Hand and wrist: MCQ AND EMQ Questions

MCQs

1. Which of the following is not a cause of a swan neck deformity?
   1. Mallet deformity.
   2. Flexor tendon tenosynovitis.
   3. Volar plate rupture.
   4. Central slip rupture.
   5. Lateral band subluxation.
2. When performing a replant of an amputated finger, which of the following is the correct order of surgery?
   1. Bone, Artery, Extensor, Flexor, Nerve, Vein.
   2. Artery, Bone, Vein, Extensor, Flexor, Nerve.
   3. Artery, Bone, Extensor, Flexor, Vein, Nerve.
   4. Bone, Extensor, Flexor, Artery, Nerve, Vein.
   5. Bone, Extensor, Flexor, Artery, Vein, Nerve.
3. When performing flexor tendon repair, which of the following pulleys must be preserved?
   1. A2 and A4.
   2. A2 only.
   3. A2 and C2.
   4. A2 and A3.
   5. A3 only.
4. A Stener lesion is significant because?
   1. Adductor aponeurosis interposition between the proximally based avulsed ligament impairs ligament healing.
   2. Adductor aponeurosis interposition between the distally based avulsed ligament impairs ligament healing.
   3. Skiing is an increasingly popular sport.
   4. It involves partial and complete ulnar collateral ligament rupture.
   5. It is associated with a fleck sign on the X-ray.

 

5. Which of the following regarding metacarpal neck fractures is true?
   1. Up to 35º of angulation of the index and middle finger can be accepted.
   2. Up to 40º of angulation of the little and ring finger can be accepted.
   3. Metacarpal neck fractures should never be operated upon unless it is an open injury.
   4. The Jahss position is the correct position to immobilize a manipulated metacarpal neck fracture.
   5. Up to 15º of angulation of the index and middle finger can be accepted.
6. When reducing a Smith’s or volar Barton’s fracture, the reduction manoeuvre should include?
   1. Supination only.
   2. Extension only.
   3. Extension and supination.
   4. Extension and pronation.
   5. Flexion and supination.
7. A 22-year-old medical student was slightly intoxicated and fell onto his extended wrist while his forearm was pronated. He has pain and a clicking sensation on the ulnar side of his wrist. X-rays and nerve conduction studies are normal. The most likely diagnosis is?
   1. Scapholunate dissociation.
   2. Hook of hamate fracture.
   3. Triangular fibrocartilage complex (TFCC) tear.
   4. Piso-triquetral subluxation.
   5. Extensor carpi ulnaris (ECU) subluxation.
8. If a 28-year-old male motorbiker had a complex distal radius fracture (volar fixation required) and acute severe carpal tunnel syndrome, which of the following surgical approaches would be correct?
   1. Perform a Henry’s approach and a separate, very ulnar carpal tunnel incision.
   2. Observe the carpal tunnel syndrome for 48 hours after surgery.
   3. Perform a Henry’s approach and a separate carpal tunnel incision.
   4. Continue Henry’s approach across the wrist with an S curve and decompress the carpal tunnel.
   5. Continue Henry’s approach across the wrist and decompress the carpal tunnel.
9. Which of the following is not a sign of an unstable scaphoid fracture?
   1. Vertical oblique fracture.
   2. Comminuted fracture.
   3. >1 mm displacement.
   4. Associated perilunate injury.
   5. Scapholunate angle <60 º.
10. In Wartenburg syndrome the compression takes place between?
    1. Brachioradialis and extensor carpi radialis longus (ECRL) in pronation.
    2. Brachioradialis and ECRL in supination.
    3. ECRL and extensor carpi radialis brevis ( ECRB ).
    4. Abductor pollicis longus (APL), extensor pollicis brevis (EPB) and ECRL, ECRB.
    5. Brachioradialis and flexor carpi radialis ( FCR ).
11. A patient presents with pain and cold insensitivity at the fingertip. There is a bluish discolouration under the nail. The most likely diagnosis is? a. Neurofibroma.
    2. Glomus tumour.
    3. Turret tumour.
    4. Epithelioid sarcoma.
    5. Raynaud’s disease.
12. The following are all good prognosis after nerve injury except?
    1. Young age.
    2. Low velocity injury.
    3. Sharp (knife) injury.
    4. Proximal injury.
    5. Early exploration.
13. All of the following make up the spiral cord except?
    1. Grayson’s ligaments.
    2. Spiral band.
    3. Lateral sheet.
    4. Natatory ligament.
    5. Pretendinous band.
14. Which of the following is not a poor prognostic indicator in traumatic brachial plexus injury?
    1. Horner’s sign.
    2. Transverse process fracture.
    3. Empty sheaths on MRI scan.
    4. Diaphragmatic flattening on inspiration/expiration X-rays.
    5. No sensation from tip of acromion to tip of fingers.
15. Which of the following is a rule of tendon transfer?
    1. The donor muscle must be at least MRC grade 3.
    2. Joints can have 50% maximum contracture.
    3. Tendon pull must be synergistic.
    4. Line of pull should be orthogonal.
    5. Tendon excursions of the finger extensors is longer than the flexors.
16. A 56-year-old obese man presents with a painless deterioration in bilateral hand function. Initially it was the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints that were involved and now it is the distal interphalangeal (DIP) joints. He has thick tight skin and a positive prayer sign.

