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7. Hand and Wrist MCQs

Practice Set 51 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 1001

Topic: 7. Hand and Wrist

A 29-year-old female sustains a high-energy radiocarpal fracture-dislocation. Radiographs demonstrate translation of the entire carpus with a small, displaced volar radial rim (lunate facet) fragment. Which of the following fixation strategies is paramount to prevent late carpal subluxation?

. Dorsal spanning plate
. Fragment-specific volar hook plate capturing the lunate facet fragment
. External fixation with percutaneous pinning
. Standard volar locking plate placed proximal to the watershed line
. Carpal tunnel release and long arm casting

Correct Answer & Explanation

. Fragment-specific volar hook plate capturing the lunate facet fragment

Explanation

Volar marginal rim fractures (lunate facet variants) are highly unstable and are frequently not captured by standard volar locking plates placed proximal to the watershed line. Fragment-specific fixation, such as a hook plate, is required to secure the rim and prevent volar carpal subluxation.

Question 1002

Topic: 7. Hand and Wrist

A 60-year-old female undergoes volar locking plate fixation of a distal radius fracture. Six months later, she presents with a sudden inability to actively flex the interphalangeal joint of her thumb. What surgical technical error most likely caused this complication?

. Drilling past the dorsal cortex during screw insertion
. Placement of the volar plate distal to the watershed line
. Placement of the plate proximal to the pronator quadratus
. Failure to repair the pronator quadratus over the plate
. Excessive retraction of the median nerve during the exposure

Correct Answer & Explanation

. Placement of the volar plate distal to the watershed line

Explanation

Placement of a volar plate distal to the watershed line impinges directly on the flexor pollicis longus (FPL) tendon, leading to mechanical attrition and subsequent rupture. Conversely, prominent screws penetrating the dorsal cortex typically cause extensor tendon (EPL or EDC) ruptures.

Question 1003

Topic: Nerve & Tendon

When utilizing the dorsal Thompson approach to expose the proximal third of the radius, which nerve is at highest risk of iatrogenic injury, and how is it biomechanically protected during the procedure?

. Median nerve; by keeping the forearm pronated
. Posterior interosseous nerve; by keeping the forearm supinated
. Superficial sensory radial nerve; by identifying it under the brachioradialis
. Posterior interosseous nerve; by keeping the forearm pronated
. Ulnar nerve; by transposing it anteriorly

Correct Answer & Explanation

. Posterior interosseous nerve; by keeping the forearm pronated

Explanation

The posterior interosseous nerve (PIN) lies within the supinator muscle. Pronating the forearm pulls the PIN anteriorly and medially, safely displacing it away from the surgical field during the dorsal Thompson approach to the proximal radius.

Question 1004

Topic: Wrist & Carpus

A 32-year-old male sustains a distal third radial shaft fracture with an associated distal radioulnar joint (DRUJ) dislocation (Galeazzi fracture). Open reduction and internal fixation of the radius is performed. Intraoperatively, the DRUJ is found to be highly unstable in pronation but reduces well in supination. What is the most appropriate next step in management of the DRUJ?

. Pinning of the DRUJ in pronation
. Open repair of the triangular fibrocartilage complex (TFCC)
. Functional bracing without further fixation
. Closed reduction and pinning of the DRUJ in supination
. Primary resection of the distal ulna

Correct Answer & Explanation

. Closed reduction and pinning of the DRUJ in supination

Explanation

Galeazzi fractures frequently involve DRUJ instability that persists after radial fixation. The DRUJ should be reduced and pinned in supination, which is the position of maximum anatomic stability for this joint.

Question 1005

Topic: 7. Hand and Wrist

A 45-year-old female presents with a volar Barton's fracture of the distal radius and undergoes ORIF with a volar locking plate. Six months postoperatively, she suddenly develops an inability to actively flex the interphalangeal joint of her thumb. Which complication has most likely occurred?

. Flexor carpi radialis (FCR) rupture
. Anterior interosseous nerve (AIN) palsy
. Median nerve transection
. Extensor pollicis longus (EPL) rupture
. Flexor pollicis longus (FPL) rupture

Correct Answer & Explanation

. Flexor pollicis longus (FPL) rupture

Explanation

Flexor pollicis longus (FPL) tendon rupture is a well-documented complication of volar plating for distal radius fractures. It typically occurs secondary to attritional wear from plate prominence at the watershed line.

