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7. Hand and Wrist MCQs

Practice Set 23 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 441

Topic: 7. Hand and Wrist

Which of the following physical examination findings is most specific for identifying a scapholunate interosseous ligament tear in the setting of acute wrist trauma?

. Pain with resisted wrist extension
. Positive Watson shift test
. Tenderness over the anatomic snuffbox
. Pain with ulnar deviation and thumb flexion
. Inability to forcefully pinch

Correct Answer & Explanation

. Positive Watson shift test

Explanation

The Watson scaphoid shift test evaluates the integrity of the scapholunate ligament. A palpable 'clunk' and pain as the scaphoid subluxates dorsally over the radial rim indicates SL ligament incompetence.

Question 442

Topic: 7. Hand and Wrist

During the surgical management of a 'fight bite' complicated by a septic 3rd MCP joint, what is the recommended surgical approach to adequately wash out the joint while preserving extensor mechanics?

. Transverse incision directly through the extensor tendon
. Volar approach through the A1 pulley
. Dorsal longitudinal approach splitting the sagittal band lateral to the central slip
. Mid-lateral approach dividing the collateral ligaments
. Dorsal transverse approach dividing the distal extensor hood

Correct Answer & Explanation

. Dorsal longitudinal approach splitting the sagittal band lateral to the central slip

Explanation

A dorsal longitudinal approach allows extension of the traumatic wound. Splitting the sagittal band laterally allows access to the MCP joint without disrupting the central extensor slip, facilitating thorough debridement.

Question 443

Topic: Nerve & Tendon

A 20-year-old collegiate baseball player sustains a hook of the hamate fracture. Nonoperative management has failed. During surgical excision of the hook, which nerve is at greatest risk of iatrogenic injury?

. Superficial branch of the radial nerve
. Recurrent motor branch of the median nerve
. Deep motor branch of the ulnar nerve
. Superficial sensory branch of the ulnar nerve
. Palmar cutaneous branch of the median nerve

Correct Answer & Explanation

. Deep motor branch of the ulnar nerve

Explanation

The deep motor branch of the ulnar nerve curves directly around the distal aspect of the hook of the hamate. It is highly susceptible to injury during excision of the hamate hook.

Question 444

Topic: 7. Hand and Wrist

Which of the following characteristics accurately describes the dominant blood supply to the scaphoid, explaining its propensity for proximal pole avascular necrosis?

. Volar carpal branch of the radial artery entering distally with retrograde flow
. Dorsal carpal branch of the radial artery entering distally with retrograde flow
. Direct branches of the ulnar artery entering proximally
. Anterior interosseous artery entering centrally
. Dorsal branch of the ulnar artery with antegrade flow

Correct Answer & Explanation

. Dorsal carpal branch of the radial artery entering distally with retrograde flow

Explanation

Approximately 70-80% of the scaphoid's blood supply comes from the dorsal carpal branch of the radial artery, which enters the dorsal ridge distally and flows in a retrograde fashion to the proximal pole.

Question 445

Topic: 7. Hand and Wrist

A 30-year-old male sustains a severe hyperextension wrist injury. Radiographs reveal a Mayfield Stage IV perilunate dislocation. What is the defining anatomical feature of this specific stage?

. Scapholunate dissociation only
. Dorsal dislocation of the capitate
. Lunotriquetral ligament disruption without lunate dislocation
. Complete volar dislocation of the lunate into the carpal tunnel
. Volar dislocation of the entire carpus

Correct Answer & Explanation

. Complete volar dislocation of the lunate into the carpal tunnel

Explanation

In Mayfield's progressive stages of perilunate instability, Stage IV is characterized by the complete volar dislocation of the lunate into the carpal tunnel, often causing acute median neuropathy.

Question 446

Topic: 7. Hand and Wrist

A 19-year-old falls on an outstretched hand and has persistent anatomic snuffbox tenderness. Initial plain radiographs are negative for fracture. What is the most appropriate and sensitive next step for definitive early diagnosis?

. Repeat plain radiographs in 2 weeks while immobilized
. Bone scintigraphy (bone scan)
. Magnetic Resonance Imaging (MRI) without contrast
. Computed Tomography (CT) arthrogram
. Diagnostic ultrasound

Correct Answer & Explanation

. Magnetic Resonance Imaging (MRI) without contrast

Explanation

MRI is the gold standard for diagnosing occult scaphoid fractures acutely, possessing a sensitivity and specificity approaching 100%. It enables immediate diagnosis and avoids unnecessary prolonged casting.

Question 447

Topic: 7. Hand and Wrist

In a Bennett fracture-dislocation, which specific ligament remains attached to the volar ulnar marginal fragment, keeping it anatomically positioned in the trapeziometacarpal joint?