The most likely disease is? a. Gout.

16. 2. Osteoarthritis.
    3. Rheumatoid arthritis.
    4. Scleroderma.
    5. Diabetic cheirarthropathy.
17. A 38-year-old man presents with dorsal wrist pain. He has a stiff wrist with very limited range of motion and can’t work as a mechanic. Plain films reveal Grade IV Kienbock’s disease. He should be treated with? a.     Proximal row carpectomy.
    2. Wrist replacement.
    3. Curettage and vascularized pronator quadratus graft.
    4. Radial shortening.
    5. Wrist arthrodesis.
18. A 41-year-old woman sustained a distal radius fracture whilst hiking in the Andes. It was treated in plaster by a local missionary doctor and went on to malunion. She presents with ulnar-sided pain and on examination she impacts on the ulnar side, with a negative grind test at the distal radioulnar joint (DRUJ). The best treatment would be?
    1. Ulnar shortening osteotomy.
    2. Darrach procedure.
    3. Sauve–Kapandji procedure.
    4. Arthroscopic debridement of DRUJ.
    5. Distal ulnar head implant arthroplasty.
19. Which of the following is not true of Dupuytren’s disease?
    1. The long-term recurrence rate is 50 %.
    2. Painful nodules are an indication for surgery.
    3. Metacarpophalangeal joint (MCPJ) contracture of greater than 30º is an indication for surgery.
    4. Myofibroblasts are the offending cells in the aetiology of the disease.
    5. Concomitant carpal tunnel release increases incidence of post-operative flare.
20. A 17-year-old snowboarder fell onto his outstretched pronated hand. He presents with ongoing ulnar-sided wrist pain. He is tender over the ulnar fovea and has no click. The distal radioulnar joint (DRUJ) is stable. Plain films are normal and a MR arthrogram show a triangular fibrocartilage complex (TFCC) defect adjacent to the ulna. How is this classified according to the Palmer classification? a.            Class 2A lesion.
    2. Class 1A lesion.
    3. Class 2B lesion.
    4. Class 1B lesion.
    5. Class 1C lesion.
21. A 16-year-old girl had multiple fractures in her forearm and hand. One year later after fracture healing she presents with trouble gripping things. When the metacarpophalangeal (MCP) joint is extended you cannot passively flex the proximal interphalangeal (PIP) joint. When the MCP joint is flexed it is possible to passively flex the PIP joint. Her extensors are at a good length. Which of the following is incorrect?
    1. She has an intrinsic plus hand.
    2. She has a claw hand.
    3. She has a positive Bunnell test.
    4. She has a likely positive Bouviere effect.
    5. There is an imbalance between the intrinsic and extrinsic muscles.
22. A 23-year-old cricketer had an avulsion of the flexor digitorum profundus ( FDP ) tendon of his ring finger. This was diagnosed early and despite proximal migration he had it reinserted with a button technique. Six months later he complains that he can’t close his fingers tightly over a cricket ball. This problem is? a.               Lumbrical plus effect.
    2. Swan neck deformity.
    3. Quadrigia effect.
    4. Intrinsic tightness.
    5. Chronic mallet finger.
23. Which of the following is true regarding a Mayfield Stage I injury?
    1. There is not always a scaphoid fracture.
    2. There is a lunotriquetral ligament injury.
    3. The lunate is extruded.
    4. There is a radio-scapho-capitate ligament detachment.
    5. There is a perilunate dislocation.
24. A 23-year-old was intoxicated at a wedding and fell through a glass window. He presents to the emergency department with a radial wrist laceration with arterial bleeding. With regards to the timing of surgery the major blood supply to the hand is provided by which of the following? a.         Deep branch of the radial artery.
    2. Radial artery.
    3. Deep palmar arch.
    4. Superficial palmar arch.
    5. Interosseous artery.
25. A 41-year-old man presents with a swelling at the level of his distal interphalangeal (DIP) joint on his right middle finger. What is the most likely diagnosis? a. Epidermoid cyst.
    2. Keratoacanthoma.
    3. Mucoid cyst.
    4. Epithelioid tumour.
    5. Sebaceous cyst.
26. Which of the following is not a recognized treatment for carpal tunnel syndrome?
    1. Nerve stimulation therapy.
    2. Steroid injection.
    3. One-portal endoscopic surgical release.
    4. Two-portal endoscopic surgical release.
    5. Yoga.
27. All of the following contribute to the wrist and hand deformity in rheumatoid arthritis except?
    1. Volar subluxation of the extensor carpi ulnaris ( ECU ).
    2. Radio-scapho-capitate ligament failure.
    3. Scaphoid extension.
    4. Supination of the carpus on the forearm.
    5. Distal radioulnar joint (DRUJ) destruction.
28. A 13-year-old boy is referred to you after a trivial fall onto his elbow. Radiographs reveal a dislocated radial head. He does not have much pain. His mother says she has always had joint pains with abnormal knee caps. She keeps pointing to her knees in an excited manner with long fake nails. The most likely diagnosis is? a. Marfan syndrome.
    2. Monteggia Bado injury.
    3. Generalized ligamentous laxity.
    4. Ehlers–Danlos syndrome.
    5. Nail patella syndrome.
29. A 43-year-old woman presents with decreased digital flexion and an injury in Zone 2 of her left hand. On exploration what percentage laceration of the flexor tendon would you repair? a. 40 %.
    2. 25 %.
    3. 45 %.
    4. 50 %.
    5. 35 %.
30. With regards to radioulnar limb formation and the zone of polarizing activity, defects in which protein will result in duplication of digits? a.       Fibroblast growth factor.
    2. Sonic hedgehog protein.
    3. LMX1.
    4. Transforming growth factor.
    5. Cartilage-derived morphogenetic protein.

