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7. Hand and Wrist MCQs

Practice Set 206 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 4101

Topic: Wrist & Carpus

A 65-year-old female presents with a volar shear fracture of the distal radius (volar Barton fracture). Which of the following is the most appropriate surgical approach and internal fixation method?

. Dorsal approach with a dorsal spanning plate
. Volar approach with a volar buttress plate
. Volar approach with a dorsal tension band
. Dorsal approach with percutaneous pinning
. Mini-open approach with a Herbert screw

Correct Answer & Explanation

. Dorsal approach with a dorsal spanning plate

Explanation

A volar Barton fracture is an unstable intra-articular shear fracture of the distal radius. It cannot be adequately held by cast immobilization due to shear forces. The standard of care is a volar approach and fixation with a volar buttress plate (or volar locking plate applied in a buttress mode) to counteract the palmar subluxation of the carpus.

Question 4102

Topic: 7. Hand and Wrist

A 28-year-old male gymnast complains of chronic central wrist pain following a fall on an extended wrist 3 months ago. Radiographs show a widened scapholunate interval (Terry Thomas sign). The scapholunate interosseous ligament (SLIL) has three distinct regions. Which region is the primary mechanical stabilizer of the scapholunate joint?

. Volar region
. Dorsal region
. Proximal membranous region
. Radial collateral region
. Ulnocarpal region

Correct Answer & Explanation

. Volar region

Explanation

The scapholunate interosseous ligament (SLIL) is a C-shaped structure divided into dorsal, volar, and proximal membranous bands. Biomechanical studies have shown that the dorsal band is the thickest and strongest, acting as the primary mechanical stabilizer of the scapholunate articulation.

Question 4103

Topic: Wrist & Carpus

A 55-year-old female undergoes volar locking plate fixation for a displaced intra-articular distal radius fracture. Six months postoperatively, she returns complaining of a sudden inability to actively flex the interphalangeal joint of her thumb. This complication is most closely associated with which of the following surgical technique errors?

. Placement of the volar plate distal to the watershed line
. Placement of the volar plate proximal to the pronator quadratus
. Intra-articular screw penetration of the radiocarpal joint
. Dorsal screw protrusion past the dorsal cortex
. Inadequate restoration of radial inclination

Correct Answer & Explanation

. Placement of the volar plate distal to the watershed line

Explanation

The inability to actively flex the thumb IP joint indicates a rupture of the flexor pollicis longus (FPL) tendon. In the setting of a prior volar plate for a distal radius fracture, FPL rupture is a known complication associated with plate prominence. When the plate is placed distal to the 'watershed line' (a transverse ridge on the volar distal radius), the prominent distal edge of the hardware causes mechanical attrition and eventual rupture of the FPL tendon.

Question 4104

Topic: 7. Hand and Wrist

A 65-year-old female presents with the inability to actively flex her thumb interphalangeal joint 6 months after open reduction and internal fixation of a distal radius fracture with a volar locking plate. What is the most likely etiology of her new deficit?

. Delayed anterior interosseous nerve (AIN) palsy.
. Flexor pollicis longus (FPL) tendon rupture.
. Adhesion of the flexor digitorum profundus (FDP) to the plate.
. Post-operative carpal tunnel syndrome.
. Nonunion of the distal radius causing dynamic impingement.

Correct Answer & Explanation

. Delayed anterior interosseous nerve (AIN) palsy.

Explanation

FPL rupture is a known complication of volar plating of the distal radius, typically occurring when the plate is placed distal to the watershed line, causing mechanical attrition of the tendon.

Question 4105

Topic: 7. Hand and Wrist

Which of the following fluoroscopic views is used to assess

intra-articular screw penetration during volar fixation of a distal radius fracture?



. Dorsal skyline view
. AP wrist view
. PA wrist view
. 23° elevated lateral view
. 45° oblique lateral view

