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7. Hand and Wrist MCQs

Practice Set 191 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 3801

Topic: Hand Trauma & Infection

After surgical debridement of a fight bite over the MCP joint, the wound is left open. The patient asks why it isn't being stitched closed. What is the best explanation?

. A. 'Closing the wound would be too painful for you.'
. B. 'Leaving it open allows for drainage and prevents trapping infection inside.'
. C. 'We are waiting for the plastic surgeon to close it cosmetically later.'
. D. 'It's a small wound, so sutures aren't necessary.'
. E. 'We need to see if it develops osteomyelitis before closing it.'

Correct Answer & Explanation

. B. 'Leaving it open allows for drainage and prevents trapping infection inside.'

Explanation

The most appropriate explanation for leaving a fight bite wound open after surgical debridement is that it allows for continuous drainage of any remaining bacteria or inflammatory exudates, thereby preventing the trapping of infection within the wound and reducing the risk of abscess formation or deeper spread. This approach prioritizes infection control over immediate cosmesis. Pain (A) is not the primary reason. While plastics may be involved later, infection control is paramount (C). Even small deep wounds are dangerous (D). Waiting to see osteomyelitis (E) before closing is an outcome, not a reason for initial wound management.

Question 3802

Topic: Hand Trauma & Infection

Which of the following scenarios in a fight bite patient would warrant a consultation with an infectious disease specialist?

. A. Routine wound requiring standard empiric antibiotics.
. B. Patient with no significant comorbidities and uncomplicated course.
. C. Failure to respond to initial appropriate empiric antibiotics, or unusual/resistant organisms identified.
. D. Superficial wound treated with oral antibiotics only.
. E. Patient requesting specific antibiotic recommendations.

Correct Answer & Explanation

. C. Failure to respond to initial appropriate empiric antibiotics, or unusual/resistant organisms identified.

Explanation

Consultation with an infectious disease specialist is warranted when a patient fails to respond to initial appropriate empiric antibiotic therapy, or if unusual or resistant organisms are identified in cultures. This suggests a need for specialized expertise in pathogen identification, antibiotic selection, and complex infection management. Routine cases (A, B, D) are typically managed by the orthopedic or emergency department team. Patient requests (E) do not, by themselves, warrant a subspecialty consult.

Question 3803

Topic: 7. Hand and Wrist

A fight bite wound over the fourth MCP joint results in septic arthritis. What is the long-term consequence of inadequate treatment of septic arthritis in the hand?

. A. Hypertrophic scarring
. B. Permanent joint stiffness and degenerative arthritis
. C. Increased sensation in the digit
. D. Chronic venous insufficiency
. E. Carpal tunnel syndrome

Correct Answer & Explanation

. B. Permanent joint stiffness and degenerative arthritis

Explanation

Inadequate treatment of septic arthritis in any joint, including the hand, can lead to severe and permanent long-term consequences. The most significant of these are irreversible destruction of articular cartilage and subchondral bone, resulting in permanent joint stiffness (ankylosis or reduced range of motion) and the development of post-infectious degenerative arthritis. Hypertrophic scarring (A) is a skin issue. Increased sensation (C) is unlikely. Chronic venous insufficiency (D) and carpal tunnel syndrome (E) are not direct long-term consequences of septic arthritis.

Question 3804

Topic: 7. Hand and Wrist

When is it appropriate to consider primary closure for a human bite wound on the hand?

. A. Always, to improve cosmetic outcome.
. B. Never, due to the high risk of infection.
. C. Only for very superficial lacerations, less than 6-8 hours old, with meticulous debridement, and no signs of deep penetration or infection.
. D. Only if the wound is deep but the patient insists on closure.
. E. After 7 days of IV antibiotics and observation.

Correct Answer & Explanation

. C. Only for very superficial lacerations, less than 6-8 hours old, with meticulous debridement, and no signs of deep penetration or infection.

Explanation

Primary closure of human bite wounds on the hand is generally discouraged due to the high risk of infection. However, in very select circumstances, it might be considered: for truly superficial lacerations (not 'fight bites' over joints), less than 6-8 hours old, after meticulous irrigation and debridement, and with absolutely no signs of deep penetration or infection. Even then, prophylactic antibiotics are indicated, and the patient must be reliable for close follow-up. 'Always' (A) or 'never' (B) are too absolute. Patient insistence (D) should not dictate medical judgment in an infected wound. After 7 days of IV antibiotics (E) would be delayed primary or secondary closure, not primary.