EMQs

1. Causes of wrist pain
   1. De Quervain’s disease
   2. Chronic triangular fibrocartilage complex (TFCC) lesion with sigmoid notch detachment
   3. Extensor carpi ulnaris (ECU) subluxation and tenosynovitis
   4. Intersection syndrome
   5. Late tendon rupture after distal radius fracture
   6. Vaughn-Jackson syndrome
   7. Extensor digitorum communis (EDC) to ring finger subluxation
   8. Wartenburg syndrome

Which of the options above is best described in each of the following statements? Each option may be used once, more than once or not at all.

1. 1. A male 27-year-old university rower who plays the drums complains of wrist pain.
   2. A 43-year-old woman on anti-tumour necrosis factor (anti-TNF) medication reports that her hand function has deteriorated dramatically.
   3. A 23-year-old woman presents with radial-sided wrist pain. Her full-time job is caring for her 6-month-old baby and 2-year-old toddler.
2. Infections in the hand
   1. Orf virus
   2. Staphylococcus aureus
   3. Clostridia and Group A b- streptococci
   4. Herpes simplex virus type 1
   5. Candida albicans
   6. Mycobacterium marinum
   7. Eikenella corrodens
   8. Pasteurella multocida

Which of the options above is best described in each of the following statements? Each option may be used once, more than once or not at all.

2. 1. A 26-year-old presents to the emergency department with a small laceration over his index metacarpal of his right hand. It is swollen with pus draining. History relates to a punching incident.
   2. A dentist presents with recurrent vesicles on the fingers and pain.
   3. A 65-year-old woman was bitten by a cat on the dorsum of the left wrist and now can’t move the hand and has severe swelling and pain.
3. Wound management
   1. Cross finger flap
   2. Heterodigital island flap
   3. Terminalization
   4. Haematoma evacuation
   5. Nail bed repair and splint
   6. V-Y plasty ( advancement )
   7. Distal replant
   8. Full thickness skin grafting

Which of the options above is best described in each of the following statements? Each option may be used once, more than once or not at all.

3. 1. A 26-year-old chef cuts the tip of his finger with a sharp knife. There is no bone exposed, the wound is volar favourable and >1 cm is exposed.
   2. A 42-year-old housewife minced the pulp of her index finger and there is a volar unfavourable wound with exposed bone >1 cm.
   3. A gardener put his hand under the blade of a lawnmower. There is very little bone in the distal phalanx with an exposed ragged flexor digitorum profundus ( FDP ) tendon and no nail visible.
4. Tumours of the hand
   1. Malignant nerve sheath tumour
   2. Synovial
   3. Epithelioid
   4. Neurofibroma
   5. Schwannoma
   6. Ewing’s
   7. Enchondroma
   8. Squamous cell carcinoma
   1. Pyogenic granuloma
   10. Sweat gland tumour

Which of the options above is best described in each of the following statements? Each option may be used once, more than once or not at all.

