Menu

7. Hand and Wrist MCQs

Practice Set 190 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 3781

Topic: Wrist & Carpus

Which of the following describes the anatomical position of the lunate relative to the capitate in a dorsal perilunate dislocation?

. The lunate is displaced volarly relative to the capitate
. The lunate is displaced dorsally relative to the capitate
. The capitate is displaced volarly relative to the lunate
. The capitate is displaced dorsally relative to the lunate
. The lunate and capitate maintain normal articulation

Correct Answer & Explanation

. The capitate is displaced dorsally relative to the lunate

Explanation

In a dorsal perilunate dislocation, the lunate maintains its articulation with the distal radius, but the capitate (and the rest of the carpus) dislocates dorsally relative to the lunate. Therefore, the capitate is displaced dorsally relative to the lunate. If the lunate itself displaces volarly, it is a true lunate dislocation. Understanding this relationship is fundamental to differentiating these injuries.

Question 3782

Topic: 7. Hand and Wrist

Which of the following ligaments is considered the 'keystone' of carpal stability?

. Triangular fibrocartilage complex
. Radioscaphocapitate ligament
. Scapholunate interosseous ligament
. Lunotriquetral interosseous ligament
. Dorsal radiocarpal ligament

Correct Answer & Explanation

. Scapholunate interosseous ligament

Explanation

While several ligaments contribute to carpal stability, the scapholunate interosseous ligament (SLIL) is often referred to as the 'keystone' or most critical intrinsic stabilizer of the proximal carpal row. Its integrity is fundamental to preventing carpal collapse and progressive instability (DISI, SLAC wrist). Damage to the SLIL is the initiating event in Mayfield Stage I perilunate instability and is central to the pathophysiology of perilunate and lunate dislocations.

Question 3783

Topic: Hand Trauma & Infection

During surgical debridement of a fight bite over the fifth MCP joint, a small, yellowish-white, firm structure is encountered within the wound. This is most likely a:

. A. Devitalized adipose tissue.
. B. Necrotic tendon fragment.
. C. Retained tooth fragment.
. D. Calcified synovial cyst.
. E. Foreign body granuloma.

Correct Answer & Explanation

. C. Retained tooth fragment.

Explanation

A small, yellowish-white, firm structure encountered in a fight bite wound is highly suggestive of a retained tooth fragment. These fragments are common in clenched-fist injuries and can act as a persistent nidus for infection, requiring meticulous removal. While devitalized adipose tissue (A) or necrotic tendon (B) can be found, they typically have a different appearance. Calcified synovial cysts (D) and foreign body granulomas (E) are typically chronic findings and less likely to be encountered as a primary foreign body during acute debridement.

Question 3784

Topic: 7. Hand and Wrist

A 30-year-old construction worker presents with a small laceration on the ulnar border of his hand, just proximal to the fifth MCP joint, sustained when his hand slipped while working. He denies striking anyone. This injury is best managed by:

. A. Urgent surgical exploration due to proximity to the MCP joint.
. B. Closure of the wound with sutures, oral antibiotics, and splinting.
. C. Thorough irrigation, delayed primary closure if clean, and observation.
. D. Referral to infectious disease for specialized antibiotic management.
. E. Admission for intravenous antibiotics and daily dressing changes.

Correct Answer & Explanation

. C. Thorough irrigation, delayed primary closure if clean, and observation.

Explanation

The key differentiating factor here is the mechanism of injury. This is described as a laceration from a work-related incident, not a 'fight bite.' While any wound near a joint should be treated with respect, if there is no suspicion of human bite or deep joint/tendon involvement, it is not treated as a fight bite. Thorough irrigation and debridement are always indicated for lacerations. Delayed primary closure is often preferred for contaminated wounds to allow for drainage. If there is no suspicion of deep penetration, urgent surgical exploration (A) or admission for IV antibiotics (E) are likely overkill. Suture closure (B) might be appropriate if the wound is clean and recent, but without clear indication, delayed closure is safer. Referral to ID (D) is not the initial step for a non-human bite wound.

Question 3785

Topic: Hand Trauma & Infection

When performing surgical debridement for a fight bite, what is the most important principle regarding wound closure?

. A. Primary closure is always preferred to minimize scarring.
. B. Delayed primary closure or leaving the wound open is generally recommended.
. C. Only absorbable sutures should be used for wound closure.
. D. Skin grafts are often required for adequate closure.
. E. Vacuum-assisted closure (VAC) therapy should be applied to all wounds.

