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7. Hand and Wrist MCQs

Practice Set 33 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 641

Topic: Nerve & Tendon

A 22-year-old rugby player grabs an opponent's jersey and feels a pop in his ring finger. He cannot actively flex the distal interphalangeal (DIP) joint. Imaging shows no fracture, and the flexor digitorum profundus (FDP) tendon is palpable in the palm. What is the optimal timing and treatment?

. Surgical repair within 7-10 days to prevent tendon retraction and myostatic contracture
. Nonoperative management with a DIP extension splint
. Surgical repair within 4-6 weeks to allow inflammation to subside
. Two-stage tendon reconstruction
. DIP joint arthrodesis

Correct Answer & Explanation

. Surgical repair within 7-10 days to prevent tendon retraction and myostatic contracture

Explanation

This is a Type 1 Jersey finger (FDP retracted into the palm), compromising its vascular supply from the vincula. It requires early surgical repair within 7-10 days to prevent permanent myostatic contracture and tendon necrosis.

Question 642

Topic: Wrist & Carpus

During open reduction and internal fixation of a distal third radial shaft fracture (Galeazzi fracture), the surgeon assesses the distal radioulnar joint (DRUJ) for instability. Which of the following intraoperative findings most strongly indicates the need for DRUJ stabilization?

. Radius fracture within 7.5 cm of the articular surface
. A small ulnar styloid tip fracture
. Instability of the DRUJ in supination only
. Gross translation of the ulna relative to the radius in neutral rotation after rigid radius fixation
. Palpable crepitus at the DRUJ during pronation

Correct Answer & Explanation

. Gross translation of the ulna relative to the radius in neutral rotation after rigid radius fixation

Explanation

Following rigid fixation of the radius in a Galeazzi fracture, the DRUJ must be assessed. Gross instability in neutral or all forearm positions dictates the need for DRUJ stabilization, typically via radioulnar pinning in supination or open TFCC repair.

Question 643

Topic: 7. Hand and Wrist

A 25-year-old male punches a wall and sustains a closed fracture of the fifth metacarpal neck. Which of the following represents the maximum acceptable volar angulation for this fracture to be treated non-operatively with expected good functional outcome?

. 10 degrees
. 30 degrees
. 45 degrees
. 70 degrees
. 90 degrees

Correct Answer & Explanation

. 70 degrees

Explanation

The fifth metacarpal neck (Boxer's fracture) can tolerate up to 70 degrees of volar angulation due to the compensatory mobility of the 5th carpometacarpal (CMC) joint. Greater angulation, or any significant malrotation, requires reduction.

Question 644

Topic: 7. Hand and Wrist

A 30-year-old male sustains a Bennett fracture of the thumb base. The main fracture fragment is small and remains attached to the anterior oblique ligament. Which muscle is primarily responsible for the proximal, dorsal, and radial displacement of the first metacarpal shaft?

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

Correct Answer & Explanation

. Abductor pollicis longus

Explanation

In a Bennett fracture, the abductor pollicis longus (APL) pulls the metacarpal shaft proximally, dorsally, and radially. The small volar ulnar fragment remains held in its anatomic position by the anterior oblique ligament.

Question 645

Topic: Wrist & Carpus

Which of the following is an absolute indication for operative intervention in an acute scaphoid waist fracture?

. Displacement greater than 1 mm
. Proximal pole fracture
. Associated radiocarpal effusion
. Patient age greater than 60 years
. Delayed presentation of 2 weeks

Correct Answer & Explanation

. Displacement greater than 1 mm

Explanation

Displacement of greater than 1 mm in an acute scaphoid fracture is an absolute indication for surgical fixation due to the high risk of nonunion and subsequent Scaphoid Nonunion Advanced Collapse (SNAC). Proximal pole fractures are a strong relative indication.

Question 646

Topic: Nerve & Tendon

A patient develops a Boutonniere deformity 4 weeks after suffering a volar PIP joint dislocation. Which of the following best describes the underlying pathomechanics of this deformity?

. Rupture of the terminal extensor tendon with dorsal subluxation of the lateral bands
. Rupture of the central slip with volar subluxation of the lateral bands
. Avulsion of the volar plate with dorsal subluxation of the central slip
. Rupture of the flexor digitorum superficialis with dorsal subluxation of the lateral bands
. Contracture of the oblique retinacular ligament

Correct Answer & Explanation

. Rupture of the central slip with volar subluxation of the lateral bands

Explanation

A Boutonniere deformity is characterized by PIP flexion and DIP extension. It is caused by rupture or attenuation of the central slip, allowing the lateral bands to subluxate volarly to the PIP joint axis of rotation, acting as PIP flexors and DIP extensors.