Question 1006

Topic: Nerve & Tendon

During a Thompson (dorsal) approach to the proximal radius for plate fixation of a comminuted fracture, the surgeon develops the interval between the extensor carpi radialis brevis (ECRB) and the extensor digitorum communis (EDC). Which nerve is at greatest risk during this exposure and requires careful protection?

. Superficial sensory branch of the radial nerve
. Anterior interosseous nerve (AIN)
. Ulnar nerve
. Median nerve
. Posterior interosseous nerve (PIN)

Correct Answer & Explanation

. Posterior interosseous nerve (PIN)

Explanation

The Thompson approach accesses the proximal radius via the interval between the ECRB and EDC. The posterior interosseous nerve (PIN) is at significant risk as it courses directly through the supinator muscle in this operative field.

Question 1007

Topic: 7. Hand and Wrist

A 22-year-old male falls on an outstretched hand and sustains a displaced proximal pole scaphoid fracture. Which vascular structure provides the primary blood supply to the proximal pole, explaining the high risk of avascular necrosis in this injury pattern?

. Dorsal carpal branch of the radial artery
. Volar carpal branch of the radial artery
. Superficial palmar arch
. Anterior interosseous artery
. Ulnar artery branches

Correct Answer & Explanation

. Dorsal carpal branch of the radial artery

Explanation

The primary blood supply to the proximal scaphoid flows retrograde via the dorsal carpal branch of the radial artery, which enters the scaphoid distally. Proximal pole fractures disrupt this supply, creating a high risk of avascular necrosis.

Question 1008

Topic: Wrist & Carpus

When evaluating a post-reduction radiograph of an adult distal radius fracture, which of the following represents the widely accepted normal radiographic parameters for radial inclination, radial height, and volar tilt, respectively?

. 10 degrees, 5 mm, 0 degrees
. 22 degrees, 11 mm, 11 degrees
. 15 degrees, 22 mm, 5 degrees
. 30 degrees, 15 mm, 20 degrees
. 5 degrees, 11 mm, 22 degrees

Correct Answer & Explanation

. 22 degrees, 11 mm, 11 degrees

Explanation

Normal radiographic parameters of the distal radius include a radial inclination of 22 degrees, a radial height of 11-12 mm, and a volar tilt of 11 degrees. Restoration of these metrics is crucial for optimizing functional outcomes.

Question 1009

Topic: Wrist & Carpus

During volar locking plate fixation of a distal radius fracture, screws placed into the distal fragments can protrude dorsally if they are too long. Which anatomical landmark serves as a critical pulley for the extensor pollicis longus (EPL) tendon, placing it at high risk of attritional rupture from prominent dorsal hardware?

. Radial styloid
. Sigmoid notch
. Lister's tubercle
. Ulnar styloid
. Volar rim

Correct Answer & Explanation

. Lister's tubercle

Explanation

Lister's tubercle acts as a bony pulley for the extensor pollicis longus (EPL) tendon, which resides in the third extensor compartment. Dorsally prominent screws near this landmark frequently cause attritional rupture of the EPL.

Question 1010

Topic: 7. Hand and Wrist
A 68-year-old male with pre-existing cervical spondylosis presents after a hyperextension injury. He exhibits motor weakness that is significantly more pronounced in his upper extremities compared to his lower extremities, with distal muscle groups affected more than proximal ones. What is the most likely diagnosis?
. Anterior cord syndrome
. Brown-Sรฉquard syndrome
. Central cord syndrome
. Posterior cord syndrome
. Cruciate paralysis

Correct Answer & Explanation

. Central cord syndrome

Explanation

Central cord syndrome is classically seen in elderly patients with pre-existing cervical spondylosis following a hyperextension injury. It presents with disproportionately greater motor impairment in the upper extremities compared to the lower extremities, typically affecting distal hand function the most.

Question 1011

Topic: Nerve & Tendon

When performing ORIF for a complex distal humerus fracture, the management of the ulnar nerve is debated. According to recent randomized controlled trials, how does routine anterior transposition of the ulnar nerve compare to in situ decompression?

