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7. Hand and Wrist MCQs

Practice Set 132 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 2621

Topic: Wrist & Carpus

A 55-year-old woman is treated in a cast for a minimally displaced distal radius fracture. Six weeks later, she notes a sudden inability to extend her thumb at the interphalangeal joint. What is the most likely etiology of this complication?

. FPL attrition rupture
. EPL ischemia and attrition
. Radial nerve neuropraxia
. Posterior interosseous nerve entrapment
. Abductor pollicis longus rupture

Correct Answer & Explanation

. EPL ischemia and attrition

Explanation

Extensor pollicis longus (EPL) ruptures typically occur after minimally displaced distal radius fractures. They result from local ischemia due to increased pressure within the intact third extensor compartment, followed by mechanical attrition.

Question 2622

Topic: 7. Hand and Wrist

A 24-year-old professional baseball player complains of hypothenar wrist pain and paresthesias in his small finger after a forceful swing. A carpal tunnel view radiograph is shown in

. He is diagnosed with a hook of hamate fracture. What is the most definitive surgical treatment to allow earliest return to professional sports?

. Open reduction internal fixation with a compression screw
. Excision of the hook fragment
. Bone grafting and Kirschner wire fixation
. Carpal tunnel release alone
. Immobilization in a cast for 6 weeks

Correct Answer & Explanation

. Excision of the hook fragment

Explanation

Excision of the hook of the hamate fragment is the treatment of choice for athletes with symptomatic nonunions or acute fractures who require rapid return to play, yielding high satisfaction and low complication rates.

Question 2623

Topic: 7. Hand and Wrist

A 30-year-old man falls onto his extended wrist. Lateral radiographs shown in

reveal a dorsal perilunate dislocation. Which of the following nerve injuries is most commonly associated with this specific trauma?

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

Correct Answer & Explanation

. Median nerve

Explanation

Median nerve neuropathy (acute carpal tunnel syndrome) is the most common neurologic complication associated with lunate and perilunate dislocations due to volar displacement of the lunate into the carpal tunnel.

Question 2624

Topic: Wrist & Carpus

A 62-year-old woman undergoes volar locked plating for a distal radius fracture. Postoperatively, she develops flexor pollicis longus (FPL) tenosynovitis. What technical error is the most likely cause of this complication?

. Screws penetrating the dorsal cortex
. Plate placed proximal to the watershed line
. Plate placed distal to the watershed line
. Failure to repair the pronator quadratus
. Over-reduction of the volar tilt

Correct Answer & Explanation

. Plate placed distal to the watershed line

Explanation

Volar plates placed too distally (beyond the watershed line of the distal radius) can impinge on the flexor tendons, most commonly the FPL, leading to tenosynovitis or attrition rupture.

Question 2625

Topic: 7. Hand and Wrist

A 22-year-old man falls on an outstretched hand and presents with anatomic snuffbox tenderness. Radiographs are negative, but MRI confirms a nondisplaced fracture of the proximal pole of the scaphoid. The blood supply placing this region at high risk for avascular necrosis originates primarily from which vessel?

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

Correct Answer & Explanation

. Dorsal carpal branch of the radial artery

Explanation

The proximal pole of the scaphoid relies on retrograde blood supply from the dorsal carpal branch of the radial artery. Because vessels enter the scaphoid distally and flow proximally, proximal pole fractures are highly susceptible to avascular necrosis.

Question 2626

Topic: Wrist & Carpus

A 65-year-old woman is evaluated 6 months after volar locked plating of a distal radius fracture. She now presents with a new-onset inability to actively flex the interphalangeal joint of her thumb. What is the most likely etiology?

. Extensor pollicis longus rupture
. Flexor pollicis longus rupture
. Anterior interosseous nerve palsy
. Trigger thumb
. Adhesions of the flexor digitorum profundus

Correct Answer & Explanation

. Flexor pollicis longus rupture

Explanation

Hardware placed prominent or volar to the watershed line of the distal radius can lead to attritional rupture of the flexor pollicis longus (FPL) tendon. The clinical presentation is a loss of active thumb interphalangeal joint flexion.

Question 2627

Topic: 7. Hand and Wrist

A 30-year-old man is involved in a motorcycle crash. His wrist is grossly swollen, and he has numbness in the median nerve distribution. A lateral wrist radiograph demonstrates that the lunate maintains its normal articulation with the distal radius, but the capitate is displaced dorsally. What is the diagnosis?

. Volar lunate dislocation
. Dorsal perilunate dislocation
. Volar perilunate dislocation
. Barton fracture
. Colles fracture

Correct Answer & Explanation

. Dorsal perilunate dislocation

Explanation

In a dorsal perilunate dislocation, the lunate maintains its alignment within the radiolunate fossa, but the capitate and the distal carpal row are displaced dorsally. Prompt closed reduction is required to relieve median nerve compression prior to definitive surgical management.