Correct Answer & Explanation

. Dorsal skyline view

Explanation

Due to radial inclination, a true lateral view of the wrist will not show whether screws from a volar plate are intra-articular; a 23° elevated lateral view is needed to adequately assess this.The amount of elevation will depend on the degree to which the surgeon restores radial inclination; for example, if the surgeon only restores 15° of radial inclination, then the surgeon would only have to elevate the wrist 15° from a true lateral in order to have the radiographic beam point down the joint line. Failure to diagnose intra-articular screws intraoperatively can lead to degenerative changes.Tweet et al. performed a survey of orthopedic surgeons regarding their preferred method of visualizing screw placement during wrist fixation. The majority of surgeons reported that they obtain multiple views, including AP/PA wrist views, a 23° lateral inclination view, and a true lateral view. They also performed a cadaveric study looking at different x-ray views and screw penetration. They reported that live rotational fluoroscopy provided the highest sensitivity (93%) and specificity (96%) for the detection of intra-articular screw penetration.Patel et al. evaluated the ability of surgeons at different levels to critically assess distal radius fixation and screw placement. They found that supplementation with a 23° lateral view increased accuracy and confidence in all position, specialty, and experience groups. Confidence scores were significantly higher following the evaluation of three views versus two views. Residents exhibited the greatest improvements in accuracy and confidence. For first-phase (standard view) assessments, accuracy scores were significantly better for attendings with less than 10 years of post-fellowship experience than those with more.Illustration A is a non-elevated lateral of the wrist, while illustration B is a 23° elevated lateral radiograph. Illustration C is an example of a skyline view, which assesses for screws penetrating the dorsal cortex.Incorrect Answers:Answer 1: The dorsal skyline view shows dorsal screw length and is useful tocheck for long distal screws.Answers 2 and 3: The AP and PA wrist views do not show intra-articular screw penetration due to the volar tilt and concavity of the joint.Answer 5: A 45° oblique lateral view does not visualize the joint as this angle does not match the radial inclination.

Question 4106

Topic: 7. Hand and Wrist

A newborn male is noted to have complete simple syndactyly of the right thumb and index finger, as well as the long and ring fingers. No other congenital anomalies are present. Which of the following is the most appropriate surgical timing and strategy?

. Release all involved digits simultaneously at 18 months
. Release the long/ring syndactyly at 6 months and thumb/index at 18 months
. Release the thumb/index syndactyly at 6 months and long/ring at 12-18 months
. Release both syndactylies simultaneously at 6 months
. Delay all releases until age 3 years to minimize anesthesia risks

Correct Answer & Explanation

. Release all involved digits simultaneously at 18 months

Explanation

Syndactyly of 'border digits' (thumb-index, and ring-small) involves digits with significantly different lengths and growth rates. Failure to release these early leads to tethering and progressive angular deformity. Therefore, border digit syndactyly should be released early, typically at 6 months of age. Syndactyly of central digits (long-ring) involves digits that grow at more similar rates; these can be released later, typically between 12-18 months to allow structures to grow larger for easier reconstruction.

Question 4107

Topic: Nerve & Tendon
A 4-year-old child sustains a mildly displaced (<2mm) lateral condyle fracture of the humerus, which is treated non-operatively in a long arm cast. Three months later, radiographs reveal a frank nonunion of the lateral condyle. If left untreated, what late neurological complication is most characteristic of this condition?
. Anterior interosseous nerve palsy
. Tardy ulnar nerve palsy
. Radial nerve palsy
. Posterior interosseous nerve palsy
. Median nerve palsy

Correct Answer & Explanation

. Tardy ulnar nerve palsy

Explanation

Nonunion of a lateral condyle fracture typically results in progressive cubitus valgus deformity. Over time, the valgus deformity progressively stretches the ulnar nerve behind the medial epicondyle, leading to a delayed neuropathy known as 'tardy ulnar nerve palsy', which can present years or even decades after the initial injury.

Question 4108

Topic: Nerve & Tendon
A 5-year-old child sustains a minimally displaced (<2 mm) lateral condyle fracture of the humerus. If left completely untreated and progressing to a nonunion, what is the most likely long-term complication?
. Cubitus varus and tardy radial nerve palsy
. Cubitus valgus and tardy ulnar nerve palsy
. Cubitus varus and anterior interosseous nerve palsy
. Recurvatum deformity and median nerve palsy
. Radiocapitellar synostosis

Correct Answer & Explanation

. Cubitus valgus and tardy ulnar nerve palsy

Explanation

A nonunion of a lateral condyle fracture leads to progressive superior migration of the lateral condyle, resulting in a progressive cubitus valgus deformity. Over time, this stretches the ulnar nerve, classically leading to a tardy ulnar nerve palsy.

Question 4109

Topic: Wrist & Carpus

During a fluoroscopically assisted closed reduction of a distal radius fracture, the surgeon initially stands 1 meter away from the C-arm beam. If the surgeon steps back to a distance of 2 meters, the radiation exposure is altered by what factor according to the inverse square law?

. Reduced to 1/2 of the original exposure
. Reduced to 1/4 of the original exposure
. Reduced to 1/8 of the original exposure
. Reduced to 1/16 of the original exposure
. Remains unchanged due to scatter radiation

Correct Answer & Explanation

. Reduced to 1/2 of the original exposure

Explanation

The inverse square law states that the intensity of radiation is inversely proportional to the square of the distance from the source (Intensity = 1/d^2). Doubling the distance (from 1 meter to 2 meters) reduces the radiation exposure to 1/2^2, which is 1/4 of the original exposure.