Correct Answer & Explanation

. B. Delayed primary closure or leaving the wound open is generally recommended.

Explanation

For human bite wounds, especially those that have penetrated deeply or are already infected, delayed primary closure or leaving the wound open to heal by secondary intention is generally recommended. This allows for continuous drainage, reduces the risk of trapping infection, and permits close monitoring. Primary closure (A) significantly increases the risk of abscess formation and subsequent complications. Absorbable sutures (C) or skin grafts (D) are not universally indicated for the initial closure. VAC therapy (E) can be useful for complex wounds or those with significant tissue loss, but it's not a universal initial closure strategy.

Question 3786

Topic: Hand Trauma & Infection

What is the recommended approach for initial wound care of a superficial, clean human bite wound (not a fight bite) that is less than 6 hours old and shows no signs of deep penetration?

. A. Primary closure with sutures and no antibiotics.
. B. Thorough irrigation, debridement, and leave the wound open; prophylactic oral antibiotics.
. C. Apply topical antiseptic and cover with a sterile bandage.
. D. Immediately admit for IV antibiotics and surgical consultation.
. E. Refer to plastics for cosmetic closure.

Correct Answer & Explanation

. B. Thorough irrigation, debridement, and leave the wound open; prophylactic oral antibiotics.

Explanation

Even superficial human bite wounds are considered contaminated and carry a risk of infection. The standard of care is thorough irrigation and debridement of any devitalized tissue. For superficial wounds without deep penetration and less than 6-12 hours old, the wound is typically left open to drain or managed with delayed primary closure. Prophylactic oral antibiotics (e.g., amoxicillin-clavulanate) are generally recommended for all human bite wounds. Primary closure (A) is contraindicated due to infection risk. Topical antiseptics alone (C) are insufficient. Admission and surgical consultation (D) are usually not necessary for truly superficial, non-fight bite wounds. Cosmetic closure (E) is secondary to infection control.

Question 3787

Topic: Hand Trauma & Infection

A 25-year-old male presents with a painful, swollen, and red index finger following a fight bite 36 hours ago. The wound is over the MCP joint. During surgical exploration, the extensor digitorum communis tendon is found to be partially lacerated. What is the most appropriate management for the partially lacerated tendon in this infected field?

. A. Primary repair of the tendon with non-absorbable sutures.
. B. Thorough irrigation and debridement of the tendon ends, and leave unrepaired for delayed secondary repair.
. C. Excise the lacerated portion of the tendon to prevent further spread of infection.
. D. Cover the tendon with a local fascial flap for protection.
. E. Administer high-dose corticosteroids to reduce inflammation.

Correct Answer & Explanation

. B. Thorough irrigation and debridement of the tendon ends, and leave unrepaired for delayed secondary repair.

Explanation

In an acutely infected wound, primary repair of a partially lacerated tendon is generally contraindicated due to the high risk of infection of the repair site, leading to tendon necrosis, rupture, and adhesion formation. The most appropriate management is thorough irrigation and debridement of the tendon ends and surrounding tissue, followed by leaving the tendon unrepaired. Definitive repair, if necessary, should be delayed until the infection is completely resolved and the wound is clean. Excising the tendon (C) would result in significant functional deficit. Covering with a flap (D) is premature. Corticosteroids (E) are contraindicated in active infection.

Question 3788

Topic: 7. Hand and Wrist

Which of the following describes the 'intrinsic plus' position commonly used for splinting in hand injuries and infections?

. A. Wrist in extension, MCP joints extended, IP joints flexed.
. B. Wrist in neutral, MCP joints flexed to 90 degrees, IP joints extended.
. C. Wrist in flexion, MCP joints extended, IP joints flexed.
. D. Wrist in 20-30 degrees extension, MCP joints flexed to 70-90 degrees, IP joints extended.
. E. Wrist in full extension, all digits in neutral position.

Correct Answer & Explanation

. D. Wrist in 20-30 degrees extension, MCP joints flexed to 70-90 degrees, IP joints extended.