Question 647

Topic: 7. Hand and Wrist
A 32-year-old male presents with progressive wrist pain 5 years after an untreated scaphoid fracture. Radiographs reveal radioscaphoid arthritis and capitolunate arthritis, but the radiolunate joint is preserved. Based on the Scaphoid Nonunion Advanced Collapse (SNAC) staging, what is the most appropriate surgical treatment?
. Radial styloidectomy
. Proximal row carpectomy (PRC)
. Scaphoid excision and four-corner fusion
. Total wrist arthrodesis
. Vascularized bone grafting of the scaphoid

Correct Answer & Explanation

. Scaphoid excision and four-corner fusion

Explanation

This patient has Stage III SNAC wrist, characterized by arthritis extending to the capitolunate joint while sparing the radiolunate joint. Scaphoid excision and four-corner fusion is the treatment of choice, whereas proximal row carpectomy is contraindicated due to capitate articular wear.

Question 648

Topic: 7. Hand and Wrist

A 25-year-old mechanic sustains a volar laceration to his index finger at the level of the proximal phalanx, resulting in complete transection of the FDP and FDS tendons (Zone II). During surgical repair, what biomechanical factor is most directly responsible for increasing the tensile strength of the repair to safely allow early active motion?

. The use of braided non-absorbable suture material
. Placing the surgical knot on the volar surface of the tendon
. Increasing the number of core suture strands crossing the repair site
. Adding a robust epitendinous running suture
. Venting the A2 pulley to decrease gliding friction

Correct Answer & Explanation

. Increasing the number of core suture strands crossing the repair site

Explanation

The tensile strength of a flexor tendon repair is directly proportional to the number of core suture strands crossing the repair site. A 4-strand or 6-strand repair provides significantly more strength than a 2-strand repair, making it robust enough to withstand the forces of early active motion protocols.

Question 649

Topic: 7. Hand and Wrist

A 30-year-old skier presents with acute ulnar-sided pain at the thumb metacarpophalangeal (MCP) joint after falling with a ski pole. Ultrasound confirms a completely displaced rupture of the ulnar collateral ligament (UCL), diagnosing a Stener lesion. What specific anatomical structure interposes between the torn UCL and its insertion site, preventing spontaneous healing?

. Extensor pollicis brevis tendon
. Abductor pollicis longus tendon
. Adductor pollicis aponeurosis
. Flexor pollicis brevis muscle
. First dorsal interosseous muscle

Correct Answer & Explanation

. Adductor pollicis aponeurosis

Explanation

A Stener lesion occurs when the distal end of the completely torn UCL flips superficial to the adductor pollicis aponeurosis. This interposition prevents the ligament from healing to its anatomic footprint on the proximal phalanx, necessitating surgical repair.

Question 650

Topic: Wrist & Carpus

A 60-year-old female sustained a non-displaced distal radius fracture treated conservatively in a short arm cast. Six weeks later, she reports a sudden inability to actively extend the interphalangeal joint of her thumb. What is the primary pathophysiology behind this specific complication?

. Laceration of the tendon by a prominent volar cortical fragment
. Ischemia of the tendon due to hematoma and edema within an intact third dorsal compartment
. Attritional mechanical rupture over a prominent dorsal Lister's tubercle spur
. Entrapment of the tendon within the healing fracture callus
. Traction neurapraxia of the posterior interosseous nerve

Correct Answer & Explanation

. Ischemia of the tendon due to hematoma and edema within an intact third dorsal compartment

Explanation

Extensor pollicis longus (EPL) ruptures following non-displaced distal radius fractures are primarily ischemic in nature. The intact extensor retinaculum of the third dorsal compartment restricts swelling, leading to increased pressure, decreased synovial perfusion, and subsequent tendon necrosis and rupture.

Question 651

Topic: Wrist & Carpus

A 28-year-old male undergoes open reduction and internal fixation for a Galeazzi fracture (middle/distal third radial shaft fracture). Intraoperatively, after rigid plating of the radius, the distal radioulnar joint (DRUJ) is noted to be highly unstable in pronation and neutral, but reduces in supination. What is the most appropriate next step in management?

. Place the arm in a long arm cast in pronation for 6 weeks
. Perform an immediate ulnar shortening osteotomy
. Pin the DRUJ with a transverse radioulnar K-wire in supination
. Resect the distal ulna to prevent post-traumatic arthrosis
. Perform primary open repair of the triangular fibrocartilage complex (TFCC) through a volar approach

Correct Answer & Explanation

. Pin the DRUJ with a transverse radioulnar K-wire in supination

Explanation

In a Galeazzi fracture with persistent DRUJ instability after anatomic radius fixation, the joint should be reduced in its most stable position (usually supination) and secured with transverse radioulnar K-wires for 4-6 weeks to allow the TFCC to heal.