. Dorsal radial ligament
. Anterior oblique ligament
. Intermetacarpal ligament
. Posterior oblique ligament
. Ulnar collateral ligament

Correct Answer & Explanation

. Anterior oblique ligament

Explanation

The anterior oblique ligament (AOL) securely holds the small volar ulnar fragment to the trapezium, while the abductor pollicis longus (APL) pulls the metacarpal shaft proximally and radially.

Question 448

Topic: 7. Hand and Wrist
A patient with stage III SNAC wrist presents for salvage surgery. A proximal row carpectomy (PRC) is considered. Which of the following radiographic findings represents an absolute contraindication to a PRC?
. Arthrosis of the radioscaphoid joint
. Arthrosis of the scaphocapitate joint
. Arthrosis of the capitate head
. Dorsal intercalated segment instability (DISI)
. Nonunion of the scaphoid waist

Correct Answer & Explanation

. Arthrosis of the capitate head

Explanation

Proximal row carpectomy relies on the articulation between the capitate head and the lunate fossa of the radius. If the capitate head is arthritic (common in advanced SNAC III), PRC is contraindicated, and 4-corner fusion is preferred.

Question 449

Topic: 7. Hand and Wrist

Which of the following factors represents the primary indication for surgical exploration and washout in a human 'fight bite' to the hand?

. Laceration length greater than 3 cm
. Involvement of the non-dominant hand
. Presence of an extensor tendon laceration or joint penetration
. Presentation within 6 hours of injury
. Associated metacarpal shaft fracture without intra-articular extension

Correct Answer & Explanation

. Presence of an extensor tendon laceration or joint penetration

Explanation

Joint penetration and extensor tendon involvement are definitive indications for surgical debridement and washout in fight bites due to the extremely high risk of deep space infection and septic arthritis.

Question 450

Topic: Hand Trauma & Infection

A patient with an untreated fight bite develops progressive swelling and severe pain out of proportion over the palmar aspect of the affected finger, extending to the proximal palm. Which of the following physical signs indicates a pyogenic flexor tenosynovitis?

. Pain with active flexion only
. Tenderness isolated to the metacarpal head
. Pain with passive extension of the digit
. Erythema confined to the dorsal web space
. A palpable thrill over the flexor tendon

Correct Answer & Explanation

. Pain with passive extension of the digit

Explanation

Pain with passive extension is one of Kanavel's four cardinal signs of pyogenic flexor tenosynovitis. The others are fusiform swelling, flexed resting posture, and tenderness along the flexor tendon sheath.

Question 451

Topic: 7. Hand and Wrist

In a trans-scaphoid perilunate fracture-dislocation, failure to anatomically reduce and fix the scaphoid fracture is most likely to result in which of the following long-term complications?

. Volar intercalated segment instability (VISI)
. Ulnar impaction syndrome
. Carpal tunnel syndrome
. Scaphoid nonunion and progressive carpal collapse (SNAC)
. Isolated radioulnar joint arthrosis

Correct Answer & Explanation

. Scaphoid nonunion and progressive carpal collapse (SNAC)

Explanation

Failure to anatomically reduce a trans-scaphoid perilunate dislocation inevitably leads to scaphoid nonunion. This disrupts the carpal column biomechanics, progressing rapidly to Scaphoid Nonunion Advanced Collapse (SNAC).

Question 452

Topic: Hand Trauma & Infection

A 25-year-old male sustains a "fight bite" over the 3rd metacarpophalangeal (MCP) joint. He presents 12 hours post-injury with early signs of infection. If surgical washout is not immediately indicated for joint penetration, what is the most appropriate empiric oral antibiotic therapy?

. Cephalexin
. Clindamycin
. Amoxicillin-clavulanate
. Ciprofloxacin
. Doxycycline

Correct Answer & Explanation

. Amoxicillin-clavulanate

Explanation

Amoxicillin-clavulanate provides excellent coverage for Eikenella corrodens, Staphylococcus, and Streptococcus species typical of human bites. Eikenella is classically resistant to first-generation cephalosporins and clindamycin.

Question 453

Topic: 7. Hand and Wrist

A 22-year-old athlete falls onto an outstretched hand and complains of anatomic snuffbox tenderness. Initial standard radiographs are negative. What is the most appropriate next step in management if he wishes to return to play as safely and quickly as possible?

. Discharge with NSAIDs and buddy taping
. Place in a short-arm cast and obtain a bone scan in 3 weeks
. Obtain an MRI of the wrist to definitively rule out a fracture
. Obtain a CT scan of the wrist in 4 weeks
. Reassure the patient and allow immediate return to play

Correct Answer & Explanation

. Obtain an MRI of the wrist to definitively rule out a fracture

Explanation

MRI is the gold standard for diagnosing occult scaphoid fractures due to its near 100% sensitivity and specificity. Early MRI prevents unnecessary prolonged casting in athletes with mere sprains and ensures timely treatment for true fractures.

Question 454

Topic: 7. Hand and Wrist

In a patient with Scaphoid Nonunion Advanced Collapse (SNAC), which of the following joints is characteristically spared from early degenerative changes?