Question 4110

Topic: Wrist & Carpus

A 45-year-old patient receives an axillary block using 0.5% bupivacaine for a distal radius fracture repair. Thirty minutes later, she develops perioral numbness, visual disturbances, muscle twitching, and subsequently progresses to ventricular fibrillation. What is the most appropriate initial specific antidote to administer?

. Intravenous dantrolene
. Intravenous calcium chloride
. Intravenous 20% lipid emulsion
. Intravenous flumazenil
. Intravenous physostigmine

Correct Answer & Explanation

. Intravenous dantrolene

Explanation

The patient is experiencing Local Anesthetic Systemic Toxicity (LAST), progressing from early CNS symptoms to catastrophic cardiovascular collapse. Bupivacaine is highly cardiotoxic. The first-line specific treatment for LAST is the administration of a 20% intravenous lipid emulsion, which acts as a 'lipid sink' to draw the highly lipophilic local anesthetic out of the myocardium and CNS tissues.

Question 4111

Topic: Nerve & Tendon

A 55-year-old female with long-standing rheumatoid arthritis presents with a finger deformity characterized by PIP joint hyperextension and DIP joint flexion.

What is the primary pathophysiologic event initiating this specific deformity?

. Attenuation of the central slip
. Volar plate laxity at the PIP joint
. Rupture of the flexor digitorum profundus
. Contracture of the terminal extensor tendon
. Subluxation of the lateral bands volarly

Correct Answer & Explanation

. Attenuation of the central slip

Explanation

Swan neck deformity is characterized by PIP hyperextension and DIP flexion. In RA, it often initiates from synovitis leading to volar plate laxity and PIP hyperextension, with secondary DIP flexion. Conversely, Boutonniere deformity starts with attenuation of the central slip, leading to volar subluxation of the lateral bands.

Question 4112

Topic: 7. Hand and Wrist

A 25-year-old carpenter sustained a laceration over the volar aspect of the proximal phalanx of his index finger. Physical examination reveals an inability to flex both the PIP and DIP joints. The injury is classified as being in Zone II.

Which of the following is true regarding repairs in this zone?

. Primary repair is contraindicated due to the 'no man's land' designation.
. The FDS should be excised to prevent adhesion formation.
. Both FDP and FDS should be repaired to optimize functional outcome.
. Only the FDP should be repaired; FDS is left unrepaired.
. A standard 2-strand repair provides enough strength for early active motion protocols.

Correct Answer & Explanation

. Primary repair is contraindicated due to the 'no man's land' designation.

Explanation

Historically considered 'no man's land,' Zone II flexor tendon injuries are now optimally managed with primary repair of both the FDS and FDP tendons when possible. Repairing both preserves the vincula, maintains blood supply, and improves tendon gliding. Early active motion protocols generally require at least a 4-strand core repair.

Question 4113

Topic: 7. Hand and Wrist

A 30-year-old male presents after a fist fight with thumb base pain. Radiographs reveal a two-part intra-articular fracture of the base of the first metacarpal with subluxation of the metacarpal shaft.

Which deforming forces are primarily responsible for the displacement of the metacarpal shaft in this injury pattern?

. Extensor pollicis longus and adductor pollicis
. Abductor pollicis longus and adductor pollicis
. Flexor pollicis longus and abductor pollicis brevis
. Extensor pollicis brevis and opponens pollicis
. Flexor carpi radialis and abductor pollicis longus

Correct Answer & Explanation

. Extensor pollicis longus and adductor pollicis

Explanation

This describes a Bennett fracture. The volar ulnar beak fragment is held in place by the anterior oblique ligament (volar beak ligament). The metacarpal shaft is displaced proximally, dorsally, and radially by the pull of the Abductor Pollicis Longus (APL), while the Adductor Pollicis (AP) pulls the metacarpal head ulnarly into the palm, resulting in supination.

Question 4114

Topic: 7. Hand and Wrist
A 40-year-old manual laborer presents with chronic wrist pain. Radiographs reveal a scaphoid nonunion with radioscaphoid arthritis and capitolunate arthritis, but the radiolunate joint is spared. Which stage of SNAC wrist does this represent, and what is the most appropriate surgical treatment?
. Stage I; Radial styloidectomy
. Stage II; Scaphoid excision and four-corner fusion
. Stage III; Scaphoid excision and four-corner fusion
. Stage III; Proximal row carpectomy
. Stage IV; Total wrist arthrodesis

Correct Answer & Explanation

. Stage III; Scaphoid excision and four-corner fusion

Explanation

SNAC staging: Stage I involves arthritis between the distal scaphoid fragment and the radial styloid. Stage II involves the entire radioscaphoid joint. Stage III involves the capitolunate joint. Stage IV involves the entire carpus, including the radiolunate joint. For Stage III, scaphoid excision and four-corner fusion is preferred. Proximal row carpectomy (PRC) is contraindicated in Stage III because the capitate articular surface (which articulates with the lunate fossa in PRC) is arthritic.