Question 652

Topic: 7. Hand and Wrist

A 45-year-old male presents with a mallet finger injury after a basketball struck his extended middle finger. Radiographs show a dorsal avulsion fracture of the distal phalanx involving 45% of the articular surface, accompanied by volar subluxation of the remaining distal phalanx. What is the recommended management?

. Strict immobilization in a stack splint for 8 continuous weeks
. Surgical intervention with extension block pinning or ORIF
. Primary arthrodesis of the distal interphalangeal joint
. Excision of the bony fragment and advancement of the extensor tendon
. Buddy taping and early passive range of motion

Correct Answer & Explanation

. Surgical intervention with extension block pinning or ORIF

Explanation

While most mallet fractures are treated non-operatively, surgical fixation (such as extension block pinning) is indicated for 'bony mallet' injuries involving greater than 30-40% of the articular surface or when there is volar subluxation of the distal phalanx.

Question 653

Topic: Wrist & Carpus

Which of the following radiographic findings in a distal radius fracture is LEAST indicative of potential instability requiring surgical intervention following an initially successful closed reduction?

. Initial dorsal angulation >20 degrees
. Radial shortening >3mm
. Significant metaphyseal comminution
. Associated ulnar styloid fracture
. Intra-articular step-off >1mm

Correct Answer & Explanation

. Associated ulnar styloid fracture

Explanation

Correct Answer: DInstability criteria often guide the decision for surgical fixation following a distal radius fracture. Common indicators of instability include initial dorsal angulation greater than 20 degrees, radial shortening exceeding 3mm, severe metaphyseal comminution, and particularly, intra-articular step-off or gap greater than 1-2mm. While an ulnar styloid fracture is frequently associated with distal radius fractures and may suggest a TFCC injury, its presencealoneis not a direct criterion forradialfracture instability or a primary indication for surgical intervention on the radius, assuming other parameters are acceptable. It might influence DRUJ stability, but not necessarily the stability of the radial reduction itself.

Question 654

Topic: 7. Hand and Wrist

During a standard volar approach (Henry approach) to the distal radius for plate fixation, which structure is primarily released or retracted radially to access the volar aspect of the radius?

. Flexor Carpi Radialis tendon
. Median nerve
. Radial artery
. Pronator Quadratus muscle
. Flexor Pollicis Longus tendon

Correct Answer & Explanation

. Pronator Quadratus muscle

Explanation

Correct Answer: DThe Henry approach for volar plating of the distal radius involves an incision between the Flexor Carpi Radialis (FCR) and the Radial Artery. The FCR tendon is retracted ulnarly, and the radial artery and brachioradialis are retracted radially. The critical step to expose the volar aspect of the distal radius is the subperiosteal elevation and L-shaped release of the Pronator Quadratus muscle from its radial and distal attachments, which is then reflected ulnarly. The median nerve lies more ulnarly, and the FPL tendon is in the deep flexor compartment and typically not the primary muscle reflected for direct radial access.

Question 655

Topic: 7. Hand and Wrist

A 70-year-old patient undergoes open reduction internal fixation with a dorsal plate for a comminuted distal radius fracture. Six months post-operatively, she presents with difficulty extending her thumb IP joint and a positive Finkelstein's test. Assuming the Finkelstein's test is a misdiagnosis or secondary finding, which tendon is most likely to have ruptured?

. Flexor Pollicis Longus
. Extensor Carpi Ulnaris
. Extensor Pollicis Longus
. Extensor Digitorum Communis
. Abductor Pollicis Longus

Correct Answer & Explanation

. Extensor Pollicis Longus

Explanation

Correct Answer: CDifficulty extending the thumb IP joint (interphalangeal joint) is the hallmark sign of Extensor Pollicis Longus (EPL) rupture. EPL rupture is a known complication of distal radius fractures, particularly after dorsal plating, due to attrition over rough bone edges, plate prominence, or direct plate impingement. It can also occur post-closed reduction due to attrition over a dorsal bony prominence or as part of a delayed presentation (e.g., following a Colles' fracture). The Finkelstein's test is for De Quervain's tenosynovitis (APL and EPB), which is not directly related to EPL rupture, hence the assumption of it being a secondary finding.

