Menu

7. Hand and Wrist MCQs

Practice Set 243 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 4841

Topic: Wrist & Carpus

A 25-year-old male sustains a diaphyseal fracture of the radius with associated distal radioulnar joint (DRUJ) dislocation. Following anatomic open reduction and internal fixation of the radius, the DRUJ remains grossly unstable in full supination. What is the most appropriate next step in management?

. Immobilization in a long arm cast in full supination for 6 weeks
. Open exploration of the DRUJ with primary repair of the triangular fibrocartilage complex
. Percutaneous trans-articular pinning of the DRUJ in neutral rotation
. Resection of the distal ulna (Darrach procedure)
. Distal ulnar shortening osteotomy

Correct Answer & Explanation

. Open exploration of the DRUJ with primary repair of the triangular fibrocartilage complex

Explanation

If the DRUJ is irreducible or remains grossly unstable after anatomic radius fixation in a Galeazzi fracture, an open approach to the DRUJ is required. This instability is often due to soft tissue interposition (such as the ECU tendon or capsule) and requires direct TFCC repair.

Question 4842

Topic: 7. Hand and Wrist

What is the primary function of the A1 pulley in the hand?

. To prevent bowstringing of the extensor tendons.
. To act as a fulcrum for the intrinsic muscles.
. To contain the flexor tendons and prevent bowstringing during finger flexion.
. To provide attachment for the lumbrical muscles.
. To limit hyperextension of the metacarpophalangeal joint.

Correct Answer & Explanation

. To contain the flexor tendons and prevent bowstringing during finger flexion.

Explanation

The A1 pulley is the most proximal of the annular pulleys in the finger. Its primary function is to hold the flexor tendons close to the bone (metacarpal or phalanx) and prevent bowstringing, thereby maintaining the mechanical efficiency of the flexor system during finger flexion. Dysfunction or inflammation of the A1 pulley is characteristic of trigger finger. The other options describe roles of different structures.

Question 4843

Topic: 7. Hand and Wrist

A 55-year-old seamstress complains of pain and swelling at the base of her thumb, worse with gripping and pinching. Physical examination reveals tenderness at the carpometacarpal (CMC) joint of the thumb and a positive grind test. Radiographs show advanced CMC joint osteoarthritis. What is the most effective surgical treatment for advanced symptomatic CMC joint osteoarthritis?

. Trapeziectomy with ligament reconstruction and tendon interposition (LRTI)
. CMC joint arthrodesis
. CMC joint arthroplasty (prosthetic replacement)
. Denervation of the CMC joint
. Corticosteroid injection

Correct Answer & Explanation

. Trapeziectomy with ligament reconstruction and tendon interposition (LRTI)

Explanation

For advanced, symptomatic osteoarthritis of the thumb carpometacarpal (CMC) joint that has failed conservative management, trapeziectomy with ligament reconstruction and tendon interposition (LRTI) is widely considered the most effective and gold standard surgical treatment. This procedure involves removing the painful trapezium and stabilizing the thumb metacarpal base, creating a space that fills with scar tissue or is occupied by a tendon interposition. Arthrodesis sacrifices motion, and prosthetic replacements have variable long-term success. Corticosteroid injections are conservative measures.

Question 4844

Topic: 7. Hand and Wrist

A 50-year-old female presents with numbness and tingling in her thumb, index, middle, and radial half of the ring finger, worse at night. Phalen's test is positive. What is the most common anatomical structure implicated in the compression causing these symptoms?

. Transverse carpal ligament
. Flexor retinaculum
. Median nerve within the carpal tunnel
. Ulnar nerve at Guyon's canal
. Radial nerve in the forearm

Correct Answer & Explanation

. Median nerve within the carpal tunnel

Explanation

This is a classic presentation of carpal tunnel syndrome, which is caused by compression of the median nerve as it passes through the carpal tunnel. While the transverse carpal ligament (also known as the flexor retinaculum) forms the roof of the carpal tunnel and is often the primary compressive structure, the question asks for the 'anatomical structure implicated in the compression,' which is ultimately the median nerve itself. Therefore, the most direct and precise answer is the median nerve within the carpal tunnel. The ulnar and radial nerves have different sensory distributions.

Question 4845

Topic: 7. Hand and Wrist

A 25-year-old male punches a wall and develops pain and swelling over the dorsal aspect of his small finger MCP joint. X-rays reveal a fracture at the neck of the 5th metacarpal with volar angulation of 40 degrees. What is the maximum acceptable volar angulation for a 5th metacarpal neck fracture that can typically be managed non-operatively in an active adult?

