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7. Hand and Wrist MCQs

Practice Set 82 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 1621

Topic: Wrist & Carpus

A 45-year-old male sustains a volar marginal articular fracture of the distal radius (volar Barton's fracture) with volar subluxation of the carpus. During open reduction and internal fixation via an FCR approach, which of the following stout ligamentous structures remains attached to the volar fracture fragment, exerting the primary proximal and volar displacing force on the carpus?

. Dorsal radiocarpal ligament
. Radioscaphocapitate ligament
. Scapholunate interosseous ligament
. Lunotriquetral ligament
. Ulnocarpal ligament

Correct Answer & Explanation

. Radioscaphocapitate ligament

Explanation

In a volar Barton's fracture (volar shear fracture of the distal radius), the strong volar radiocarpal ligaments—specifically the radioscaphocapitate (RSC) and the long/short radiolunate ligaments—remain attached to the avulsed volar bony fragment. Because the carpus is tethered to this fragment via these ligaments, the entire carpus subluxates volarly and proximally along with the fracture fragment.

Question 1622

Topic: Hand Trauma & Infection

A 30-year-old male presents with a deep, purulent laceration over the third metacarpophalangeal joint after striking another individual in the mouth ('fight bite'). Which fastidious gram-negative rod is characteristically associated with human bite wounds and must be covered by the chosen empiric antibiotic regimen?

. Pasteurella multocida
. Eikenella corrodens
. Bartonella henselae
. Capnocytophaga canimorsus
. Mycobacterium marinum

Correct Answer & Explanation

. Eikenella corrodens

Explanation

Eikenella corrodens is a fastidious gram-negative facultative anaerobe that is part of normal human oral flora. It is a classic pathogen in clenched-fist injuries (fight bites) and human bite wounds. Empiric therapy typically involves amoxicillin-clavulanate. Pasteurella and Capnocytophaga are seen in dog/cat bites, Bartonella in cat scratch disease, and M. marinum in aquatic exposures.

Question 1623

Topic: Hand Trauma & Infection

A 34-year-old mechanic presents with an infected puncture wound on his index finger. He exhibits the four cardinal signs of suppurative flexor tenosynovitis (Kanavel's signs). Which of these signs is typically the earliest to manifest and is considered the most sensitive indicator of this condition?

. Symmetrical uniform swelling of the entire digit
. Slightly flexed resting posture of the digit
. Tenderness strictly along the course of the flexor tendon sheath
. Pain with passive extension of the digit
. Erythema extending proximally to the palmar crease

Correct Answer & Explanation

. Pain with passive extension of the digit

Explanation

Kanavel's four signs of flexor tenosynovitis are: 1) fusiform swelling, 2) flexed resting posture, 3) tenderness along the flexor sheath, and 4) pain with passive extension. Pain with passive extension is typically the earliest and most sensitive sign of suppurative flexor tenosynovitis.

Question 1624

Topic: 7. Hand and Wrist
A 42-year-old college professor reports persistent pain at the hypothenar eminence 9 months after falling from his bicycle. Initial radiographs were reportedly normal. Use of a wrist splint for the last 2 months has failed to provide relief. A radiograph obtained by his primary care physician prior to referral is seen in Figure 31. What is the most appropriate treatment?
. Continued splint immobilization for 6 weeks
. Pisiform excision
. Hook of hamate excision
. Open reduction and internal fixation with bone grafting
. Lunotriquetral arthrodesis

Correct Answer & Explanation

. Pisiform excision

Explanation

The oblique radiograph of the wrist reveals a displaced fracture of the pisiform that usually occurs following a direct blow or sudden contraction of the flexor carpi ulnaris tendon. Persistent pain secondary to pisotriquetral incongruity and degenerative arthritis warrants pisiform excision, which does not compromise wrist flexion strength. Pisiform fractures are usually missed on routine radiographic views.

Question 1625

Topic: 7. Hand and Wrist
Based on the image findings, what is the most likely diagnosis?
. Preiser’s disease
. Scaphoid nonunion and osteonecrosis
. Kienbock’s disease
. Intraosseous ganglion
. Scapholunate dissociation

Correct Answer & Explanation

. Scaphoid nonunion and osteonecrosis

Explanation

The coronal MRI scan of the wrist shows the scaphoid. There is a subtle fracture line with a step-off at the radial surface consistent with a nonunion. The signal intensity is markedly different between the two fragments of the scaphoid. This strongly suggests osteonecrosis.