Question 656

Topic: 7. Hand and Wrist

When measuring volar tilt on a true lateral radiograph of the wrist, a normal range is considered to be:

. 0-5 degrees dorsal
. 5-10 degrees volar
. 10-15 degrees volar
. 15-20 degrees volar
. 20-25 degrees volar

Correct Answer & Explanation

. 10-15 degrees volar

Explanation

Correct Answer: COn a true lateral radiograph of the wrist, the distal articular surface of the radius normally exhibits a volar tilt. The accepted normal range is typically 10 to 15 degrees of volar tilt. A neutral or dorsal tilt is considered abnormal and is a characteristic deformity of a Colles' fracture.

Question 657

Topic: Wrist & Carpus

Which of the following anatomical structures is considered the primary static stabilizer of the distal radioulnar joint (DRUJ)?

. Interosseous membrane
. Extensor Carpi Ulnaris tendon sheath
. Triangular Fibrocartilage Complex (TFCC)
. Pronator Quadratus muscle
. Dorsal radioulnar ligament

Correct Answer & Explanation

. Triangular Fibrocartilage Complex (TFCC)

Explanation

Correct Answer: CThe Triangular Fibrocartilage Complex (TFCC) is the primary static stabilizer of the DRUJ. It is a complex structure comprising the articular disc, dorsal and volar radioulnar ligaments, and the meniscal homologue. While the dorsal and volar radioulnar ligaments within the TFCC are key components, the TFCC as a whole unit provides the most significant static stability. The interosseous membrane provides some longitudinal stability to the forearm, and the Pronator Quadratus offers dynamic stability. The ECU tendon sheath is adjacent but not a primary stabilizer.

Question 658

Topic: Wrist & Carpus

A 55-year-old female develops symptoms consistent with Complex Regional Pain Syndrome (CRPS) Type I following a distal radius fracture treated non-operatively. Her symptoms include severe pain out of proportion to injury, allodynia, swelling, and trophic changes. Which of the following is considered the MOST critical early intervention in managing CRPS?

. Oral corticosteroids
. Lumbar sympathetic block
. Aggressive physical therapy and occupational therapy
. Gabapentin
. Spinal cord stimulator

Correct Answer & Explanation

. Aggressive physical therapy and occupational therapy

Explanation

Correct Answer: CEarly recognition and aggressive physical and occupational therapy focused on pain-free range of motion, desensitization, and functional use are paramount in managing CRPS. While medications (gabapentin, tricyclic antidepressants) and interventional treatments (sympathetic blocks) have a role, they are often adjuncts. Steroids may be used, but not as the initial most critical step. Spinal cord stimulators are reserved for refractory cases. The key to preventing progression and improving outcomes is early, consistent, and active rehabilitation.

Question 659

Topic: Wrist & Carpus

A 30-year-old active male sustains a distal radius fracture with a 4mm intra-articular step-off, 5 degrees dorsal tilt, and 1mm radial shortening. Which of these parameters ALONE typically warrants surgical intervention for definitive management?

. 4mm intra-articular step-off
. 5 degrees dorsal tilt
. 1mm radial shortening
. Age
. Active lifestyle

Correct Answer & Explanation

. 4mm intra-articular step-off

Explanation

Correct Answer: AWhile age and activity level influence treatment decisions, the specific fracture characteristic of a 4mm intra-articular step-off is a very strong, if not absolute, indication for surgical management, regardless of other parameters. Even 1-2mm of articular incongruity is often considered unacceptable, particularly in a younger, active individual, due to the high risk of post-traumatic arthritis. The dorsal tilt and radial shortening mentioned are relatively minor compared to the articular step-off.

Question 660

Topic: 7. Hand and Wrist

Following reduction and casting of a distal radius fracture, a patient complains of persistent ulnar-sided wrist pain, particularly with pronation/supination and grasping. Tenderness is noted just distal to the ulnar head. Which of the following tests would be most appropriate to further evaluate for a potential Triangular Fibrocartilage Complex (TFCC) injury?

. Scaphoid shift test
. Finkelstein's test
. Grind test
. Piano key test
. TFCC compression test

Correct Answer & Explanation

. TFCC compression test

Explanation

Correct Answer: EUlnar-sided wrist pain after a distal radius fracture, especially with DRUJ movements, strongly suggests a TFCC injury. The TFCC compression test (axial load with ulnar deviation and rotation) is a specific provocative test for TFCC tears, eliciting pain and sometimes a click. The Scaphoid Shift (Watson) test assesses scapholunate instability. Finkelstein's test is for De Quervain's tenosynovitis. The Grind test is for carpometacarpal arthritis. The Piano Key test assesses DRUJ stability (dorsal/volar translation of the ulnar head).

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