rheumatoid arthritis presents with an inability to extend her small, ring, and long fingers at the metacarpophalangeal (MCP) joints. She first noticed the drop in her small finger two months ago, which progressively involved the ring and long fingers. What is the most likely diagnosis?





Explanation

Vaughan-Jackson syndrome refers to the sequential attritional rupture of the extensor tendons, typically starting ulnarly (extensor digiti minimi and extensor digitorum communis to the small finger) and progressing radially. This is caused by friction over a dorsally prominent, subluxated distal ulna (caput ulnae syndrome) commonly seen in rheumatoid arthritis. Mannerfelt syndrome refers to the attritional rupture of the FPL tendon over a prominent volar scaphoid osteophyte.

Question 84

During a surgical fasciectomy for Dupuytren's contracture, the surgeon must carefully release the contracted fascial cords while protecting the digital neurovascular bundles. Which of the following normal fascial structures is typically SPARED from disease involvement and remains dorsal to the neurovascular bundle?





Explanation

In Dupuytren's disease, Cleland's ligaments are generally spared. They are located dorsal to the neurovascular bundles and help stabilize the digital skin during flexion/extension. Conversely, Grayson's ligaments are located volar to the neurovascular bundles and are frequently involved in the disease process, pulling the neurovascular bundle centrally and superficially when contracted.

Question 85

A 25-year-old basketball player 'jams' his finger and presents with a swollen proximal interphalangeal (PIP) joint. He has no gross deformity but complains of pain. The examiner flexes the PIP joint 90 degrees over the edge of a table and asks the patient to extend the middle phalanx against resistance. The patient demonstrates weak PIP extension, and the distal interphalangeal (DIP) joint remains rigid rather than floppy. Which test was performed, and what does it diagnose?





Explanation

The Elson test is used to detect early/acute central slip ruptures before a boutonniere deformity fully develops. When the PIP is flexed to 90 degrees over a table edge, the central slip normally initiates extension while the lateral bands are lax (causing a 'floppy' DIP). If the central slip is ruptured, PIP extension is weak or absent, and the effort is transmitted through the lateral bands, causing the DIP joint to become rigid or hyperextend.

Question 86

A 42-year-old carpenter presents with cold intolerance and rest pain in his right long and ring fingers. Exam reveals a pulsatile mass in the hypothenar eminence and a positive modified Allen test demonstrating ulnar artery occlusion. What is the primary anatomic etiology of this specific syndrome?





Explanation

The scenario describes Hypothenar Hammer Syndrome (HHS). HHS is caused by repetitive blunt trauma to the hypothenar eminence (often from using the heel of the hand as a hammer). The underlying pathomechanism is compression and injury of the superficial branch of the ulnar artery against the bony prominence of the hook of the hamate, leading to intimal damage, aneurysm formation, or thrombosis.

Question 87

A 30-year-old factory worker sustains a volar tactile pad amputation of his right thumb. The defect measures 1.5 x 1.5 cm and exposes bone. The surgeon selects a classic Moberg advancement flap for coverage. Which of the following best describes the blood supply of this specific flap?





Explanation

The classic Moberg flap is a volar rectangular advancement flap used for thumb tip amputations (up to 1.5 - 2 cm). It relies on a bipedicled axial blood supply provided by both the radial and ulnar volar digital neurovascular bundles. It is unique to the thumb because the dorsal blood supply to the thumb tip is robust enough to prevent dorsal skin necrosis when the volar tissues are advanced.

Question 88

According to the Leddy and Packer classification of flexor digitorum profundus (FDP) avulsion injuries (Jersey finger), what specific anatomic presentation characterizes a Type III injury?





Explanation

In the Leddy and Packer classification of FDP avulsions: Type I retracts to the palm (blood supply disrupted, early repair needed). Type II retracts to the PIP joint level (caught at camper's chiasm, long vinculum intact). Type III involves a large bony fragment that gets caught at the A4 pulley (level of the middle phalanx), preventing further proximal retraction.