Question 2628

Topic: 7. Hand and Wrist
A 50-year-old man with a chronic, untreated scapholunate ligament tear presents with progressive wrist pain. Radiographs show joint space narrowing exclusively at the radioscaphoid articulation. As Scapholunate Advanced Collapse (SLAC) progresses to Stage III, which articulation is typically affected next?
. Capitolunate joint
. Radiolunate joint
. Pisotriquetral joint
. Distal radioulnar joint
. Scaphocapitate joint

Correct Answer & Explanation

. Capitolunate joint

Explanation

Scapholunate Advanced Collapse (SLAC) arthritis progresses in a predictable pattern: Stage I involves the radial styloid, Stage II involves the entire radioscaphoid fossa, and Stage III progresses to the capitolunate joint. The radiolunate joint is classically spared.

Question 2629

Topic: Wrist & Carpus

A 32-year-old man sustains a Galeazzi fracture. After achieving anatomic open reduction and internal fixation of the radius, intraoperative assessment reveals the distal radioulnar joint (DRUJ) remains unstable in supination. What is the most appropriate next step in management?

. Transfix the DRUJ with K-wires in supination
. Transfix the DRUJ with K-wires in neutral rotation
. Proceed to immediate open reduction of the DRUJ
. Perform a distal ulnar resection (Darrach procedure)
. Immobilize the patient in a cast in full pronation

Correct Answer & Explanation

. Transfix the DRUJ with K-wires in supination

Explanation

In a Galeazzi fracture-dislocation, if the DRUJ remains unstable despite anatomic radius fixation, the joint should be transfixed with K-wires in the position of maximum stability, which is typically full supination.

Question 2630

Topic: 7. Hand and Wrist
A 28-year-old manual laborer presents with chronic wrist pain 5 years after an untreated scaphoid fracture. Radiographs demonstrate a scaphoid nonunion with advanced radioscaphoid and capitolunate osteoarthritis, while the radiolunate joint is preserved. What is the most appropriate surgical treatment?
. Scaphoid open reduction and internal fixation with vascularized bone graft
. Proximal row carpectomy
. Four-corner arthrodesis
. Scaphotrapeziotrapezoid (STT) arthrodesis
. Total wrist arthroplasty

Correct Answer & Explanation

. Four-corner arthrodesis

Explanation

This patient has Scaphoid Nonunion Advanced Collapse (SNAC) stage III, which involves the capitolunate joint. Proximal row carpectomy is contraindicated due to capitate head arthritis, making four-corner fusion the treatment of choice.

Question 2631

Topic: 7. Hand and Wrist

A 28-year-old motorcycle rider presents with severe wrist pain after a crash. Radiographs reveal a volar dislocation of the lunate. The rest of the carpus remains aligned with the radius. What is the most commonly associated nerve injury with this specific pattern?

. Anterior interosseous nerve neuropraxia
. Posterior interosseous nerve neuropraxia
. Ulnar nerve laceration
. Superficial radial nerve injury
. Median nerve compression

Correct Answer & Explanation

. Median nerve compression

Explanation

Volar lunate dislocations classically protrude into the carpal tunnel, placing direct pressure on the median nerve. This frequently causes acute carpal tunnel syndrome, which requires urgent reduction.

Question 2632

Topic: Wrist & Carpus

During open reduction and internal fixation of a Galeazzi fracture-dislocation in a 30-year-old man, the distal radius is anatomically plated. Intraoperative evaluation reveals that the distal radioulnar joint (DRUJ) remains grossly unstable in supination. What is the most appropriate next step in management?

. Repair the triangular fibrocartilage complex (TFCC) and/or pin the DRUJ
. Resect the distal ulna (Darrach procedure)
. Perform a Sauve-Kapandji procedure
. Immobilize the wrist in full pronation for 6 weeks
. Accept the instability as it will self-stabilize with soft tissue healing

Correct Answer & Explanation

. Repair the triangular fibrocartilage complex (TFCC) and/or pin the DRUJ

Explanation

In a Galeazzi fracture, if the DRUJ remains unstable after anatomic stabilization of the radius, operative intervention of the DRUJ is required. This consists of repairing the TFCC or pinning the DRUJ in the position of maximum stability (usually supination).

Question 2633

Topic: 7. Hand and Wrist

A 50-year-old man sustains a highly comminuted, high-energy distal radius fracture. Two hours later in the emergency department, he complains of severe, progressively worsening pain and numbness in his thumb, index, and middle fingers. Passive extension of his fingers causes excruciating pain out of proportion to the injury. What is the most urgent intervention?

. Intravenous corticosteroid administration
. Immediate closed reduction and urgent carpal tunnel release / fasciotomy
. Median nerve block to control pain
. MRI of the cervical spine to rule out root avulsion
. Discharge with a volar splint and prompt outpatient follow-up

Correct Answer & Explanation

. Immediate closed reduction and urgent carpal tunnel release / fasciotomy

Explanation

The patient is exhibiting signs of acute carpal tunnel syndrome with impending volar compartment syndrome (pain with passive stretch). This is an orthopedic emergency requiring immediate gross reduction and, if symptoms persist, emergent carpal tunnel release and forearm fasciotomies.

Question 2634

Topic: Wrist & Carpus

A 45-year-old woman sustains a nondisplaced distal radius fracture treated in a short arm cast. Six weeks later, after cast removal, she suddenly loses the ability to actively extend the interphalangeal joint of her thumb. What is the most likely diagnosis?