4. 1. This is the most common soft tissue sarcoma of the hand.
   2. This is the most common benign bone tumour and if multiple carries a 30% risk of sarcoma.
   3. A lesion of the nerves that shells out like a pea from a pod.
5. Inflammatory conditions
   1. Rheumatoid arthritis
   2. Scleroderma
   3. Systemic lupus erythematosus
   4. Gout
   5. Amyloidosis
   6. Psoriasis
   7. Osteoarthritis
   8. Calcium pyrophosphate deposits

Which of the options above is best described in each of the following statements? Each option may be used once, more than once or not at all.

5. 1. A 47-year-old with onycholysis and a ‘pencil in cup’ appearance of the fingers on X-ray presents with painful distal interphalangeal (DIP) joints.
   2. A 52-year-old woman presents with subcutaneous calcinosis, Raynaud’s phenomenon and painful fingers.
   3. This 65-year-old man on renal dialysis presents with stiff painful fingers and one of the digits triggers. A research project has revealed b2 microglobulins in the soft tissues of his fingers.
6. Nerve compression
   1. Parsonage–Turner syndrome
   2. Posterior interosseous nerve palsy
   3. Pronator syndrome
   4. Radial tunnel syndrome
   5. Anterior interosseous nerve palsy
   6. Cubital tunnel syndrome
   7. Carpal tunnel syndrome
   8. Mannerfelt–Norman syndrome

Which of the options above is best described in each of the following statements? Each option may be used once, more than once or not at all.

6. 1. A 45-year-old man has a viral illness and then develops motor weakness in flexion of the thumb and index finger.
   2. A 25-year-old man has a weak pronator quadratus and a weak OK sign. An ultrasound reveals thick bicipital bursae.
   3. A 57-year-old woman with rheumatoid arthritis has a sudden inability to make the OK sign.
7. Surgical options
   1. Wrist fusion
   2. Lunotriquetral fusion
   3. Ulnar shortening
   4. Radial shortening
   5. Proximal row carpectomy
   6. Lunate excision
   7. Capitate lengthening

Which of the options above is best described in each of the following statements? Each option may be used once, more than once or not at all.

7. 1. A patient with dorsal wrist pain and an ulnar minus variance with Lichtman stage 3A disease.
   2. A patient with dorsal wrist pain and an ulnar minus variance with Lichtman stage 3B disease.
   3. A patient with dorsal wrist pain and an ulnar minus variance with Lichtman stage 4 disease.
8. Hand deformities
   1. Intrinsic plus hand
   2. Boutonnière deformity
   3. Pseudo-boutonnière deformity
   4. Swan neck deformity
   5. Intrinsic minus hand
   6. Quadrigia effect
   7. Lumbrical plus finger
   8. Caput ulnae wrist

Which of the options above is best described in each of the following statements? Each option may be used once, more than once or not at all.

8. 1. On metacarpophalangeal joint (MCPJ) extension there is less flexion of the proximal interphalangeal joint (PIPJ) than with passive flexion of the MCPJ.
   2. Tendons adjacent to an injured finger (usually flexor tendon) don’t flex owing to a shared muscle belly.
   3. Central slip rupture leads to this condition.
9. Injuries around the wrist
   1. Dorsal wrist ganglion
   2. Hamate hook fracture
   3. Piso-triquetral arthritis
   4. Scapho-trapezio-trapezoid (STT) osteoarthritis
   5. Scaphoid non-union advanced collapse
   6. Distal radioulnar joint osteoarthritis
   7. Ulnocarpal abutment
   8. Extensor carpi ulnaris tendonitis
   1. De Quervain’s disease
   10. First carpometacarpal osteoarthritis
   11. Scaphoid lunate advanced collapse
   50. Triangular fibrocartilage complex (TFCC) injury

Which of the options above is best described in each of the following statements? Each option may be used once, more than once or not at all.

9. 1. A 22-year-old medical student presents 3 weeks after falling onto his hand after a few drinks at a party. He says his little finger feels a bit numb.
   2. A 62-year-old woman presents 6 months after a Colles fracture that was treated in plaster. Radiographs reveal a loss of radial height (2þ ulnar positive).
   3. A 29-year-old with radial-sided wrist pain has a positive ring sign on X-ray with an increased scapholunate angle.
10. Surgery for the wrist
    1. Wrist fusion with AO fusion plate
    2. Radio-scapholunate fusion
    3. Scaphoidectomy and four-corner fusion
    4. Proximal row carpectomy
    5. Arthroscopic debridement
    6. Scapholunate ligament reconstruction
    7. Lunotriquetral arthrodesis
    8. Triquetral-hamate fusion

Which of the options above is best described in each of the following statements? Each option may be used once, more than once or not at all.

