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7. Hand and Wrist MCQs

Practice Set 124 of 266

This practice set contains high-yield board review questions covering key concepts in 7. Hand and Wrist. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 2461

Topic: 7. Hand and Wrist

A 28-year-old manual laborer presents to the emergency department following a high-energy fall. Radiographs show a perilunate dislocation. Which of the following nerve palsies is most commonly associated with this injury?

. Radial nerve
. Ulnar nerve
. Anterior interosseous nerve
. Posterior interosseous nerve
. Median nerve

Correct Answer & Explanation

. Median nerve

Explanation

Acute median nerve compression in the carpal tunnel is the most common neurologic complication associated with lunate and perilunate dislocations. If symptoms of acute carpal tunnel syndrome are present, emergent reduction and possible carpal tunnel release are indicated.

Question 2462

Topic: 7. Hand and Wrist

A 35-year-old man presents with chronic radial-sided wrist pain 6 months after a fall. Radiographs reveal a scapholunate gap of 4 mm and a widened scapholunate angle. What is the classic radiographic sign seen on the AP view of a complete scapholunate ligament tear?

. Terry Thomas sign
. Spilled teacup sign
. Piece of pie sign
. Gilula's line disruption at the midcarpal joint
. Lightbulb sign

Correct Answer & Explanation

. Terry Thomas sign

Explanation

The "Terry Thomas" sign refers to the abnormal widening of the scapholunate interval (greater than 3 mm) seen on the AP or PA view of the wrist. This indicates a disruption of the scapholunate interosseous ligament.

Question 2463

Topic: 7. Hand and Wrist

A 25-year-old male presents with a painful wrist. He sustained a scaphoid fracture 8 months ago treated nonoperatively. Current imaging demonstrates a scaphoid waist nonunion with a "humpback" deformity. Which of the following is the most appropriate surgical treatment?

. Percutaneous screw fixation
. Volar wedge grafting and internal fixation
. Dorsal structural bone grafting
. Proximal row carpectomy
. Four-corner fusion

Correct Answer & Explanation

. Volar wedge grafting and internal fixation

Explanation

A humpback deformity involves volar flexion of the distal scaphoid fragment. It is best corrected using a volar approach with structural wedge bone grafting and internal fixation to restore scaphoid length and alignment.

Question 2464

Topic: Wrist & Carpus

During the surgical treatment of a Galeazzi fracture, after plate fixation of the radius, the distal radioulnar joint (DRUJ) is found to be grossly unstable in supination. What is the most appropriate next step?

. Pinning of the DRUJ in supination
. Pinning of the DRUJ in neutral
. Open repair of the triangular fibrocartilage complex (TFCC)
. Ulnar styloid excision
. Casting in pronation

Correct Answer & Explanation

. Pinning of the DRUJ in supination

Explanation

If the DRUJ remains unstable after anatomic radius fixation in a Galeazzi fracture, it should be stabilized. This is commonly achieved by percutaneous K-wire pinning of the ulna to the radius with the forearm in full supination.

Question 2465

Topic: 7. Hand and Wrist

A 22-year-old male falls on an outstretched hand and sustains a displaced fracture of the proximal pole of the scaphoid. He is at high risk for avascular necrosis due to the retrograde blood supply. The predominant blood supply to the proximal pole is derived from which of the following?

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

Correct Answer & Explanation

. Dorsal carpal branch of the radial artery

Explanation

The dorsal carpal branch of the radial artery supplies 80% of the scaphoid via vessels entering the dorsal ridge distally. This creates a retrograde blood flow to the proximal pole, making proximal fractures highly susceptible to avascular necrosis.

Question 2466

Topic: Wrist & Carpus

A 65-year-old female undergoes volar locking plate fixation for a displaced distal radius fracture. Four months postoperatively, she suddenly loses the ability to flex the interphalangeal joint of her thumb. Which of the following technical errors most likely contributed to this complication?