Question 1626

Topic: 7. Hand and Wrist

A 24-year-old male presents with a symptomatic proximal pole scaphoid nonunion 8 months after a fall. MRI shows early signs of avascular necrosis in the proximal pole, but there is no evidence of carpal collapse (SNAC wrist). Based on the retrograde blood supply to the scaphoid, which of the following is an established pedicled vascularized bone graft used to address this specific pathology?

. 1,2 intercompartmental supraretinacular artery (1,2 ICSRA) graft
. Free fibula vascularized graft
. Medial femoral condyle free flap
. Pronator quadratus pedicled bone graft
. Pisiform transfer

Correct Answer & Explanation

. 1,2 intercompartmental supraretinacular artery (1,2 ICSRA) graft

Explanation

The 1,2 intercompartmental supraretinacular artery (1,2 ICSRA) pedicled vascularized bone graft (Zaidemberg graft) is harvested from the dorsal distal radius. It is particularly useful for proximal pole scaphoid nonunions with avascular necrosis where carpal geometry is maintained. The scaphoid receives its primary blood supply from retrograde branches of the radial artery entering distally, making proximal pole fractures highly susceptible to AVN.

Question 1627

Topic: 7. Hand and Wrist

A 55-year-old female treated with a volar locking plate for a distal radius fracture 6 months ago presents with the sudden inability to actively flex the interphalangeal joint of her thumb. What is the most likely underlying technical cause of this complication?

. The plate was placed distal to the watershed line
. Prominent dorsal screws extending beyond the dorsal cortex
. Unrecognized intrinsic tightness during rehabilitation
. Intra-articular screw penetration into the radiocarpal joint
. Secondary entrapment of the median nerve in the carpal tunnel

Correct Answer & Explanation

. The plate was placed distal to the watershed line

Explanation

The sudden inability to flex the thumb IP joint post-volar plating strongly suggests a rupture of the flexor pollicis longus (FPL) tendon. The most common iatrogenic cause is placing the volar plate too far distally, beyond the watershed line (the volar margin of the distal radius articular surface). Prominent hardware in this area causes attrition, fraying, and eventual rupture of the overlying FPL tendon.

Question 1628

Topic: 7. Hand and Wrist

A 68-year-old male presents with a central cord syndrome following a hyperextension injury to his cervical spine. Which of the following best describes the expected typical progression of his neurologic recovery?

. Hand function, proximal upper extremity, bladder, lower extremity
. Lower extremity, bladder, proximal upper extremity, hand function
. Bladder, lower extremity, hand function, proximal upper extremity
. Proximal upper extremity, hand function, lower extremity, bladder
. Recovery occurs simultaneously across all affected domains

Correct Answer & Explanation

. Lower extremity, bladder, proximal upper extremity, hand function

Explanation

In Central Cord Syndrome, the classic pattern of motor recovery occurs in a specific sequence: lower extremity recovery usually occurs first, followed by bowel/bladder function, then proximal upper extremity, and finally distal upper extremity (hand/fine motor function). Distal upper extremity function often remains the most permanently impaired.

Question 1629

Topic: 7. Hand and Wrist

In the setting of a volar shear fracture of the distal radius (volar Barton's fracture), failure to adequately reduce and stabilize the volar lunate facet fragment most commonly leads to volar carpal subluxation. This occurs due to the direct attachment of which critical ligament to this specific bony fragment?

. Radioscaphocapitate ligament
. Long radiolunate ligament
. Short radiolunate ligament
. Volar radioulnar ligament
. Ulnocapitate ligament

Correct Answer & Explanation

. Short radiolunate ligament

Explanation

The short radiolunate ligament originates from the volar lunate facet of the distal radius and inserts onto the lunate. It is critical for stabilizing the lunate and the entire carpus. If the volar lunate facet fragment is not surgically stabilized (e.g., with a buttress plate), the short radiolunate ligament pulls the carpus volarly, resulting in volar carpal subluxation.

Question 1630

Topic: 7. Hand and Wrist

A 24-year-old male presents with a displaced fracture of the proximal pole of the scaphoid. He is counseled on the high risk of avascular necrosis. The tenuous blood supply to the proximal pole is predominantly provided by retrograde flow from which of the following vessels?

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

Correct Answer & Explanation

. Dorsal carpal branch of the radial artery

Explanation

The major blood supply to the scaphoid is from the dorsal carpal branch of the radial artery, which enters the dorsal ridge and supplies the proximal 80% of the scaphoid via retrograde blood flow. This retrograde supply explains the high risk of AVN in proximal pole fractures.