. Routine transposition completely eliminates the risk of postoperative neuropathy
. Routine transposition is associated with a higher rate of postoperative ulnar neuritis compared to in situ decompression
. In situ decompression has a significantly higher rate of late ulnar nerve entrapment
. Transposition results in improved triceps strength
. There is no difference in any clinical outcome between the two techniques

Correct Answer & Explanation

. Routine transposition is associated with a higher rate of postoperative ulnar neuritis compared to in situ decompression

Explanation

Recent studies suggest that routine anterior transposition of the ulnar nerve during distal humerus ORIF increases the incidence of postoperative ulnar neuritis. Therefore, leaving the nerve in situ after releasing compression points is often preferred unless hardware placement demands transposition.

Question 1012

Topic: Nerve & Tendon
A 72-year-old female with severe osteoporosis presents with a comminuted olecranon fracture (Mayo Type III) requiring ORIF. The surgeon opts for a Kocher posterior approach with an olecranon osteotomy. During the closure phase, after fixation of the distal humerus fracture, the olecranon osteotomy must be meticulously reduced and fixed. Which of the following is a common complication specifically associated with olecranon osteotomy?
. Posterior Interosseous Nerve (PIN) injury.
. Lateral Ulnar Collateral Ligament (LUCL) avulsion.
. Nonunion or hardware prominence/irritation of the osteotomy site.
. Median nerve entrapment at the cubital tunnel.
. Radial head subluxation.

Correct Answer & Explanation

. Nonunion or hardware prominence/irritation of the osteotomy site.

Explanation

Nonunion and hardware prominence/irritation are specific issues associated with olecranon osteotomy. PIN injury is primarily associated with the Kaplan anterolateral approach, not the Kocher posterior approach.

Question 1013

Topic: 7. Hand and Wrist

A 45-year-old male undergoes total elbow arthroplasty (TEA) for severe post-traumatic arthritis. The procedure is performed via a Kocher posterior approach. Post-operatively, the patient develops symptoms consistent with ulnar neuropathy, including numbness in the small finger and ulnar half of the ring finger, and weakness of intrinsic hand muscles. Which of the following is the most likely cause of this complication during the surgical approach, and what is a common intraoperative protective measure?

. A. Traction injury to the radial nerve during lateral retraction; protected by careful subperiosteal elevation of the supinator.
. B. Direct trauma or traction to the ulnar nerve in the cubital tunnel; protected by identification, neurolysis, and potential anterior transposition.
. C. Compression of the median nerve in the carpal tunnel; protected by wrist splinting.
. D. Injury to the musculocutaneous nerve during biceps reflection; protected by avoiding excessive proximal dissection.
. E. Damage to the Posterior Interosseous Nerve (PIN) during supinator splitting; protected by subperiosteal elevation.

Correct Answer & Explanation

. B. Direct trauma or traction to the ulnar nerve in the cubital tunnel; protected by identification, neurolysis, and potential anterior transposition.

Explanation

Correct Answer: BExplanation:The text, under 'Kocher Posterior Approach - Nerves,' identifies the 'Ulnar Nerve' as the 'most critical neurovascular structure at risk.' It states, 'Its vulnerability to direct trauma, traction, or entrapment is high during posterior approaches.' Under 'Detailed Surgical Approach / Technique - Kocher Posterior Approach - Superficial Dissection,' it specifies: 'Ulnar Nerve Identification: This is thefirst and most critical step. Incise the fascia over the cubital tunnel... Carefully identify the ulnar nerve, neurolyse it... and protect it with a vessel loop or Penrose drain. The nerve is often transposed anteriorly... at the end of the procedure.' This directly matches the scenario and protective measures.A. Traction injury to the radial nerve during lateral retraction:While the radial nerve innervates the triceps, its main trunk and PIN are not directly in the field of the standard posterior approach.C. Compression of the median nerve in the carpal tunnel:This is a wrist-level issue and not a direct complication of an elbow approach.D. Injury to the musculocutaneous nerve during biceps reflection:The musculocutaneous nerve is not typically at risk during a posterior elbow approach.E. Damage to the Posterior Interosseous Nerve (PIN) during supinator splitting:PIN injury is a risk of the Kaplan anterolateral approach, not the Kocher posterior approach.