Question 89

A 28-year-old nurse presents with a painful, erythematous, and swollen index finger pulp. Exam shows multiple coalescing vesicles filled with clear fluid on the volar pad. The pulp is tense, but no focal fluctuance is felt. What is the most appropriate initial management?





Explanation

The patient has a herpetic whitlow, a viral infection of the distal finger caused by Herpes Simplex Virus (HSV 1 or 2). It classically presents with coalescing vesicles. It is typically self-limiting but can be treated with oral acyclovir. Incision and drainage is strictly contraindicated as it provides no benefit, delays healing, and carries a high risk of secondary bacterial superinfection.

Question 90

Which of the following intrinsic carpal ligaments is considered the primary stabilizer of the proximal pole of the scaphoid, and when completely torn, leads to a dorsal intercalated segment instability (DISI) deformity?





Explanation

The scapholunate interosseous ligament (SLIL) is the primary stabilizer between the scaphoid and the lunate. It is divided into dorsal, membranous, and volar regions. The dorsal band is the thickest, strongest, and most critical for preventing scapholunate dissociation and the subsequent dorsal intercalated segment instability (DISI) deformity.

Question 91

During the surgical approach for a perilunate dislocation, the surgeon evaluates the volar wrist capsule and identifies the Space of Poirier. This anatomic weak point, which is frequently disrupted in perilunate injuries, is located between which two volar ligaments?





Explanation

The Space of Poirier is a relative weakness in the palmar radiocarpal joint capsule located between the radioscaphocapitate (RSC) and long radiolunate (LRL) ligaments. It overlies the volar aspect of the midcarpal joint (capitolunate articulation) and is the site where the lunate typically escapes volarly during a perilunate/lunate dislocation.

Question 92

A 60-year-old woman is scheduled for a volar plating of a distal radius fracture. She has a high risk profile for developing Complex Regional Pain Syndrome (CRPS) Type I. Which of the following prophylactic medications, started at the time of injury or surgery, has been shown in some studies to decrease the risk of developing CRPS?





Explanation

Vitamin C (ascorbic acid), typically dosed at 500 mg daily for 50 days following a distal radius fracture, has been shown in some randomized controlled trials to significantly reduce the incidence of Complex Regional Pain Syndrome (CRPS) Type I. While gabapentin and amitriptyline are used to treat neuropathic pain, they are not established as standard prophylaxis for CRPS.

Question 93

A 50-year-old male with an irreversible high radial nerve palsy is undergoing tendon transfers. The surgeon elects to perform a Boyes transfer rather than the standard set of tendon transfers. Which of the following specific tendon transfers is a defining feature of the Boyes technique for restoring finger extension?





Explanation

In the treatment of high radial nerve palsy, standard tendon transfers (e.g., Jones or modified standard) often use the FCR or FCU for finger extension. The Boyes transfer is uniquely characterized by utilizing the Flexor Digitorum Superficialis (FDS) of the long finger transferred through the interosseous membrane to the EDC to restore finger extension. PT to ECRB is common to almost all methods to restore wrist extension.

Question 94

A 35-year-old man presents with his index finger locked in 30 degrees of flexion at the metacarpophalangeal (MCP) joint after a minor twisting injury. He can actively flex the finger further, but he absolutely cannot extend it, either actively or passively. Radiographs are negative for fracture. What is the most common anatomical cause for this specific clinical entity?





Explanation

A locked MCP joint (most commonly affecting the index finger) typically occurs when the prominent radial condyle of the metacarpal head catches the proper collateral ligament or accessory collateral ligament. The joint is locked in flexion (usually around 30 degrees) and resists both active and passive extension, while further flexion is often preserved. Volar plate interposition can happen but is less common and usually prevents flexion.

Question 95

A 65-year-old man presents with a slow-growing, firm, painless mass on the volar aspect of his right wrist. MRI reveals a well-circumscribed soft tissue mass along the median nerve. An incisional biopsy demonstrates biphasic architecture with hypercellular Antoni A areas and hypocellular Antoni B areas. Which of the following is true regarding the surgical management of this lesion?