Explanation

The 'intrinsic plus' or 'safe position' for hand splinting is characterized by the wrist in 20-30 degrees of extension, the metacarpophalangeal (MCP) joints flexed to approximately 70-90 degrees, and the interphalangeal (IP) joints in full extension. This position helps prevent contractures by maintaining the collateral ligaments of the MCP joints in their elongated position, and avoids shortening of the IP joint collateral ligaments. This is a critical position to understand for managing hand trauma and infections.

Question 3789

Topic: 7. Hand and Wrist

A 28-year-old patient presents with a fight bite to the hand. He reports a penicillin allergy (rash). Which oral antibiotic would be an appropriate alternative for outpatient management of a superficial wound without deep involvement, if such management were deemed appropriate?

. A. Cephalexin
. B. Azithromycin
. C. Doxycycline
. D. Clindamycin
. E. Trimethoprim-sulfamethoxazole (Bactrim)

Correct Answer & Explanation

. D. Clindamycin

Explanation

For a penicillin-allergic patient with a superficial human bite wound (where outpatient oral antibiotics might be considered, though fight bites usually need aggressive management), Clindamycin is a suitable alternative. It provides good coverage against anaerobes and many Gram-positive organisms (Staphylococcus and Streptococcus species). Cephalexin (A) has a cross-reactivity risk with penicillin, especially in rash-type reactions. Azithromycin (B) and Doxycycline (C) do not adequately cover the full spectrum of oral flora, particularly anaerobes and Eikenella corrodens. Trimethoprim-sulfamethoxazole (E) has variable activity against oral flora and is not typically first-line for human bites.

Question 3790

Topic: Hand Trauma & Infection

Which of the following statements regarding extensor tendon injuries associated with fight bites is correct?

. A. Complete lacerations of extensor tendons should always be primarily repaired, even in an infected field.
. B. Extensor tendons are less susceptible to infection than flexor tendons due to better vascularity.
. C. Post-operative rehabilitation for extensor tendon repairs should avoid any joint motion for at least 6 weeks.
. D. Small, partial extensor tendon lacerations in an infected wound are best debrided and left open for delayed repair if needed.
. E. Extensor tendon injuries associated with fight bites rarely lead to functional deficits.

Correct Answer & Explanation

. D. Small, partial extensor tendon lacerations in an infected wound are best debrided and left open for delayed repair if needed.

Explanation

In an infected wound, small, partial extensor tendon lacerations are best managed by thorough debridement and leaving them open. Primary repair of any tendon in an infected field carries a very high risk of infection, adhesion, and rupture of the repair. Extensor tendons (A) are very susceptible to infection. While extensor tendons may be slightly less prone to catastrophic adhesion than flexor tendons, they can still become significantly affected. Extensor tendons can be significantly impacted by infection (B), and can lead to major functional deficits (E). Post-operative rehabilitation (C) is typically initiated early, often with controlled motion, not complete immobilization for 6 weeks, though specific protocols vary.

Question 3791

Topic: 7. Hand and Wrist

Which of the following is a key component of patient education following a fight bite injury to the hand, regardless of the severity?

. A. Reassurance that infection is unlikely if antibiotics are taken.
. B. Instruction on signs and symptoms of worsening infection and when to seek immediate medical attention.
. C. Encouragement of immediate full return to activity to prevent stiffness.
. D. Advising against reporting the incident to legal authorities.
. E. Recommendation for self-management with over-the-counter pain relievers only.

Correct Answer & Explanation

. B. Instruction on signs and symptoms of worsening infection and when to seek immediate medical attention.

Explanation

Patient education is crucial in all cases of human bite wounds. Patients must be thoroughly instructed on the signs and symptoms of worsening infection (increased pain, swelling, redness, fever, purulent discharge, functional loss) and unequivocally advised to seek immediate medical attention if any of these occur. Human bite wounds carry a high risk of complications, and infection can progress rapidly. Reassurance that infection is unlikely (A) is false and misleading. Full return to activity (C) is inappropriate for an infected or recovering hand. Advising against reporting (D) is unethical and outside the scope of medical advice. Self-management (E) is insufficient and dangerous.

Question 3792

Topic: 7. Hand and Wrist

A patient presents with a deep fight bite to the hand. During surgical debridement, a small, smooth, hard, white object is removed. After removing it, copious irrigation is performed, and the wound is left open. The object is sent for pathological analysis. What specific element of oral flora is particularly important to cover with antibiotics in this scenario, assuming the object was a tooth fragment?