. Radioscaphoid joint
. Capitolunate joint
. Radiolunate joint
. Scaphocapitate joint
. Trapeziometacarpal joint

Correct Answer & Explanation

. Radiolunate joint

Explanation

In both SNAC and SLAC wrist arthritis, the radiolunate joint is characteristically spared. This preservation allows for carpal salvage procedures like a proximal row carpectomy or four-corner fusion.

Question 455

Topic: 7. Hand and Wrist

A 30-year-old male presents with a displaced proximal pole scaphoid fracture. Operative fixation with a headless compression screw is planned. Which of the following surgical approaches is most appropriate?

. Volar approach of Russe
. Dorsal approach to the wrist
. Lateral approach through the anatomical snuffbox
. Minimally invasive volar percutaneous approach
. Carpal tunnel approach

Correct Answer & Explanation

. Dorsal approach to the wrist

Explanation

The dorsal approach is preferred for proximal pole scaphoid fractures. It allows direct visualization of the proximal pole, ensures central screw placement, and avoids disrupting the vital volar radiocarpal ligaments.

Question 456

Topic: 7. Hand and Wrist

A 28-year-old male sustains a Bennett fracture. Which of the following structures is the primary deforming force responsible for the proximal and dorsal displacement of the main metacarpal shaft fragment?

. Extensor pollicis brevis
. Extensor pollicis longus
. Abductor pollicis longus
. Adductor pollicis
. Flexor pollicis longus

Correct Answer & Explanation

. Abductor pollicis longus

Explanation

In a Bennett fracture, the abductor pollicis longus (APL) pulls the metacarpal shaft proximally and dorsally. The volar ulnar base fragment remains anatomically located, held by the strong anterior oblique ligament.

Question 457

Topic: 7. Hand and Wrist

A 40-year-old male presents with a massively swollen wrist after a high-energy motorcycle crash. Radiographs demonstrate a perilunate dislocation. Which of the following neurological deficits is most commonly associated with this specific injury pattern?

. Loss of sensation over the dorsal first web space
. Weakness of finger abduction and adduction
. Numbness in the volar radial three-and-a-half digits
. Inability to actively extend the IP joint of the thumb
. Clawing of the ring and small fingers

Correct Answer & Explanation

. Numbness in the volar radial three-and-a-half digits

Explanation

Acute median nerve neuropathy (carpal tunnel syndrome) is the most common neurologic complication associated with lunate and perilunate dislocations. Symptoms include numbness, tingling, or pain in the volar radial three-and-a-half digits.

Question 458

Topic: 7. Hand and Wrist
A 55-year-old manual laborer with Stage III SLAC wrist (involving the radioscaphoid and capitolunate joints) is being evaluated for salvage surgery. Which of the following procedures is contraindicated in this patient?
. Scaphoid excision and four-corner fusion
. Total wrist arthrodesis
. Proximal row carpectomy (PRC)
. Denervation of the wrist
. Total wrist arthroplasty

Correct Answer & Explanation

. Proximal row carpectomy (PRC)

Explanation

Proximal row carpectomy (PRC) relies on a preserved, cartilage-covered proximal capitate to articulate with the lunate fossa of the radius. In Stage III SLAC wrist, capitolunate arthritis is present, making PRC contraindicated.

Question 459

Topic: 7. Hand and Wrist

A 24-year-old male punches a wall and sustains a closed, isolated fracture of the fifth metacarpal neck (Boxer's fracture). There is no rotational deformity. What is the maximum acceptable degree of volar angulation for this specific fracture before reduction is definitively required to prevent functional deficits?

. 10 degrees
. 20 degrees
. 30 degrees
. 40 to 50 degrees
. 70 degrees

Correct Answer & Explanation

. 40 to 50 degrees

Explanation

The carpometacarpal joint of the small finger has significant compensatory mobility in the sagittal plane. Therefore, volar angulation of up to 40 to 50 degrees is generally well tolerated in 5th metacarpal neck fractures without causing symptomatic pseudo-clawing.

Question 460

Topic: 7. Hand and Wrist

Which of the following microbiological characteristics is true regarding the most common fastidious gram-negative rod associated with "fight bites" to the hand?

. It is an obligate anaerobe that produces gas in tissues.
. It is highly susceptible to first-generation cephalosporins.
. It often requires incubation in a carbon dioxide-enriched environment to grow.
. It causes massive tissue necrosis similar to clostridial myonecrosis.
. It primarily infects via hematogenous seeding rather than direct inoculation.

Correct Answer & Explanation

. It often requires incubation in a carbon dioxide-enriched environment to grow.

Explanation

Eikenella corrodens is a fastidious, facultatively anaerobic gram-negative rod that is capnophilic (requires a CO2-enriched environment for optimal growth). It is classically associated with human bite wounds and is resistant to clindamycin and first-generation cephalosporins.

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