Question 1631

Topic: 7. Hand and Wrist

During open reduction and internal fixation of a volar shear distal radius fracture, the surgeon notes that the critical volar ulnar corner (lunate facet fragment) escapes the standard volar plate. Failure to capture this fragment puts the patient at risk for volar carpal subluxation due to the attachment of which critical ligament?

. Short radiolunate ligament
. Long radiolunate ligament
. Radioscaphocapitate ligament
. Dorsal radiocarpal ligament
. Ulnocapitate ligament

Correct Answer & Explanation

. Short radiolunate ligament

Explanation

The short radiolunate ligament firmly attaches the lunate to the volar ulnar corner of the distal radius (lunate facet). If this fragment is not rigidly stabilized, the radiocarpal joint can subluxate volarly.

Question 1632

Topic: Wrist & Carpus

A 29-year-old male undergoes open reduction and internal fixation for a Galeazzi fracture (distal one-third radial shaft fracture). Following anatomic and rigid fixation of the radius, the distal radioulnar joint (DRUJ) remains highly unstable to dorsal translation of the ulna. The surgeon decides to temporarily pin the DRUJ. In what position is the forearm most commonly pinned to maximize DRUJ stability?

. Maximum pronation
. Neutral rotation
. Maximum supination
. 45 degrees of pronation
. 90 degrees of flexion at the elbow

Correct Answer & Explanation

. Maximum supination

Explanation

Following a Galeazzi fracture, if the DRUJ remains unstable after radius fixation, it is typically due to a massive TFCC tear. The position of maximal stability for the DRUJ is supination, as the intact volar radioulnar ligaments become taught, reducing the dorsal subluxation of the ulna.

Question 1633

Topic: Wrist & Carpus
  • What is the primary reason for choosing a bone graft substitute rather than an autologous cancellous graft in the treatment of distal radius fractures with metaphyseal comminution and impaction?
. Reduced morbidity
. Improved osteoinduction
. Improved osteoconduction
. More rapid revascularization
. Lower risk of disease transmission

Correct Answer & Explanation

. More rapid revascularization

Explanation

Autologous grafts provide the best osteoinductive and conductive properties. These properties lead to increased revascularization in incorporation of the graft. In the study quoted, there was a 10% minor and 6% major complication rate for iliac crest bone graft harvesting. The most frequent complications included; superficial infections and seromas, as well as minor hematomas. Major complications included herniation of abdominal contents, vascular injury, deep infection or hematoma, and iliac wing fracture.

Question 1634

Topic: Wrist & Carpus

In the surgical treatment of a displaced volar Barton's fracture (volar marginal shear fracture of the distal radius), failure to properly reduce and stabilize the volar lunate facet fragment most reliably leads to volar radiocarpal subluxation. This subluxation occurs due to the incompetence of which critical ligament attached to this fragment?

. Radioscaphocapitate ligament
. Long radiolunate ligament
. Short radiolunate ligament
. Dorsal radiocarpal ligament
. Volar radioulnar ligament

Correct Answer & Explanation

. Short radiolunate ligament

Explanation

The volar lunate facet of the distal radius serves as the origin for the short radiolunate ligament, which inserts onto the volar aspect of the lunate. This ligament is the primary restraint preventing volar translation of the lunate and the entire carpus. If the volar lunate facet fracture fragment is not rigidly stabilized with a volar buttress plate, the carpus will subluxate volarly.

Question 1635

Topic: Wrist & Carpus

In a patient demonstrating the classic progression of scaphoid nonunion advanced collapse (SNAC), which specific area of the radiocarpal joint is characteristically spared from arthritic changes, even in the late stages of the disease?

. Radioscaphoid articulation
. Scaphocapitate articulation
. Radiolunate articulation
. Capitolunate articulation
. Trapeziometacarpal articulation

Correct Answer & Explanation

. Radiolunate articulation

Explanation

In both SNAC and SLAC wrist pathology, the radiolunate joint is characteristically spared from arthrosis. This is due to the congruent, concentric articulation between the lunate and the lunate fossa of the distal radius, which distributes loads evenly.

Question 1636

Topic: Wrist & Carpus

A 55-year-old female undergoes open reduction and volar locked plating for a displaced distal radius fracture. Six weeks postoperatively, she suddenly loses the ability to actively extend her thumb interphalangeal joint. What is the most likely etiology of this complication?