Question 3805

Topic: 7. Hand and Wrist

A patient sustained a fight bite to the hand. They have a known allergy to penicillin with a history of maculopapular rash. Which alternative oral antibiotic regimen for a mild, superficial infection might be appropriate?

. A. Azithromycin
. B. Ciprofloxacin
. C. Doxycycline
. D. Clindamycin plus Ciprofloxacin
. E. Cephalexin

Correct Answer & Explanation

. D. Clindamycin plus Ciprofloxacin

Explanation

For a penicillin allergy with a maculopapular rash, there is a lower (but still present) risk of cross-reactivity with cephalosporins like Cephalexin (E). However, for a human bite, especially one with potential deep inoculation, broader coverage than a single agent is often preferred. Clindamycin plus Ciprofloxacin (D) is a well-regarded alternative combination. Clindamycin covers anaerobes and Gram-positives, while Ciprofloxacin covers Gram-negatives including Eikenella. Azithromycin (A) and Doxycycline (C) do not provide consistent broad-spectrum coverage against the typical polymicrobial flora of human bites. Ciprofloxacin alone (B) lacks adequate anaerobic and Gram-positive coverage.

Question 3806

Topic: 7. Hand and Wrist

What type of imaging is best for detecting air in the joint or soft tissues in a hand infection, which might suggest gas-producing organisms or a communication with the outside environment?

. A. Ultrasound
. B. MRI
. C. Plain Radiographs
. D. Bone scan
. E. Arthrography

Correct Answer & Explanation

. C. Plain Radiographs

Explanation

Plain radiographs are surprisingly effective and often the initial imaging modality used to detect air (gas) in the joint or soft tissues. Gas appears as a dark lucency on X-ray films. While CT and MRI can also show gas, plain films are readily available, quick, and sufficient for this specific finding. Ultrasound (A) is good for fluid, not typically gas. MRI (B) is good for soft tissue and bone marrow edema but gas can cause artifacts. Bone scan (D) assesses metabolic activity. Arthrography (E) involves injecting contrast into a joint.

Question 3807

Topic: 7. Hand and Wrist

What is the primary goal of early hand therapy and rehabilitation after a fight bite infection has resolved?

. A. To strengthen grip muscles immediately.
. B. To prevent stiffness and restore range of motion.
. C. To reduce superficial scarring.
. D. To desensitize nerve injuries.
. E. To enhance antibiotic penetration.

Correct Answer & Explanation

. B. To prevent stiffness and restore range of motion.

Explanation

The primary goal of early hand therapy and rehabilitation after a severe hand infection has resolved is to prevent stiffness and restore range of motion. Prolonged immobilization and inflammation can lead to significant joint contractures and soft tissue adhesions, severely impacting hand function. Early, controlled motion (once the wound is stable and infection cleared) is crucial. Strengthening (A) comes later. Scarring (C) is a secondary concern. Desensitization (D) is for nerve injuries, not the primary goal for infection recovery. Enhancing antibiotic penetration (E) is irrelevant to rehab.

Question 3808

Topic: 7. Hand and Wrist

What is the typical presentation of acute extensor tenosynovitis in the hand?

. A. Pain along the volar aspect of the digit, with fusiform swelling.
. B. Tenderness and swelling over the dorsum of the hand, specifically along the course of the affected extensor tendon.
. C. Locking of the digit in flexion.
. D. Significant atrophy of intrinsic hand muscles.
. E. Paresthesias in the radial nerve distribution.

Correct Answer & Explanation

. B. Tenderness and swelling over the dorsum of the hand, specifically along the course of the affected extensor tendon.

Explanation

Acute extensor tenosynovitis typically presents with tenderness and swelling localized to the dorsum of the hand, specifically along the course of the affected extensor tendon. Pain with active and passive range of motion of the involved digit, particularly against resistance, is also common. Volar pain and fusiform swelling (A) are characteristic of flexor tenosynovitis. Locking of the digit (C) is seen in trigger finger. Atrophy (D) is a chronic change. Paresthesias (E) indicate nerve involvement.