. Use of screws that were too long, protruding dorsally
. Placement of the volar plate distal to the watershed line
. Failure to repair the pronator quadratus over the plate
. Over-distraction of the fracture fragment
. Inadequate reduction of the dorsal cortex

Correct Answer & Explanation

. Placement of the volar plate distal to the watershed line

Explanation

Placement of a volar plate distal to the watershed line of the distal radius causes prominence of the hardware against the flexor tendons. This places the flexor pollicis longus (FPL) tendon at high risk for attritional rupture.

Question 2467

Topic: 7. Hand and Wrist
A 30-year-old mechanic sustains a severe hyperextension injury to his wrist. Radiographs reveal a 'spilled teacup' sign on the lateral view, confirming a lunate dislocation. According to Mayfield's stages of perilunate instability, a complete lunate dislocation represents which stage?
. Stage I
. Stage II
. Stage III
. Stage IV
. Stage V

Correct Answer & Explanation

. Stage IV

Explanation

Mayfield described four stages of progressive perilunate instability. Stage I is scapholunate dissociation, Stage II adds capitate dislocation, Stage III adds lunotriquetral disruption, and Stage IV is a complete volar dislocation of the lunate.

Question 2468

Topic: Wrist & Carpus

A 35-year-old male undergoes ORIF for a distal-third radial shaft fracture with an associated distal radioulnar joint (DRUJ) dislocation (Galeazzi fracture). Intraoperatively, after rigid fixation of the radius, the DRUJ is found to be reducible but stable ONLY in full supination. What is the most appropriate next step in management?

. Immobilization in a long-arm cast or splint in supination
. Immobilization in a long-arm cast or splint in pronation
. Transfixion of the DRUJ with K-wires in neutral rotation
. Immediate open repair of the triangular fibrocartilage complex (TFCC)
. Darrach procedure

Correct Answer & Explanation

. Immobilization in a long-arm cast or splint in supination

Explanation

In a Galeazzi fracture, if the DRUJ is reducible and stable in supination after anatomic fixation of the radius, it is appropriate to immobilize the arm in supination for 4 to 6 weeks. K-wire transfixion or open repair is indicated if the joint remains unstable in all positions.

Question 2469

Topic: Wrist & Carpus

A 48-year-old female was treated non-operatively in a cast for a nondisplaced distal radius fracture. Six weeks later, she reports a sudden inability to actively extend her thumb interphalangeal joint. What is the most appropriate and reliable surgical treatment?

. Primary end-to-end repair of the extensor pollicis longus (EPL)
. Extensor indicis proprius (EIP) to EPL tendon transfer
. Flexor carpi radialis (FCR) to EPL tendon transfer
. Palmaris longus interposition autograft
. Tenodesis of the EPL to the extensor digitorum communis (EDC)

Correct Answer & Explanation

. Extensor indicis proprius (EIP) to EPL tendon transfer

Explanation

Attritional rupture of the EPL tendon is a known complication of nondisplaced distal radius fractures due to ischemia or mechanical wear in Lister's tubercle. The standard and most reliable treatment is an EIP to EPL tendon transfer, as the native tendon ends are typically retracted and degenerated.

Question 2470

Topic: 7. Hand and Wrist

Following a severe crush injury to the wrist, a patient develops acute carpal tunnel syndrome requiring emergent release. During the procedure, all flexor tendons are inspected. Which of the following tendons is NOT contained within the carpal tunnel?

. Flexor pollicis longus
. Flexor carpi radialis
. Flexor digitorum superficialis to the index finger
. Flexor digitorum profundus to the small finger
. Flexor digitorum superficialis to the long finger

Correct Answer & Explanation

. Flexor carpi radialis

Explanation

The carpal tunnel contains the median nerve and nine flexor tendons (four FDS, four FDP, and the FPL). The flexor carpi radialis (FCR) runs in its own separate fibro-osseous sheath within the split of the transverse carpal ligament.