. 10 degrees
. 20 degrees
. 30 degrees
. 40 degrees
. 50 degrees

Correct Answer & Explanation

. 30 degrees

Explanation

For 5th metacarpal neck fractures (Boxer's fractures), the maximum acceptable volar angulation for non-operative management varies, but generally, 30 degrees is considered the upper limit in an active adult. While some surgeons may accept up to 40 degrees in the 5th metacarpal (more so than in the 2nd or 3rd due to greater intrinsic mobility of the 4th and 5th rays), angulation beyond 30 degrees can lead to a noticeable extensor lag, reduced grip strength, and a poorer cosmetic outcome. Therefore, 30 degrees represents a more conservative and often preferred threshold for surgical intervention.

Question 4846

Topic: 7. Hand and Wrist

A 30-year-old male presents with a 'drop wrist' deformity after falling asleep with his arm draped over a chair. He has weakness in wrist and finger extension but preserved sensation on the dorsum of the hand. Which nerve is most likely affected?

. Ulnar nerve at the elbow
. Median nerve at the wrist
. Radial nerve in the spiral groove of the humerus
. Anterior interosseous nerve
. Posterior interosseous nerve

Correct Answer & Explanation

. Radial nerve in the spiral groove of the humerus

Explanation

A 'drop wrist' deformity, characterized by weakness in wrist and finger extension, is a classic sign of radial nerve palsy. When the injury occurs at or above the spiral groove of the humerus (as with 'Saturday night palsy' from compression, often by draping the arm over a chair), it typically affects both the motor branches to the wrist/finger extensors and the sensory branch to the dorsum of the hand (superficial radial nerve). However, if sensation on the dorsum of the hand ispreserved, it indicates that the superficial radial nerve may have been spared or its sensory function is less affected, still pointing to a high radial nerve compression. If the posterior interosseous nerve (PIN) were affected, wrist extension would typically be preserved (due to sparing of ECRL/ECRB), but finger extension would be weak.

Question 4847

Topic: 7. Hand and Wrist

A 22-year-old amateur boxer punches a wall in frustration, sustaining a deformity and pain in his dominant right hand. Examination reveals swelling and tenderness over the fifth metacarpal head, with mild rotational deformity of the small finger. Radiographs show an angulated, irreducible fracture of the fifth metacarpal neck with dorsal angulation of 60 degrees. Which of the following is the most appropriate management?

. Closed reduction and ulnar gutter splinting
. Open reduction and internal fixation with K-wires
. Open reduction and internal fixation with a plate and screws
. Observation with immediate return to boxing activities
. Buddy taping to the ring finger

Correct Answer & Explanation

. Closed reduction and ulnar gutter splinting

Explanation

For an angulated, irreducible fifth metacarpal neck fracture (Boxer's fracture) with 60 degrees of dorsal angulation, closed reduction and ulnar gutter splinting is often the preferred initial treatment. The acceptable angulation for a fifth metacarpal neck fracture is typically up to 70 degrees due to the inherent mobility of the carpometacarpal joint. While 60 degrees is significant, it is often reducible, and stability can be achieved with an ulnar gutter splint. Surgical fixation (K-wires or plate) is reserved for unstable fractures, severe rotational deformity, or excessive angulation that cannot be reduced or maintained, especially in the fourth and fifth metacarpals, which tolerate more angulation than the second and third. Observation or buddy taping is insufficient for this degree of angulation and instability.

Question 4848

Topic: 7. Hand and Wrist

A 78-year-old female falls onto her outstretched left hand. She presents with severe pain, swelling, and a 'dinner fork' deformity of her left wrist. Radiographs show a dorsally displaced and angulated fracture of the distal radius with involvement of the articular surface. The fracture is comminuted with significant dorsal tilt and shortening. What is the most important factor in determining the need for surgical intervention for this fracture?

. Patient's age and activity level
. Type of mechanism of injury
. Degree of comminution
. Amount of dorsal tilt and radial shortening
. Presence of an associated ulnar styloid fracture

Correct Answer & Explanation

. Amount of dorsal tilt and radial shortening

Explanation

For distal radius fractures, the key radiographic parameters that dictate the need for surgical intervention are generally the amount of dorsal tilt (angulation), radial shortening, and articular step-off/gap. Significant dorsal angulation (e.g., >20 degrees), radial shortening (e.g., >3-5 mm), or articular step-off/gap (e.g., >2 mm) are indications for surgical stabilization, especially in active patients. While age and activity level are important in shared decision-making, these radiographic parameters are critical objective measures of fracture stability and potential for functional outcome. Comminution contributes to instability but the primary focus is on the resultant alignment. An associated ulnar styloid fracture is common but usually does not determine the need for distal radius surgery.