. Posterior interosseous nerve palsy
. Extensor pollicis longus tendon rupture
. Flexor pollicis longus tendon rupture
. Anterior interosseous nerve palsy
. Stenosing tenosynovitis of the first dorsal compartment

Correct Answer & Explanation

. Extensor pollicis longus tendon rupture

Explanation

Extensor pollicis longus (EPL) ruptures frequently occur following nondisplaced distal radius fractures due to mechanical attrition or local ischemia at Lister's tubercle. Treatment typically involves an extensor indicis proprius (EIP) to EPL tendon transfer.

Question 2635

Topic: Wrist & Carpus

Which of the following factors most significantly increases the risk of avascular necrosis and nonunion following a scaphoid fracture?

. Distal pole location
. Volar comminution
. Delay in casting of 3 days
. Proximal pole location
. Associated distal radius fracture

Correct Answer & Explanation

. Proximal pole location

Explanation

The blood supply to the scaphoid enters at the dorsal ridge distally and flows in a retrograde fashion. Consequently, proximal pole fractures are at the highest risk for ischemia, avascular necrosis, and nonunion.

Question 2636

Topic: 7. Hand and Wrist

In the setting of an acute perilunate dislocation, what neurological complication is most frequently encountered on initial presentation?

. Radial sensory nerve palsy
. Ulnar nerve motor palsy
. Acute median nerve neuropathy
. Posterior interosseous nerve palsy
. Axillary nerve palsy

Correct Answer & Explanation

. Acute median nerve neuropathy

Explanation

Perilunate dislocations frequently cause acute carpal tunnel syndrome due to the lunate rotating into the carpal canal and compressing the median nerve. Emergent reduction and potential carpal tunnel release are required.

Question 2637

Topic: Wrist & Carpus

A 28-year-old active manual laborer complains of ulnar-sided wrist pain 6 months after a nonoperatively treated distal radius fracture. Radiographs show a shortened, dorsally angulated distal radius with DRUJ incongruity. What is the most appropriate definitive surgical intervention?

. Darrach procedure (ulnar head resection)
. Sauve-Kapandji procedure
. Ulnar shortening osteotomy
. Distal radius corrective opening-wedge osteotomy
. Total wrist arthrodesis

Correct Answer & Explanation

. Distal radius corrective opening-wedge osteotomy

Explanation

In a young, active patient with an extra-articular distal radius malunion causing secondary DRUJ dysfunction, a corrective osteotomy of the radius restores native anatomy, mechanics, and DRUJ congruity. Procedures like the Darrach are reserved for low-demand or elderly patients.

Question 2638

Topic: 7. Hand and Wrist
A 45-year-old mechanic presents with chronic radial-sided wrist pain. Imaging shows a scaphoid waist nonunion with radioscaphoid and capitolunate arthritis. The radiolunate joint is entirely spared. What is the most appropriate surgical treatment?
. Proximal row carpectomy
. Scaphoid excision and four-corner fusion
. Total wrist arthroplasty
. Vascularized bone grafting of the scaphoid
. Radial styloidectomy

Correct Answer & Explanation

. Scaphoid excision and four-corner fusion

Explanation

In SNAC stage III, arthritis involves the radioscaphoid and capitolunate joints but spares the radiolunate joint. Scaphoid excision and four-corner fusion is indicated, whereas proximal row carpectomy is contraindicated due to the presence of capitolunate arthritis.

Question 2639

Topic: 7. Hand and Wrist

A 35-year-old weightlifter undergoes a single-incision anterior repair of a distal biceps tendon rupture using suture anchors. Postoperatively, he exhibits weakness in thumb and finger extension, but normal wrist flexion. Wrist extension is weak and deviates radially. Which nerve was most likely injured during the procedure?

. Lateral antebrachial cutaneous nerve
. Median nerve
. Posterior interosseous nerve
. Superficial radial nerve
. Ulnar nerve

Correct Answer & Explanation

. Posterior interosseous nerve

Explanation

The posterior interosseous nerve (PIN) is at risk during the single-incision anterior approach for distal biceps repair, especially with excessive lateral retraction. PIN injury presents with weakness in finger/thumb extension and weak, radially-deviated wrist extension (due to ECRL preservation via the radial nerve proper).

Question 2640

Topic: 7. Hand and Wrist

A 28-year-old carpenter sustains a laceration to the volar index finger at the proximal phalanx, completely dividing the FDP and FDS tendons. He undergoes primary 6-strand core repair. Which rehabilitation protocol provides the best combination of tendon glide and prevention of rupture?

. Strict cast immobilization for 6 weeks
. Early active motion (flexion and extension) with protective splinting
. Passive flexion only for 4 weeks
. Unrestricted active motion without splinting
. Dynamic flexion splinting with no active motion

Correct Answer & Explanation

. Early active motion (flexion and extension) with protective splinting

Explanation

Modern 4- and 6-strand core suture techniques for Zone II flexor tendon repairs are strong enough to allow early active motion protocols. This approach minimizes peritendinous adhesions and improves functional excursion compared to strict immobilization or passive-only protocols.

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