Question 1014

Topic: 7. Hand and Wrist

A 68-year-old female presents with a displaced intra-articular distal radius fracture after a fall. She has a history of osteoporosis and is otherwise healthy. Pre-operative CT scan confirms significant comminution of the articular surface. The orthopedic surgeon plans for open reduction and internal fixation (ORIF) with a volar locking plate. During the approach, the surgeon identifies the flexor carpi radialis (FCR) tendon. Which of the following statements regarding the surgical technique for volar plating of the distal radius in osteoporotic bone is most accurate?

. A. The plate should be positioned distal to the watershed line to maximize articular support.
. B. The distal locking screws should be placed as close to the subchondral bone as possible.
. C. Direct anatomical reduction of every fragment is paramount to ensure optimal outcome.
. D. The brachioradialis insertion must be preserved to maintain wrist stability.
. E. Non-locking screws are preferred to allow for dynamic compression at the fracture site.

Correct Answer & Explanation

. B. The distal locking screws should be placed as close to the subchondral bone as possible.

Explanation

Correct Answer: BIn osteoporotic distal radius fractures, the metaphyseal cancellous bone is often crushed, leaving a void upon reduction. The volar locking screws act as a rigid structural scaffold holding the articular fragments in space. Therefore, placing the distal locking screws as close to the subchondral bone as possible is crucial to support the articular surface and prevent dorsal settling, which is a common complication in osteoporotic bone.Option A (The plate should be positioned distal to the watershed line to maximize articular support)is incorrect. The plate must be positioned proximal to the watershed line to prevent flexor tendon irritation and subsequent rupture. Positioning distal to the watershed line significantly increases the risk of flexor tendon complications.Option C (Direct anatomical reduction of every fragment is paramount to ensure optimal outcome)is incorrect. The case emphasizes that in osteoporotic bone, direct exposure and anatomical reduction of every fragment will inevitably strip the periosteal blood supply, leading to nonunion and implant failure. Indirect reduction techniques are preferred, focusing on restoration of length, alignment, and rotation (spatial reduction) rather than absolute anatomical cortical contact.Option D (The brachioradialis insertion must be preserved to maintain wrist stability)is incorrect. The case states that release of the brachioradialis insertion is often necessary to neutralize its deforming supinator and flexing forces on the distal fragment, especially in comminuted fractures, to achieve adequate reduction.Option E (Non-locking screws are preferred to allow for dynamic compression at the fracture site)is incorrect. The case explicitly states that volar locking plates are the implant of choice for distal radius fragility fractures. Locking screws thread directly into the plate, creating a fixed-angle construct that functions as an internal fixator, which is essential in osteoporotic bone where standard cortical screws often strip due to poor bone quality.

Question 1015

Topic: 7. Hand and Wrist

A 32-year-old construction worker presents with chronic wrist pain and tenderness in the anatomical snuffbox after falling onto an outstretched hand 6 months ago. Initial radiographs taken at an urgent care clinic were reported as normal, and he was treated conservatively with a wrist brace. Current radiographs show a sclerotic nonunion of the scaphoid at the waist with evidence of early degenerative changes in the radiocarpal joint. What is the most appropriate next step in management?

. Continued conservative management with a longer period of immobilization
. Excision of the scaphoid fragment
. Percutaneous screw fixation of the scaphoid
. Scaphoid nonunion bone graft with internal fixation
. Wrist arthrodesis

Correct Answer & Explanation

. Scaphoid nonunion bone graft with internal fixation

Explanation

Correct Answer: DThe presence of chronic pain, tenderness in the anatomical snuffbox, and radiographic evidence of a sclerotic scaphoid nonunion with early degenerative changes (SNAC wrist) indicates the need for surgical intervention. Percutaneous screw fixation is not appropriate for established nonunions, especially with sclerosis. Given the presence of a nonunion and early degenerative changes, a vascularized or non-vascularized bone graft with internal fixation (e.g., screw or K-wires) is the standard treatment to achieve union and prevent progression of osteoarthritis. Continued conservative management has failed. Excision of the fragment is not a reconstructive option. Wrist arthrodesis is a salvage procedure for advanced radiocarpal arthritis after failed reconstruction.