Question 4849

Topic: 7. Hand and Wrist

A 45-year-old female office worker presents with 6 months of worsening numbness and tingling in her right thumb, index, middle, and radial half of the ring finger, particularly at night. She reports dropping objects and difficulty with fine motor tasks. Physical examination reveals a positive Phalen's test and Tinel's sign at the wrist, and thenar atrophy. What is the most appropriate next step in management after failed conservative treatment (splinting, NSAIDs)?

. Electromyography (EMG) and nerve conduction studies (NCS)
. Cervical spine MRI
. Wrist MRI
. Corticosteroid injection into the carpal tunnel
. Surgical carpal tunnel release

Correct Answer & Explanation

. Corticosteroid injection into the carpal tunnel

Explanation

The patient's symptoms and signs are highly classic for Carpal Tunnel Syndrome (CTS). Given that conservative management (splinting, NSAIDs) has failed, a corticosteroid injection into the carpal tunnel is the next appropriate step. This provides diagnostic confirmation if symptoms improve and often provides significant, albeit temporary, relief, potentially delaying or obviating surgery. EMG/NCS are useful for confirming diagnosis and severity but are not typically thenextstep after failed non-invasive conservative treatment. Cervical or wrist MRI are generally not indicated unless there are atypical symptoms or concerns for other pathology. Surgical carpal tunnel release is indicated if non-operative measures, including injections, fail or if there is severe, unrelenting nerve compression with motor deficits.

Question 4850

Topic: Nerve & Tendon

A 68-year-old male presents with chronic pain and paresthesias along the medial aspect of his elbow and forearm, extending into his ring and small fingers. He reports weakness in grip strength and difficulty with fine motor movements. Examination reveals a positive Tinel's sign at the cubital tunnel, atrophy of the intrinsic muscles of the hand (e.g., first dorsal interosseous), and impaired two-point discrimination in the small finger. What is the most likely diagnosis?

. Carpal tunnel syndrome
. Cervical radiculopathy (C8-T1)
. Ulnar nerve entrapment at the wrist (Guyon's canal)
. Ulnar nerve entrapment at the elbow (cubital tunnel syndrome)
. Radial tunnel syndrome

Correct Answer & Explanation

. Ulnar nerve entrapment at the elbow (cubital tunnel syndrome)

Explanation

The symptoms (paresthesias in ring/small fingers, grip weakness, intrinsic muscle atrophy, positive Tinel's at the elbow) and signs are classic for ulnar nerve entrapment at the elbow, also known as cubital tunnel syndrome. Carpal tunnel syndrome affects the median nerve distribution (thumb, index, middle, radial half of ring finger). Cervical radiculopathy can mimic these symptoms but would typically have neck pain and different reflex findings. Ulnar nerve entrapment at the wrist (Guyon's canal) typically spares the dorsal ulnar sensory branch, which supplies the dorsal aspect of the small finger and ulnar half of the ring finger. Radial tunnel syndrome affects the radial nerve and presents with lateral elbow pain and forearm weakness.

Question 4851

Topic: 7. Hand and Wrist

A 60-year-old male presents with progressive flexion contractures of his ring and small fingers, making it difficult to put his hand in his pocket or wear gloves. He has a history of Scandinavian descent and no prior trauma. Examination reveals palpable cords and pits in the palm, with fixed flexion contractures of 40 degrees at the MCP joint of the ring finger and 30 degrees at the PIP joint of the small finger. What is the most appropriate indication for surgical intervention in this case?

. Any palpable cord in the palm
. Difficulty with fine motor tasks
. MCP joint contracture of 20 degrees or more
. PIP joint contracture of 20 degrees or more
. Inability to place the palm flat on a table (Tabletop test positive)

Correct Answer & Explanation

. Inability to place the palm flat on a table (Tabletop test positive)

Explanation

This patient has Dupuytren's contracture. The traditional indication for surgical intervention (e.g., fasciectomy, needle aponeurotomy) is a positive 'Tabletop test,' meaning the patient cannot place their palm flat on a table. This correlates with significant functional impairment and generally indicates a MCP joint contracture of 30 degrees or more, or any significant PIP joint contracture (often 20 degrees or more due to the more debilitating effect on function). A palpable cord alone without significant contracture is not an indication. Difficulty with fine motor tasks is a symptom, but the Tabletop test is the objective measure.