Question 2471

Topic: Nerve & Tendon

A 25-year-old male sustains a distal-third spiral fracture of the humeral shaft (Holstein-Lewis fracture). Which nerve is most at risk of entrapment, and what is its anatomic relationship to the intermuscular septum at this level?

. Radial nerve; passes from anterior to posterior through the lateral septum
. Radial nerve; passes from posterior to anterior through the lateral septum
. Ulnar nerve; passes from anterior to posterior through the medial septum
. Ulnar nerve; passes from posterior to anterior through the medial septum
. Median nerve; runs directly anterior to the medial septum

Correct Answer & Explanation

. Radial nerve; passes from posterior to anterior through the lateral septum

Explanation

In a Holstein-Lewis fracture, the radial nerve is tethered as it pierces the lateral intermuscular septum. At this level (distal third of the humerus), it passes from the posterior compartment to the anterior compartment.

Question 2472

Topic: 7. Hand and Wrist
A 28-year-old male presents with acute severe wrist pain and median nerve paresthesias following a high-energy motorcycle collision. Radiographs demonstrate a volar dislocation of the lunate into the carpal tunnel. According to Mayfield's progressive stages of perilunate instability, this specific finding represents which stage of the injury pattern?
. Stage I
. Stage II
. Stage III
. Stage IV
. Stage V

Correct Answer & Explanation

. Stage IV

Explanation

Mayfield's stages of perilunate instability progress sequentially around the lunate: Stage I (scapholunate dissociation), Stage II (capitolunate dislocation), Stage III (lunotriquetral dissociation), and Stage IV (volar lunate dislocation). In Stage IV, the lunate is fully separated from its dorsal attachments and translates volarly into the carpal tunnel, often compressing the median nerve.

Question 2473

Topic: Nerve & Tendon

A 40-year-old recreational weightlifter feels a sudden pop in his anterior elbow during a deadlift. Clinical examination reveals a reverse Popeye deformity and weakness in resisted supination. If a single anterior incision approach is utilized for repair, which nerve is at greatest risk of iatrogenic injury?

. Median nerve
. Anterior interosseous nerve
. Posterior interosseous nerve
. Lateral antebrachial cutaneous nerve
. Ulnar nerve

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve

Explanation

The lateral antebrachial cutaneous nerve is the most commonly injured structure during a single anterior incision approach for distal biceps repair. The posterior interosseous nerve is at higher risk during a two-incision approach if retractors are placed poorly.

Question 2474

Topic: Nerve & Tendon

A 35-year-old male bodybuilder reports a sudden, painful "pop" in his right antecubital fossa while performing biceps curls. Physical examination reveals a "Popeye" deformity and weakness in forearm supination. If a single-incision anterior surgical approach is chosen for repair, the patient is at highest risk for injury to which of the following structures?

. Posterior interosseous nerve (PIN)
. Lateral antebrachial cutaneous nerve (LABCN)
. Median nerve
. Ulnar nerve
. Radial artery

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve (LABCN)

Explanation

The lateral antebrachial cutaneous nerve (LABCN) is the most commonly injured structure during a single-incision distal biceps tendon repair due to its superficial location in the anterior approach. In contrast, the posterior interosseous nerve (PIN) is more commonly at risk during a two-incision approach.

Question 2475

Topic: Nerve & Tendon

A 50-year-old man requires an open capsular release for severe post-traumatic elbow stiffness. During a lateral column procedure, the anterior capsule is sharply elevated off the anterior humerus. Which neurovascular structure is at highest risk during this specific step?

. Median nerve
. Brachial artery
. Ulnar nerve
. Radial nerve
. Posterior interosseous nerve

Correct Answer & Explanation

. Radial nerve

Explanation

During a lateral column approach for anterior capsulectomy, the radial nerve is at the greatest risk of injury. The nerve courses directly over the anterior aspect of the joint capsule near the radiocapitellar articulation and can be injured if the capsule is inadvertently penetrated or poorly elevated.