Question 1016

Topic: Nerve & Tendon

A patient sustains a complete transection of the ulnar nerve at the elbow. When discussing the prognosis for nerve regeneration, it is important to understand that Wallerian degeneration, the process of axonal degeneration distal to the injury, typically begins how long after axon transection?

. Immediately
. Within minutes
. Within 6-12 hours
. Within 24-48 hours
. After 72 hours

Correct Answer & Explanation

. Within 24-48 hours

Explanation

Correct Answer: DWallerian degeneration, the process of axonal degeneration distal to a site of injury, typically begins within 24-48 hours after axon transection. While some changes might be observed earlier, the complete breakdown of the axon and myelin sheath becomes evident within this timeframe. This process clears the debris to allow for potential regeneration, especially in the peripheral nervous system.

Question 1017

Topic: 7. Hand and Wrist
A 25-year-old carpenter suffers a laceration to the volar aspect of his index finger at the level of the proximal interphalangeal (PIP) joint. Examination reveals inability to flex both the PIP and DIP joints. What zone of flexor tendon injury does this represent?
. Zone I
. Zone II
. Zone III
. Zone IV
. Zone V

Correct Answer & Explanation

. Zone II

Explanation

Zone II, historically known as 'no man's land', extends from the A1 pulley to the insertion of the flexor digitorum superficialis (FDS) on the middle phalanx. Injuries here typically involve both the FDS and FDP tendons and carry a high risk of adhesions.

Question 1018

Topic: 7. Hand and Wrist

A 22-year-old mechanic sustains a scaphoid proximal pole fracture. He is informed that this fracture is at high risk for nonunion and avascular necrosis. The examiner asks you to explain the anatomic basis for this risk. Which of the following best describes the predominant vascular supply to the scaphoid?

. Antegrade flow via the volar carpal branch of the radial artery
. Retrograde flow via the dorsal carpal branch of the radial artery
. Direct branches from the ulnar artery supplying the proximal pole
. Intraosseous supply from the distal radius via the scapholunate ligament
. Retrograde flow via the deep palmar arch

Correct Answer & Explanation

. Retrograde flow via the dorsal carpal branch of the radial artery

Explanation

The scaphoid receives 70-80% of its blood supply from the dorsal carpal branch of the radial artery, which enters distally and flows retrograde to the proximal pole. This retrograde perfusion leaves proximal pole fractures highly susceptible to avascular necrosis and nonunion.

Question 1019

Topic: 7. Hand and Wrist
When evaluating a patient with suspected Carpal Tunnel Syndrome (CTS), you perform several clinical exams. Which of the following physical examination modalities is considered the most sensitive for detecting early sensory nerve compression in CTS?
. Tinel's sign at the wrist
. Phalen's maneuver
. Durkan's carpal compression test
. Semmes-Weinstein monofilament testing
. Two-point discrimination testing

Correct Answer & Explanation

. Semmes-Weinstein monofilament testing

Explanation

Semmes-Weinstein monofilament testing assesses the threshold of sensory perception and is widely considered the most sensitive clinical test for detecting early nerve compression and sensory loss in carpal tunnel syndrome.

Question 1020

Topic: 7. Hand and Wrist
A 25-year-old carpenter sustains a laceration over the proximal phalanx of the index finger, resulting in an inability to flex the DIP and PIP joints. In which flexor tendon zone is this injury, and why has this zone historically been termed "no man's land"?
. Zone I; poor blood supply to the FDP insertion
. Zone II; presence of both FDS and FDP within a tight fibro-osseous sheath leading to adhesions
. Zone III; high risk of concomitant lumbrical injury
. Zone IV; complexity of the carpal tunnel structures
. Zone V; high risk of neurovascular bundle transection

Correct Answer & Explanation

. Zone II; presence of both FDS and FDP within a tight fibro-osseous sheath leading to adhesions

Explanation

Zone II extends from the A1 pulley to the FDS insertion. It was historically called "no man's land" due to the high rate of postoperative adhesions between the FDS, FDP, and the flexor sheath, leading to predictably poor functional outcomes.

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