Explanation

The pathology describes a schwannoma (neurilemmoma), which is the most common benign peripheral nerve sheath tumor. Schwannomas grow eccentrically from the nerve sheath, displacing the nerve fascicles to the periphery. Because they do not infiltrate the fascicles (unlike neurofibromas), schwannomas can typically be carefully dissected and enucleated under magnification, sparing the native nerve function.

Question 96

A 48-year-old laborer undergoes a four-corner fusion (capitate, hamate, lunate, triquetrum) with scaphoid excision for Scaphoid Nonunion Advanced Collapse (SNAC) stage III. Following complete rehabilitation, what is the anticipated remaining range of motion of the wrist relative to the uninjured contralateral side?





Explanation

A four-corner fusion (scaphoid excision and fusion of the lunate, capitate, hamate, and triquetrum) is a salvage procedure for SNAC and SLAC wrists. Biomechanical studies and clinical outcomes show that this procedure preserves approximately 50% of normal wrist flexion/extension arc and 50% of radioulnar deviation, while maintaining roughly 80% of grip strength.

Question 97

A 30-year-old male is diagnosed with Lichtman Stage IIIA Kienböck's disease (lunate collapse without scaphoid rotation or fixed carpal instability). Radiographs demonstrate a negative ulnar variance of 2 mm. Which of the following is the most appropriate surgical treatment for this patient?





Explanation

In Kienböck's disease (avascular necrosis of the lunate), the treatment depends on the Lichtman stage and ulnar variance. For early stages with lunate fragmentation/collapse but no carpal instability (Stage II or IIIA) in a patient with negative ulnar variance, joint leveling procedures, particularly a radial shortening osteotomy, are considered the gold standard. This unloads the lunate by re-distributing axial loads to the ulnocarpal joint.

Question 98

A 45-year-old cyclist reports numbness and tingling strictly isolated to the volar aspect of his right small finger and the volar-ulnar half of his ring finger. Sensation over the dorso-ulnar aspect of his hand is perfectly normal. He also exhibits intrinsic muscle weakness (positive Wartenberg sign and Froment sign). Where is the most likely site of compression?





Explanation

The dorsal ulnar cutaneous nerve branches off the ulnar nerve ~5-8 cm proximal to the wrist. Because his dorso-ulnar sensation is preserved, the lesion must be at or distal to the wrist (Guyon's canal). Guyon's canal has 3 zones. Zone 1 (proximal to bifurcation) contains both motor and sensory fibers. Zone 2 contains only the deep motor branch. Zone 3 contains only the superficial sensory branch. Since he has BOTH sensory (volar digits) and motor deficits, the compression is in Zone 1.

Question 99

A 5-year-old child sustains a deep palmar friction burn from a treadmill. The wound requires debridement and grafting. To prevent an adduction contracture of the first web space during the healing process, what is the optimal splinting position for the thumb?





Explanation

Palmar burns are highly prone to severe contractures during wound healing. The first web space is particularly vulnerable to adduction contracture, which severely limits hand function (grasp and pinch). The optimal splinting position to maximize the thumb web space and counteract the scar contraction force is positioning the thumb in palmar abduction and extension.

Question 100

A 42-year-old woman with advanced systemic sclerosis (scleroderma) presents with severe, medically refractory Raynaud's phenomenon and multiple chronic ischemic digital ulcers. She has failed trials of calcium channel blockers, PDE-5 inhibitors, and intravenous prostaglandins. Which of the following surgical interventions is most likely to improve digital perfusion and facilitate ulcer healing in this patient?





Explanation

In patients with severe, medically refractory Raynaud's phenomenon or scleroderma who develop ischemic digital ulcers, surgical periarterial sympathectomy (digital sympathectomy) is indicated. This involves stripping the adventitia of the common and proper digital arteries, which interrupts the overactive sympathetic nerve fibers that run in the adventitia, thereby relieving vasospasm, reducing pain, and promoting ulcer healing.

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