Question 4115

Topic: Hand Trauma & Infection

A patient presents with a swollen, erythematous, and painful index finger 3 days after a puncture wound. Which of the following is considered the most sensitive and earliest, albeit least specific, of Kanavel's signs for pyogenic flexor tenosynovitis?

. Flexed posture of the digit
. Fusiform swelling of the digit
. Pain with passive extension of the digit
. Tenderness along the flexor tendon sheath
. Erythema extending to the palm

Correct Answer & Explanation

. Flexed posture of the digit

Explanation

Kanavel's four cardinal signs of pyogenic flexor tenosynovitis are: 1) flexed posture of the digit, 2) fusiform swelling, 3) tenderness along the flexor sheath, and 4) pain with passive extension. Pain with passive extension is typically the earliest and most sensitive sign, although it may be the least specific.

Question 4116

Topic: 7. Hand and Wrist

A 52-year-old male presents with wrist pain. Radiographs show scapholunate dissociation with associated radiocarpal and midcarpal arthritis. The radiolunate joint is notably preserved.

Why is the radiolunate joint typically spared in SLAC wrist?

. The lunate has a separate blood supply from the scaphoid.
. The spherical shape of the lunate allows it to concentrically articulate with the lunate fossa despite abnormal kinematics.
. The radiolunate ligament is the strongest ligament in the wrist.
. The scaphoid absorbs all the axial loading forces from the radius.
. The lunate remains firmly attached to the capitate, sharing the load.

Correct Answer & Explanation

. The lunate has a separate blood supply from the scaphoid.

Explanation

In SLAC wrist, the abnormal kinematics caused by scapholunate ligament rupture lead to arthritis. The radiolunate joint is classically spared because the lunate's spherical shape allows it to remain congruous and concentrically rotate within the spherical lunate fossa of the radius, preventing edge-loading and cartilage wear, unlike the elliptical scaphoid in the elliptical scaphoid fossa.

Question 4117

Topic: 7. Hand and Wrist

Trigger finger typically involves constriction of the flexor tendon as it passes through which pulley?

. A1
. A2
. A3
. A4
. C1

Correct Answer & Explanation

. A1

Explanation

Trigger finger (stenosing tenosynovitis) is caused by a size mismatch between the flexor tendon (often a nodule on the tendon) and the first annular (A1) pulley at the level of the metacarpal head. Treatment consists of splinting, corticosteroid injections, or surgical release of the A1 pulley. Release of A2 or A4 should be avoided as they are critical for preventing tendon bowstringing.

Question 4118

Topic: 7. Hand and Wrist
A 28-year-old manual worker presents with dorsal wrist pain. X-rays show sclerosis of the lunate with no collapse. MRI confirms avascular necrosis of the lunate. Radiographs also demonstrate ulnar minus variance. Which of the following is the most appropriate initial surgical intervention for this patient (Lichtman Stage II)?
. Proximal row carpectomy
. Radial shortening osteotomy
. Scaphocapitate fusion
. Lunate excision and silastic replacement
. Total wrist arthrodesis

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

The patient has Kienböck's disease, Lichtman Stage II (sclerosis of the lunate, no collapse). In the setting of ulnar negative variance, joint-leveling procedures such as radial shortening osteotomy or ulnar lengthening are indicated to offload the lunate. Proximal row carpectomy or fusions are reserved for more advanced stages with carpal collapse and arthritis.

Question 4119

Topic: 7. Hand and Wrist

In congenital syndactyly, what is the most common anatomical web space involved?

. Thumb-index web space
. Index-long web space
. Long-ring web space
. Ring-small web space
. All web spaces are equally affected

Correct Answer & Explanation

. Thumb-index web space

Explanation

Congenital syndactyly most commonly involves the 3rd web space (between the long and ring fingers). It is followed in frequency by the 4th, 2nd, and 1st web spaces.

Question 4120

Topic: 7. Hand and Wrist

A 60-year-old female presents with pain at the base of her thumb, worsened by pinch grasp. A positive 'grind test' is elicited. Eaton-Littler classification on radiograph shows pantrapezial arthritis.

Which ligament attenuation is the primary initiator of thumb carpometacarpal (CMC) joint osteoarthritis?

. Dorsal radial ligament
. Anterior oblique ligament (beak ligament)
. Intermetacarpal ligament
. Ulnar collateral ligament
. Volar plate

Correct Answer & Explanation

. Dorsal radial ligament

Explanation

The anterior oblique ligament (AOL), also known as the volar beak ligament, provides primary stability to the thumb CMC joint. Attenuation or rupture of this ligament leads to dorsal and radial subluxation of the metacarpal on the trapezium, shifting contact stresses and precipitating osteoarthritis.

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