Question 4852

Topic: 7. Hand and Wrist

You are asked about the surgical management of carpal tunnel syndrome. To achieve maximum marks, what aspect should be emphasized, beyond the basic technique?

. The exact length of the skin incision.
. The brand of the surgical blade.
. Precise anatomical landmarks for safe release of the transverse carpal ligament, careful identification and protection of vital neurovascular structures (e.g., recurrent motor branch of median nerve), and discussion of potential complications (e.g., pillar pain, nerve injury).
. Only discussing endoscopic vs. open technique.
. Ignoring post-operative care.

Correct Answer & Explanation

. Precise anatomical landmarks for safe release of the transverse carpal ligament, careful identification and protection of vital neurovascular structures (e.g., recurrent motor branch of median nerve), and discussion of potential complications (e.g., pillar pain, nerve injury).

Explanation

For carpal tunnel release, while technique is important, demonstrating anatomical precision and an awareness of surgical safety is paramount for high marks. This includes identifying specific anatomical landmarks to ensure complete release while protecting critical structures, particularly the recurrent motor branch of the median nerve. Discussing potential complications like pillar pain further enhances the answer, showing a comprehensive understanding.

Question 4853

Topic: 7. Hand and Wrist

When discussing surgical site infection (SSI) prevention, what single intervention, if overlooked, would significantly lower your score?

. Using colored sutures.
. Administering post-operative antibiotics for 2 weeks.
. Adherence to strict pre-operative antibiotic prophylaxis protocols (timing, choice), meticulous surgical technique (hemostasis, gentle tissue handling, debridement), and appropriate wound care.
. Only focusing on surgeon hand hygiene.
. Using only topical antiseptics.

Correct Answer & Explanation

. Adherence to strict pre-operative antibiotic prophylaxis protocols (timing, choice), meticulous surgical technique (hemostasis, gentle tissue handling, debridement), and appropriate wound care.

Explanation

SSI prevention is multifaceted, but for optimal marks, candidates must highlight the key pillars: appropriate pre-operative antibiotic prophylaxis (correct timing, agent, dosing), meticulous surgical technique (including gentle tissue handling, adequate hemostasis, debridement of devitalized tissue), and effective wound care. Overlooking any of these critical, evidence-based interventions would indicate an incomplete understanding of infection control.

Question 4854

Topic: 7. Hand and Wrist

You are asked about the surgical management of carpal tunnel syndrome. The examiner asks, 'What is the primary goal of carpal tunnel release surgery, and how does it achieve this?'

. To excise the entire transverse carpal ligament to prevent recurrence of symptoms.
. To decompress the median nerve by transecting the transverse carpal ligament, thereby relieving pressure and improving nerve function and symptom resolution.
. To remove any osteophytes or inflamed synovium within the carpal tunnel to create more space.
. To resect the flexor retinaculum and relocate the median nerve anteriorly.
. To perform a neurolysis of the median nerve to improve its conductivity directly.

Correct Answer & Explanation

. To decompress the median nerve by transecting the transverse carpal ligament, thereby relieving pressure and improving nerve function and symptom resolution.

Explanation

The primary goal of carpal tunnel release surgery is to decompress the median nerve within the carpal tunnel. This is achieved by transecting (cutting) the transverse carpal ligament, which forms the roof of the tunnel. This increases the volume of the carpal tunnel, relieving pressure on the median nerve and allowing for restoration of its function and resolution of symptoms (pain, numbness, tingling). Excising the entire ligament (A) is an overstatement. Removing osteophytes/synovium (C) is not the primary goal but can be an adjunct in some cases. Relocating the nerve (D) is not the standard procedure. Neurolysis (E) is a separate procedure, usually only if intrinsic nerve pathology persists or is suspected.

Question 4855

Topic: 7. Hand and Wrist

What is the MOST crucial non-verbal communication aspect to be aware of during an oral exam?

. Constantly maintaining intense eye contact.
. Leaning back casually in your chair to appear relaxed.
. Maintaining good posture, making appropriate eye contact, using open hand gestures, and having a calm, confident demeanor.
. Avoiding all hand gestures to prevent distraction.
. Fidgeting frequently to release nervous energy.

Correct Answer & Explanation

. Maintaining good posture, making appropriate eye contact, using open hand gestures, and having a calm, confident demeanor.