10. 1. A 28-year-old female had a comminuted intra-articular distal radius fracture. It was treated with a locking plate and was out to length. She now has wrist pain and radiocarpal osteoarthritis.
    2. A 39-year-old mechanic has a stage III SLAC wrist with constant pain. Arthroscopy shows erosion of the proximal capitate.
    3. A 50-year-old woman with a stage IV SNAC wrist and severe pain.
11. Neurovascular conditions
    1. Thromboangiitis obliterans (TAO) or Buerger’s disease
    2. Embolism
    3. Raynaud’s phenomenon
    4. Ulnar hammer syndrome
    5. Pseudo-aneurysm
    6. Aneurysm
    7. Raynaud’s disease
    8. Arteriovenous fistula
    1. Haemangioma

Which of the options above is best described in each of the following statements? Each option may be used once, more than once or not at all.

1. 1. A 52-year-old smoker presents with pain and numbness in the hand. He works as a carpenter.
   2. A 22-year-old girl has a 2 year history of painful hands that change colour. Laboratory tests are normal.
   3. A 42-year-old woman complains about a painful left hand that changes colour.

Her collagen is abnormal.

12. Neurovascular conditions
    1. Carpal tunnel syndrome
    2. Neurogenic thoracic outlet syndrome
    3. Disputed thoracic outlet syndrome
    4. Venous thoracic outlet syndrome
    5. Raynaud’s disease
    6. Arterial thoracic outlet syndrome
    7. Takayasu’s arteritis
    8. Cervical spondylosis

Which of the options above is best described in each of the following statements? Each option may be used once, more than once or not at all.

1. 1. A 21-year-old presents with Raynaud’s phenomenon and a cervical rib.
   2. A 38-year-old university rower who body builds has arm and hand pain after a long rowing session.
   3. A 31-year-old female nurse presents with a painful right hand with tingling.

Doppler and electromyography (EMG) testing are normal.

13. Hand deformities in rheumatoid arthritis
    1. Metacarpophalangeal joint (MCPJ) subluxation
    2. Vaughn-Jackson syndrome
    3. Jackson Pollock syndrome
    4. Posterior interosseous nerve palsy
    5. Intrinsic deficiency
    6. Tendon subluxation
    7. Caput ulnae syndrome
    8. Mannerfelt–Norman syndrome
    1. Wartenburg syndrome

Which of the options above is best described in each of the following statements? Each option may be used once, more than once or not at all.

13. 1. A 32-year-old woman with uncontrolled rheumatoid arthritis cannot extend her ring finger. Her thumb extension is also weak.
    2. A 64-year-old woman with rheumatoid arthritis cannot extend her ring finger. She has had Swanson’s MCPJ replacements on the other hand.
    3. A 64-year-old woman with rheumatoid arthritis cannot actively extend her ring finger but on tenodesis testing, it extends.
14. Tendon transfers
    1. Zancolli’s lasso procedure
    2. Flexor carpi radialis to extensor digitorum communis
    3. Pronator teres to extensor carpi radialis longus
    4. Split flexor pollicis longus to extensor pollicis longus transfer-tenodesis
    5. Brachioradialis re-routing
    6. Camitz transfer
    7. Flexor carpi ulnaris to extensor digitorum communis
    8. Extensor indicis to extensor pollicis longus

Which of the options above is best described in each of the following statements? Each option may be used once, more than once or not at all.

14. 1. A 25-year-old arm wrestler had a Holstein–Lewis humeral fracture and has grade 0/5 power in his wrist extensors.
    2. A 47-year-old with a Colles fracture was treated non-operatively. Three months after injury she is unable to extend her thumb.
    3. A 62-year-old man sustained an injury to his ulnar nerve at decompression of Guyon’s canal. He has a claw hand.
15. Special examinations of the hand and wrist
    1. Distal ulnar ballottement
    2. Hueston’s tabletop test
    3. Watson’s shift test
    4. Tinel’s test
    5. Elson’s test
    6. Bunnell test
    7. Lichtman’s catch-up clunk
    8. Bouvier’s manoeuvre
    1. Distal radioulnar joint squeeze test
    10. Reagan’s test

Which of the options above is best described in each of the following statements? Each option may be used once, more than once or not at all.

1. 1. This is a useful test in deciding whether or not to proceed with surgery for Dupuytren’s disease.
   2. This test is good for evaluating a scapholunate advanced collapse wrist.
   3. This test will confirm intrinsic tightness.

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