Question 3809

Topic: Hand Trauma & Infection

For a patient with a confirmed Eikenella corrodens infection in a fight bite wound, which antibiotic is generally considered effective?

. A. Metronidazole
. B. Clindamycin
. C. Cefazolin
. D. Penicillin G
. E. Gentamicin

Correct Answer & Explanation

. D. Penicillin G

Explanation

Eikenella corrodens is typically sensitive to penicillin and ampicillin, as well as second and third-generation cephalosporins, tetracyclines, and fluoroquinolones. Metronidazole (A) has poor activity against Eikenella. Clindamycin (B) has variable activity against Eikenella and should not be relied upon as a sole agent. Cefazolin (C), a first-generation cephalosporin, generally covers Eikenella. Gentamicin (E) is an aminoglycoside which has limited activity against Eikenella and generally requires combination therapy. Penicillin G (D) is a good choice for confirmed Eikenella infection.

Question 3810

Topic: 7. Hand and Wrist

What is the role of continuous passive motion (CPM) machines in the post-operative management of fight bite infections?

. A. They are routinely used immediately after surgery to prevent adhesions.
. B. They are contraindicated due to the risk of re-infection.
. C. They can be considered for selected cases once the infection is controlled and wound stable, to aid in regaining joint mobility.
. D. They are only used for flexor tendon injuries, not extensor.
. E. They have no proven benefit in hand rehabilitation.

Correct Answer & Explanation

. C. They can be considered for selected cases once the infection is controlled and wound stable, to aid in regaining joint mobility.

Explanation

Continuous passive motion (CPM) machines can be a useful adjunct in post-operative rehabilitation for hand stiffness, including cases following resolved fight bite infections, particularly for regaining joint mobility. However, their use is not immediate or routine (A) and they are only considered once the acute infection is completely controlled, the wound is stable, and there is no risk of further infection or wound breakdown. They are not contraindicated by infection risk (B) if the infection is resolved. They can be used for both flexor and extensor issues (D), and they do have proven benefit in certain situations (E).

Question 3811

Topic: 7. Hand and Wrist

Which of the following is an anatomical consideration unique to fight bites over the MCP joint that contributes to the high rate of joint infection?

. A. The large number of nerves surrounding the joint.
. B. The thin skin and subcutaneous tissue directly over the joint capsule.
. C. The absence of lymphatic drainage in the dorsal hand.
. D. The presence of numerous large arteries in the area.
. E. The rich blood supply to the extensor tendons.

Correct Answer & Explanation

. B. The thin skin and subcutaneous tissue directly over the joint capsule.

Explanation

The thinness of the skin and subcutaneous tissue directly overlying the metacarpophalangeal (MCP) joint capsule, especially on the dorsal aspect, makes the joint highly vulnerable to penetration during a fight bite. This allows for direct inoculation of bacteria into the joint space with minimal overlying tissue protection. While nerves (A), lymphatics (C), arteries (D), and tendon blood supply (E) are anatomical considerations, the thin barrier directly to the joint capsule is critical for infection risk.

Question 3812

Topic: 7. Hand and Wrist

A fight bite over the MCP joint of the little finger presents with a full-thickness skin defect. After surgical debridement and antibiotic treatment, the wound is clean but cannot be closed primarily due to tissue loss. What is the most appropriate next step for definitive wound coverage?

. A. Allow it to heal by secondary intention, as it will close eventually.
. B. Apply a bulky dressing and refer for hand therapy.
. C. Perform skin grafting (split-thickness or full-thickness).
. D. Apply topical corticosteroids to reduce inflammation.
. E. Initiate vacuum-assisted closure (VAC) therapy as the definitive solution.

Correct Answer & Explanation

. C. Perform skin grafting (split-thickness or full-thickness).

Explanation

For a clean wound with a full-thickness skin defect after initial infection control, definitive wound coverage is necessary. Skin grafting (either split-thickness for larger defects or full-thickness for smaller, critical areas) is often the most appropriate solution to achieve durable coverage and facilitate rehabilitation. Healing by secondary intention (A) can lead to prolonged healing, poor cosmesis, and contractures, especially over joints. Bulky dressings and therapy (B) are part of post-op care, not definitive coverage. Corticosteroids (D) are contraindicated in healing wounds. VAC therapy (E) is used for wound bed preparation and can aid in closing complex wounds, but it's not the definitive coverage itself; it prepares for grafting or other closure.