. A. MRSA
. B. Pseudomonas aeruginosa
. C. Eikenella corrodens
. D. Clostridium difficile
. E. Candida albicans

Correct Answer & Explanation

. C. Eikenella corrodens

Explanation

Eikenella corrodens is a fastidious Gram-negative facultative anaerobe that is a characteristic pathogen of human bite wounds, originating from oral flora. Its presence, especially in deep infections or those involving tooth fragments, necessitates appropriate antibiotic coverage. While MRSA (A) can be present, Eikenella is specifically pathognomonic for human bites. Pseudomonas (B) is more associated with water exposures. Clostridium difficile (D) is related to gut flora dysbiosis from antibiotics. Candida albicans (E) is a yeast, not a primary bacterial pathogen for acute fight bites.

Question 3793

Topic: 7. Hand and Wrist

What is the primary concern when considering early active range of motion for a hand affected by a resolved fight bite with a history of septic arthritis?

. A. Increased risk of re-infection.
. B. Development of joint stiffness and contractures.
. C. Exacerbation of systemic inflammatory response.
. D. Damage to collateral ligaments due to excessive force.
. E. Prolongation of antibiotic therapy.

Correct Answer & Explanation

. B. Development of joint stiffness and contractures.

Explanation

After resolution of a severe hand infection like septic arthritis, the primary concern and often the most challenging complication is the development of joint stiffness and contractures. Inflammation and subsequent fibrosis within the joint capsule and surrounding soft tissues can severely limit range of motion. Early, controlled active range of motion, once the infection is controlled and wound healing permits, is crucial to prevent these long-term functional deficits. While re-infection (A) is always a concern, it's managed by thorough debridement and antibiotics. Systemic response (C) should be resolving. Ligament damage (D) can occur but is secondary to stiffness. Prolongation of antibiotics (E) is generally determined by infection resolution, not motion.

Question 3794

Topic: 7. Hand and Wrist

Which of the following is most likely to be absent in a patient presenting with a 'fight bite' injury to the hand versus other hand lacerations?

. A. Pain
. B. Laceration
. C. History of an altercation or striking another person
. D. Swelling
. E. Tenderness

Correct Answer & Explanation

. C. History of an altercation or striking another person

Explanation

The defining characteristic of a 'fight bite' (also known as a clenched-fist injury) is the mechanism: the patient sustained the injury by striking another person's teeth with their clenched fist. Therefore, a history of an altercation or striking another person is essential for diagnosing a 'fight bite.' Pain, laceration, swelling, and tenderness are common findings in many types of hand lacerations and do not specifically distinguish a fight bite from other injuries.

Question 3795

Topic: 7. Hand and Wrist

When evaluating a fight bite over the MCP joint, what specific maneuver should be performed to assess for potential joint capsule penetration by the wound tract?

. A. Gentle palpation of the wound margins.
. B. Assessment of neurovascular status distal to the wound.
. C. Flexing the digit to align the skin wound with the underlying joint capsule defect, then probing or irrigating.
. D. Applying a tourniquet and observing for pulsatile bleeding.
. E. Performing a Tinel's sign over the wound.

Correct Answer & Explanation

. C. Flexing the digit to align the skin wound with the underlying joint capsule defect, then probing or irrigating.

Explanation

To assess for potential joint capsule penetration in a fight bite, the digit should be flexed to the position of injury (typically 70-90 degrees flexion at the MCP joint). This maneuver realigns the skin wound with the underlying joint capsule defect, which was created when the hand was clenched. In this position, the wound tract can be carefully probed or irrigated (e.g., with saline and observation for fluid efflux from the joint) to determine if the joint capsule has been violated. Palpation (A), neurovascular assessment (B), tourniquet (D), and Tinel's sign (E) are important parts of a hand exam but do not specifically assess joint capsule penetration.

Question 3796

Topic: 7. Hand and Wrist

What is the main advantage of delayed primary closure over immediate primary closure for a contaminated hand wound from a human bite?

. A. Reduced need for antibiotics.
. B. Better cosmetic outcome.
. C. Allows for drainage and reduced risk of deep infection.
. D. Faster healing time.
. E. Less painful for the patient.

Correct Answer & Explanation

. C. Allows for drainage and reduced risk of deep infection.