Explanation

Non-verbal cues significantly influence an examiner's perception. Good posture, appropriate (not overly intense) eye contact, and open, natural hand gestures convey confidence, engagement, and professionalism. A calm demeanor helps project control and competence. Fidgeting, avoiding eye contact, or appearing overly casual can be interpreted negatively, suggesting nervousness or a lack of seriousness.

Question 4856

Topic: 7. Hand and Wrist
When performing a stress radiograph for an AC joint injury, what specific methodology is typically employed?
. AP views with the arm in maximal external rotation.
. Scapular Y views with the arm abducted to 90 degrees.
. Bilateral AP views of the AC joints with 10-15 lbs of weight held in each hand.
. Lateral views of the AC joint with the patient in the supine position.
. Axillary views with the arm in maximal internal rotation.

Correct Answer & Explanation

. Bilateral AP views of the AC joints with 10-15 lbs of weight held in each hand.

Explanation

Stress radiographs for AC joint injuries involve obtaining bilateral AP views of the AC joints while the patient holds weights (typically 10-15 lbs) in each hand. This downward traction on the arms can exaggerate any existing superior displacement of the clavicle, making subtle instabilities more apparent and aiding in classification, particularly for differentiating Type II from Type III.

Question 4857

Topic: Nerve & Tendon

In a patient presenting with an AC joint dislocation, which nerve is most commonly at risk for injury due to the proximity of the distal clavicle and the forces involved in high-grade dislocations?

. Axillary nerve
. Suprascapular nerve
. Long thoracic nerve
. Ulnar nerve
. Median nerve

Correct Answer & Explanation

. Suprascapular nerve

Explanation

The suprascapular nerve is most commonly at risk in high-grade AC joint dislocations, particularly those with significant posterior displacement (Type IV) or severe inferior displacement (Type VI). It runs through the suprascapular notch and around the spinoglenoid notch and can be compressed or stretched. While the other nerves are part of the brachial plexus, they are less directly vulnerable to the specific mechanisms and deformities of AC joint injuries than the suprascapular nerve.

Question 4858

Topic: 7. Hand and Wrist

What is the typical mechanism of injury for most AC joint dislocations?

. Falling on an outstretched hand (FOOSH)
. Direct blow to the anterior shoulder (e.g., from behind)
. Indirect trauma with an anteriorly directed force on the humerus
. Direct blow to the superior aspect of the acromion with the arm adducted
. Hyperabduction and external rotation of the arm

Correct Answer & Explanation

. Direct blow to the superior aspect of the acromion with the arm adducted

Explanation

The most common mechanism of injury for AC joint dislocations is a direct blow to the superior or superolateral aspect of the acromion with the arm in an adducted position. This drives the acromion (and scapula) inferiorly, while the clavicle remains relatively stable due to its sternal attachments, leading to disruption of the AC and potentially CC ligaments. Falling on an outstretched hand is more common for clavicle shaft fractures or distal radius fractures. Anterior blows can cause GH dislocations. Hyperabduction/ER causes GH dislocations.

Question 4859

Topic: Nerve & Tendon

A 42-year-old weightlifter undergoes surgical repair of a distal biceps tendon rupture. Comparing the single-incision anterior approach to the two-incision approach, the single-incision technique carries a higher risk of injury to which of the following structures?

. Posterior interosseous nerve (PIN)
. Lateral antebrachial cutaneous nerve (LABC)
. Median nerve
. Superficial radial nerve
. Ulnar nerve

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve (LABC)

Explanation

The single-incision anterior approach carries a higher risk of lateral antebrachial cutaneous (LABC) nerve neurapraxia due to superficial retraction. The two-incision approach is historically associated with a higher risk of heterotopic ossification and radioulnar synostosis.

Question 4860

Topic: 7. Hand and Wrist

Which of the following compartments of the hand is most frequently involved in compartment syndrome secondary to severe crush injuries, and which nerve provides primary motor innervation to the muscles contained within it?

. Thenar compartment; Median nerve
. Hypothenar compartment; Ulnar nerve
. Interosseous compartments; Ulnar nerve
. Adductor compartment; Median nerve
. Central compartment; Radial nerve

Correct Answer & Explanation

. Interosseous compartments; Ulnar nerve

Explanation

The hand contains 10 separate osteofascial compartments (4 dorsal interosseous, 3 volar interosseous, thenar, hypothenar, and adductor). The interosseous compartments are the most frequently involved in acute compartment syndrome of the hand due to crush injuries. The dorsal and volar interossei muscles within these compartments are innervated by the deep branch of the ulnar nerve.

Test Yourself

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

On this Page