Question 2476

Topic: Nerve & Tendon

A 45-year-old man presents with persistent numbness in the ring and small fingers and intrinsic weakness. EMG confirms severe ulnar neuropathy at the elbow. During an anterior submuscular transposition of the ulnar nerve, which structure must be meticulously released to prevent secondary compression of the nerve as it exits the elbow?

. Arcade of Struthers
. Ligament of Struthers
. Osborne's ligament
. Deep aponeurosis of the flexor-pronator mass
. Lacertus fibrosus

Correct Answer & Explanation

. Deep aponeurosis of the flexor-pronator mass

Explanation

During an anterior transposition of the ulnar nerve, it is critical to release the deep flexor-pronator aponeurosis. Failure to do so can create a sharp fascial band that causes secondary compression or kinking of the nerve distally.

Question 2477

Topic: Nerve & Tendon

A 17-year-old javelin thrower reports medial-sided elbow pain and diminished grip strength while throwing. He has decreased sensation in the little and ring fingers of his throwing hand only while throwing. The sensory deficits resolve at rest. Examination of the elbow reveals no instability and full motion. He has a positive Tinel's sign over the cubital tunnel and a positive elbow flexion test. Radiographs are normal. What is the next most appropriate step in management?

. Anterior ulnar nerve transposition
. Cortisone injection
. Nighttime elbow extension splinting
. Medial collateral ligament reconstruction
. Ulnar nerve decompression in situ

Correct Answer & Explanation

. Nighttime elbow extension splinting

Explanation

The patient's symptoms and examination findings are consistent with ulnar neuritis/cubital tunnel syndrome, most probably exacerbated by javelin throwing. The first step includes rest and extension splinting. Surgical intervention should only be considered after failure of nonsurgical management. Posner MA: Compressive neuropathies of the ulnar nerve at the elbow and wrist. Instr Course Lect 2000;49:305-317.

Question 2478

Topic: 7. Hand and Wrist

A 24-year-old man falls on an outstretched hand. Radiographs and subsequent MRI confirm a displaced proximal pole scaphoid fracture. What is the most appropriate surgical approach and fixation method?

. Volar approach, headless compression screw
. Dorsal approach, headless compression screw
. Volar approach, K-wires
. Dorsal approach, K-wires
. Percutaneous volar screw

Correct Answer & Explanation

. Dorsal approach, headless compression screw

Explanation

Proximal pole scaphoid fractures are best approached dorsally to preserve the tenuous blood supply entering distally. This also allows for a straight-line screw trajectory perpendicular to the fracture.

Question 2479

Topic: Wrist & Carpus

A 28-year-old construction worker falls from a height and sustains a wrist injury. Radiographs show the lunate is displaced and rotated volar to the radius, while the capitate remains aligned with the radius. What is this injury pattern?

. Dorsal perilunate dislocation
. Volar lunate dislocation
. Scaphoid fracture dislocation
. Trans-scaphoid perilunate dislocation
. Barton fracture

Correct Answer & Explanation

. Volar lunate dislocation

Explanation

A volar lunate dislocation represents the final stage (Mayfield IV) of perilunate instability. The lunate is displaced volarly (the "spilled teacup" sign), while the capitate falls back into alignment with the radius.

Question 2480

Topic: 7. Hand and Wrist

A 32-year-old man falls on an extended wrist. Radiographs reveal a scapholunate gap of 4 mm and a cortical ring sign of the scaphoid. What is the most appropriate management for an acute, repairable scapholunate ligament tear?

. Proximal row carpectomy
. Four-corner fusion
. Open reduction and dorsal capsulodesis with ligament repair
. Scaphoid excision and midcarpal fusion
. Closed reduction and casting for 12 weeks

Correct Answer & Explanation

. Open reduction and dorsal capsulodesis with ligament repair

Explanation

Acute scapholunate ligament tears with diastasis should be treated surgically with open reduction and primary ligament repair. This is often augmented with a dorsal capsulodesis or K-wire pinning to restore carpal kinematics.

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