Explanation

Delayed primary closure involves leaving a contaminated wound open for several days, allowing for drainage and close monitoring for signs of infection, before proceeding with formal closure if the wound appears clean. This strategy significantly reduces the risk of trapping bacteria and developing deep-seated infections or abscesses, which can occur with immediate primary closure of a contaminated wound. It does not necessarily reduce the need for antibiotics (A), lead to a better cosmetic outcome (B, often worse), or faster healing (D). Pain (E) is subjective and not the primary driver for this decision.

Question 3797

Topic: 7. Hand and Wrist

Which of the following complications is most likely to result in permanent functional impairment following a severe, neglected fight bite infection of the hand?

. A. Mild cellulitis
. B. Superficial skin scarring
. C. Septic arthritis leading to irreversible joint destruction
. D. Localized nerve paresthesia
. E. Transient lymphangitis

Correct Answer & Explanation

. C. Septic arthritis leading to irreversible joint destruction

Explanation

Severe, neglected fight bite infections can lead to septic arthritis, which, if untreated or inadequately treated, can rapidly destroy articular cartilage and subchondral bone, resulting in irreversible joint destruction, ankylosis, and significant permanent functional impairment. Mild cellulitis (A), superficial scarring (B), localized nerve paresthesia (D), and transient lymphangitis (E) are generally less severe and less likely to cause permanent, significant functional loss.

Question 3798

Topic: 7. Hand and Wrist

A patient with a fight bite requires surgical exploration. Which type of regional anesthesia is generally preferred for hand surgery, assuming no contraindications?

. A. General anesthesia
. B. Wrist block
. C. Axillary block
. D. Bier block (intravenous regional anesthesia)
. E. Digital block

Correct Answer & Explanation

. C. Axillary block

Explanation

For hand surgery, including fight bite exploration, an axillary block is often the preferred regional anesthesia technique. It provides excellent anesthesia and muscle relaxation for the entire hand and often a portion of the forearm, without the need for a tourniquet on the upper arm if performed appropriately with long-acting agents. Wrist blocks (B) provide anesthesia distal to the wrist but may not provide adequate muscle relaxation or cover the proximal forearm if needed. A Bier block (D) requires a tourniquet, limiting duration, and is usually reserved for shorter procedures. Digital blocks (E) are too localized. General anesthesia (A) is also an option but carries higher systemic risks and is often avoided if regional anesthesia is feasible.

Question 3799

Topic: 7. Hand and Wrist

A 35-year-old patient with a fight bite over the fifth MCP joint presents with a positive 'lag' in active extension of the little finger, but full passive extension. This indicates injury to the:

. A. Flexor digitorum profundus tendon
. B. Lumbrical muscles
. C. Extensor digitorum communis tendon
. D. Ulnar nerve
. E. Flexor digitorum superficialis tendon

Correct Answer & Explanation

. C. Extensor digitorum communis tendon

Explanation

A positive 'lag' in active extension (inability to actively extend the digit fully) with preserved full passive extension is a classic sign of extensor tendon injury, in this case, the extensor digitorum communis tendon to the little finger. If the passive range of motion is full but active is limited, it implies a disruption of the motor unit (tendon or muscle), not a fixed contracture or severe joint issue. Flexor tendons (A, E) are involved in flexion. Lumbricals (B) contribute to MCP flexion and IP extension. Ulnar nerve injury (D) would cause weakness of intrinsic muscles and sensory changes, not typically an isolated extensor lag in this specific context.

Question 3800

Topic: 7. Hand and Wrist

A 50-year-old male with a history of intravenous drug use presents with a fight bite to his hand. What additional infectious disease screening should be considered in this patient population?

. A. Malaria and Dengue Fever
. B. Hepatitis B, Hepatitis C, and HIV
. C. Tuberculosis and Legionnaires' disease
. D. Lyme disease and Rocky Mountain Spotted Fever
. E. Chlamydia and Gonorrhea

Correct Answer & Explanation

. B. Hepatitis B, Hepatitis C, and HIV

Explanation

Patients with a history of intravenous drug use are at higher risk for blood-borne viral infections. Therefore, screening for Hepatitis B, Hepatitis C, and HIV should be considered, especially if the source individual's status is unknown or if there's any concern for transmission through blood exposure in the altercation. The other options (A, C, D, E) are not specifically linked to IV drug use or human bites in this context.

Test Yourself

Switch to an interactive, timed exam simulation to truly master this topic.

On this Page