Question 3813

Topic: Hand Trauma & Infection

Which of the following describes the potential impact of a 'fight bite' injury on the psychological well-being of the patient?

. A. Patients are typically unaffected psychologically, focusing only on physical recovery.
. B. There may be feelings of guilt, shame, anxiety, or post-traumatic stress, particularly given the circumstances of injury.
. C. Patients often develop a heightened sense of self-esteem due to surviving the altercation.
. D. The injury primarily affects memory and cognitive function.
. E. Long-term psychological effects are rare and insignificant.

Correct Answer & Explanation

. B. There may be feelings of guilt, shame, anxiety, or post-traumatic stress, particularly given the circumstances of injury.

Explanation

Fight bite injuries often occur in the context of altercations, violence, and sometimes substance abuse. Patients may experience significant psychological distress, including feelings of guilt, shame, anxiety, or even post-traumatic stress disorder (PTSD). The injury can be a source of social stigma and may affect personal relationships and employment. Therefore, considering the psychological impact and offering appropriate support or referral is an important aspect of holistic patient care. Patients are not typically unaffected (A), nor do they usually experience heightened self-esteem (C). Cognitive function (D) is not primarily affected. Psychological effects can be significant and long-lasting (E).

Question 3814

Topic: Hand Trauma & Infection

What is the recommended approach for debriding a necrotic extensor tendon in a fight bite wound?

. A. Extensive excision of all visible necrotic tendon up to healthy tissue.
. B. Gentle scraping of the tendon surface only.
. C. Application of enzymatic debridement agents.
. D. Leaving it in place to revascularize naturally.
. E. Repairing it immediately with a graft.

Correct Answer & Explanation

. A. Extensive excision of all visible necrotic tendon up to healthy tissue.

Explanation

When a tendon is necrotic in an infected field, extensive excision of all visible necrotic tendon up to healthy, bleeding tissue is crucial. Necrotic tissue serves as a nidus for infection and prevents healing. While this may result in a tendon defect, addressing the infection takes precedence. Gentle scraping (B) or enzymatic agents (C) are insufficient for significant necrosis in an infected field. Leaving it in place (D) will perpetuate the infection. Immediate repair with a graft (E) is contraindicated in an infected field due to high failure rates and risk of graft infection.

Question 3815

Topic: 7. Hand and Wrist

Which statement regarding follow-up care for a fight bite is most accurate?

. A. Patients only require a single follow-up visit if they feel better.
. B. Close, regular follow-up is essential to monitor for infection resolution, wound healing, and functional recovery.
. C. Follow-up is typically handled by general practitioners without specialist input.
. D. Once discharged from the hospital, no further medical attention is required.
. E. Follow-up consists solely of antibiotic refills.

Correct Answer & Explanation

. B. Close, regular follow-up is essential to monitor for infection resolution, wound healing, and functional recovery.

Explanation

Close, regular follow-up is absolutely essential for patients with fight bite injuries. These are serious, high-risk wounds requiring ongoing monitoring for signs of persistent or recurrent infection, assessment of wound healing progression, and evaluation of functional recovery. This often involves a multidisciplinary approach, including orthopedic surgeons, hand therapists, and potentially infectious disease specialists. A single visit (A) or no further attention (D) is irresponsible. While GPs may be involved, specialist input is usually needed (C). Follow-up encompasses much more than just antibiotic refills (E).

Question 3816

Topic: Wrist & Carpus

A 10-year-old child presents with a Galeazzi-type injury. Compared to adults, what is the most common management approach?

. Always requires ORIF of the radius and DRUJ stabilization
. External fixation is the preferred method
. Closed reduction and long arm cast immobilization are often successful
. Ulnar shortening osteotomy is typically performed
. Observation with close follow-up

Correct Answer & Explanation

. Closed reduction and long arm cast immobilization are often successful

Explanation

In children, due to greater remodeling potential and thicker periosteum, closed reduction of the radial fracture and subsequent cast immobilization (usually a long arm cast with the forearm in supination or neutral to stabilize the DRUJ) are often successful, provided anatomical reduction of the radial shaft and stability of the DRUJ can be achieved. ORIF is reserved for unstable or irreducible cases. This is a key difference from adult management.