. Rupture of the extensor pollicis longus (EPL) tendon
. Rupture of the extensor pollicis brevis (EPB) tendon
. Anterior interosseous nerve (AIN) neuropraxia
. Flexor pollicis longus (FPL) tendon rupture
. Nonunion of the distal radius fracture

Correct Answer & Explanation

. Rupture of the extensor pollicis longus (EPL) tendon

Explanation

EPL tendon rupture is a well-known complication after distal radius fractures. In the setting of volar plating, it is typically caused by prominent dorsal screw tips penetrating the third extensor compartment, leading to attritional wear and sudden rupture.

Question 1637

Topic: Wrist & Carpus

A 55-year-old female is unable to extend her thumb interphalangeal joint 6 weeks after non-operative management of a minimally displaced distal radius fracture. Extensor indicis proprius (EIP) to extensor pollicis longus (EPL) transfer is planned. Where is the most reliable anatomical landmark to locate the proximal stump of the ruptured EPL tendon?

. Lister's tubercle
. First dorsal compartment
. Fourth dorsal compartment
. Intersection of the first and second compartments
. Volar to the brachioradialis insertion

Correct Answer & Explanation

. Lister's tubercle

Explanation

The EPL tendon wraps directly around Lister's tubercle (occupying the third dorsal compartment), making it the most reliable anatomical landmark. Following spontaneous rupture in a distal radius fracture, the proximal stump typically retracts but is found just proximal to the retinaculum at this location.

Question 1638

Topic: Wrist & Carpus
Which of the following represents the correct sequence of degenerative changes seen in Scaphoid Nonunion Advanced Collapse (SNAC)?
. Radioscaphoid joint, followed by lunocapitate joint, followed by radiolunate joint
. Radioscaphoid joint, followed by scaphocapitate joint, followed by lunocapitate joint
. Radiolunate joint, followed by radioscaphoid joint, followed by midcarpal joint
. Scaphotrapezial joint, followed by radioscaphoid joint, followed by lunocapitate joint
. Radioscaphoid joint, followed by radiolunate joint, followed by pisotriquetral joint

Correct Answer & Explanation

. Radioscaphoid joint, followed by scaphocapitate joint, followed by lunocapitate joint

Explanation

SNAC wrist arthritis follows a predictable pattern of progression due to abnormal kinematics of the distal scaphoid fragment. Stage I: arthritis at the radial styloid and distal scaphoid. Stage II: arthritis progresses to the scaphocapitate joint. Stage III: arthritis involves the lunocapitate joint. The radiolunate joint is characteristically spared in both SLAC and SNAC wrists due to its concentric, purely spherical articulation.

Question 1639

Topic: Wrist & Carpus

A 28-year-old tennis player presents with ulnar-sided wrist pain and clicking. Examination reveals instability of the distal radioulnar joint (DRUJ) in both supination and pronation. MRI arthrogram demonstrates a full-thickness tear of the triangular fibrocartilage complex (TFCC) at its foveal attachment. Which of the following is the primary stabilizing structure of the DRUJ disrupted in this patient?

. The volar radioulnar ligament
. The dorsal radioulnar ligament
. The radiocarpal ligaments
. The superficial limb of the TFCC attaching to the ulnar styloid
. The deep limb of the TFCC attaching to the fovea

Correct Answer & Explanation

. The deep limb of the TFCC attaching to the fovea

Explanation

The primary stabilizers of the DRUJ are the radioulnar ligaments (volar and dorsal). However, it is the deep (proximal) fibers of these ligaments that converge to attach at the fovea of the ulna (ligamentum subcruentum) that serve as the true isometric axis of rotation and the primary restraint to DRUJ translation. Tears of the superficial attachment to the ulnar styloid (Palmer 1B) typically do not cause gross DRUJ instability, whereas deep foveal avulsions do.

Question 1640

Topic: 7. Hand and Wrist
A 32-year-old construction worker presents with chronic dorsal wrist pain. Radiographs reveal sclerosis and fragmentation of the lunate with a radioscaphoid angle of 65 degrees and proximal migration of the capitate. According to the Lichtman classification of Kienböck's disease, what stage does this represent?
. Stage II
. Stage IIIA
. Stage IIIB
. Stage IV
. Stage V

Correct Answer & Explanation

. Stage IIIA

Explanation

The Lichtman classification of Kienböck's disease is based on radiographic findings. Stage I: normal x-ray, MRI shows changes. Stage II: lunate sclerosis without collapse. Stage III: lunate collapse. Stage III is subdivided: Stage IIIA has normal carpal alignment, whereas Stage IIIB has carpal collapse (fixed scaphoid rotation/flexion with a radioscaphoid angle > 60 degrees, and proximal capitate migration). Stage IV involves degenerative arthritis of the midcarpal or radiocarpal joints.

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