Question 3817

Topic: Wrist & Carpus

Post-operatively for a Galeazzi fracture treated with ORIF, what is the primary goal of early rehabilitation regarding the DRUJ?

. Immediate full range of motion exercises for the DRUJ
. Maintaining forearm immobilization in full pronation
. Protecting the DRUJ while initiating forearm rotation only after pin removal (if used)
. Strengthening the wrist flexors to stabilize the DRUJ
. Applying continuous passive motion to the wrist and forearm

Correct Answer & Explanation

. Protecting the DRUJ while initiating forearm rotation only after pin removal (if used)

Explanation

The primary goal of early rehabilitation after Galeazzi ORIF, especially if the DRUJ was unstable and temporarily pinned, is to protect the DRUJ. This means maintaining forearm immobilization (typically in supination if pins were used for dorsal instability) until the pins are removed (usually 4-6 weeks) to allow capsuloligamentous healing. Initiating gentle, controlled forearm rotation begins only after pin removal and clinical assessment of DRUJ stability. Early aggressive motion could disrupt healing and lead to recurrent instability.

Question 3818

Topic: Wrist & Carpus

A patient with a Galeazzi malunion presents with chronic pain and limited forearm rotation. The radial shaft is shortened by 10mm. Which salvage procedure might be considered for the DRUJ pathology?

. Scaphoidectomy
. Trapezectomy
. Darrach procedure (ulnar head excision)
. Staple arthrodesis of the DRUJ
. Radial styloidectomy

Correct Answer & Explanation

. Darrach procedure (ulnar head excision)

Explanation

In cases of symptomatic Galeazzi malunion with radial shortening leading to painful positive ulnar variance and DRUJ pathology, a Darrach procedure (excision of the distal ulna or ulnar head) can be considered as a salvage procedure. This procedure aims to relieve impingement and restore forearm rotation by effectively creating a pseudoarthrosis at the DRUJ. Other options like Sauve-Kapandji (arthrodesis of DRUJ with pseudoarthrosis proximal to allow rotation) or ulnar shortening osteotomy (to correct ulnar variance) might also be considered depending on the specific deformity and patient factors.

Question 3819

Topic: Wrist & Carpus

Which ligament is considered the primary stabilizer of the distal radioulnar joint?

. Radial collateral ligament
. Ulnar collateral ligament
. Dorsal radioulnar ligament of the TFCC
. Palmar radioulnar ligament of the TFCC
. Scapholunate ligament

Correct Answer & Explanation

. Palmar radioulnar ligament of the TFCC

Explanation

The triangular fibrocartilage complex (TFCC) is the primary stabilizer of the DRUJ. Within the TFCC, both the dorsal and palmar (volar) radioulnar ligaments are critical. The palmar radioulnar ligament is the primary stabilizer in supination, and the dorsal radioulnar ligament is the primary stabilizer in pronation. However, generally, the anterior (volar) and posterior (dorsal) limbs are considered the main components providing stability. In the context of the choices, the Palmar radioulnar ligament of the TFCC is generally considered the stronger and most important stabilizer, especially against dorsal subluxation, as the DRUJ commonly dislocates dorsally in Galeazzi fractures with forearm pronation.

Question 3820

Topic: 7. Hand and Wrist

What is the characteristic clinical sign that suggests DRUJ instability, often referred to during physical examination?

. Finkelstein's test
. Phalen's maneuver
. Piano key sign
. Tinel's sign at the wrist
. Froment's sign

Correct Answer & Explanation

. Piano key sign

Explanation

The 'piano key sign' is a classic test for DRUJ instability. It involves pressing down on the ulnar head, which if unstable, will depress and spring back up like a piano key. This indicates laxity or disruption of the DRUJ stabilizers. Finkelstein's test is for De Quervain's tenosynovitis. Phalen's maneuver is for carpal tunnel syndrome. Tinel's sign assesses nerve irritation. Froment's sign is for ulnar nerve palsy.

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