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7. Hand and Wrist MCQs

Practice Set 142 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 2821

Topic: Wrist & Carpus

A 28-year-old male falls on his outstretched hand and presents with a displaced distal third radial shaft fracture.

After anatomic rigid plate fixation of the radius, how should the distal radioulnar joint (DRUJ) be managed?

. Assess DRUJ stability; if stable, allow early ROM; if unstable, pin the DRUJ in supination.
. Assess DRUJ stability; if unstable, pin the DRUJ in pronation.
. Always pin the DRUJ in neutral regardless of intraoperative stability testing.
. Perform a primary resection of the distal ulna (Darrach procedure).
. Routinely perform open reduction and internal fixation of the ulnar styloid.

Correct Answer & Explanation

. Assess DRUJ stability; if stable, allow early ROM; if unstable, pin the DRUJ in supination.

Explanation

This describes a Galeazzi fracture-dislocation. Following anatomic fixation of the radius, DRUJ stability must be assessed; if it is unstable, it is most stable in supination and should be pinned in this position for 4 to 6 weeks.

Question 2822

Topic: Wrist & Carpus

A 65-year-old woman treated nonoperatively for a minimally displaced distal radius fracture presents 6 weeks later unable to actively extend her thumb interphalangeal joint. What is the most appropriate definitive management?

. Direct extensor pollicis longus (EPL) end-to-end repair
. Extensor indicis proprius (EIP) to EPL tendon transfer
. Flexor carpi radialis (FCR) to EPL tendon transfer
. Corticosteroid injection into the first dorsal compartment
. Observation and physical therapy

Correct Answer & Explanation

. Direct extensor pollicis longus (EPL) end-to-end repair

Explanation

Extensor pollicis longus (EPL) rupture after nondisplaced distal radius fractures is due to ischemia or attrition within the third dorsal compartment. Because the tendon ends are typically degenerative and retracted, direct repair is contraindicated and an EIP to EPL transfer is the standard of care.

Question 2823

Topic: Wrist & Carpus

In a healthy 40-year-old patient with a closed distal radius fracture, which of the following radiographic parameters is universally considered a primary indication for operative intervention to minimize post-traumatic arthritis?

. Radial shortening of 1 mm
. Dorsal tilt of 5 degrees
. Intra-articular step-off of 2 mm or greater
. Volar tilt of 10 degrees
. Radial inclination of 20 degrees

Correct Answer & Explanation

. Radial shortening of 1 mm

Explanation

An intra-articular step-off or gap of 2 mm or greater in the radiocarpal joint significantly alters joint contact mechanics and is a universally accepted indication for surgical fixation to reduce the risk of post-traumatic arthritis.

Question 2824

Topic: Nerve & Tendon

When performing the standard volar Henry approach for fixation of a distal radius fracture, which structure is at greatest risk of iatrogenic injury if the dissection inappropriately strays ulnar to the flexor carpi radialis (FCR) tendon sheath?

. Radial artery
. Median nerve proper
. Palmar cutaneous branch of the median nerve
. Ulnar nerve
. Superficial branch of the radial nerve

Correct Answer & Explanation

. Radial artery

Explanation

The palmar cutaneous branch of the median nerve lies just ulnar to the FCR tendon. Retracting the FCR tendon ulnarly or splitting its sheath and dissecting radially protects this nerve and the median nerve proper.

Question 2825

Topic: 7. Hand and Wrist

A 55-year-old man sustains a highly comminuted, intra-articular distal radius fracture with severe metaphyseal comminution. The surgeon opts for a dorsal spanning distraction plate. Distally, where should the screws of this bridge plate be primarily anchored?

. First metacarpal
. Second or third metacarpal
. Trapezium
. Capitate
. Scaphoid

Correct Answer & Explanation

. First metacarpal

Explanation

A dorsal spanning plate relies on ligamentotaxis to maintain length and alignment. It is typically anchored proximally to the radial diaphysis and distally to the sturdy diaphyses of the second or third metacarpal.

Question 2826

Topic: 7. Hand and Wrist

Six weeks following volar plate fixation of a distal radius fracture, a patient presents with severe disproportionate hand pain, joint stiffness, skin color changes, and hyperhidrosis. Which of the following daily supplements has been shown in some studies to decrease the risk of developing this condition?

. Calcium channel blockers
. Vitamin C
. Vitamin D
. Glucosamine
. Magnesium

Correct Answer & Explanation

. Calcium channel blockers

Explanation

The patient is exhibiting signs of Complex Regional Pain Syndrome (CRPS). Administration of Vitamin C (500 mg daily for 50 days) after distal radius fractures has been shown in some randomized controlled trials to significantly reduce the incidence of CRPS.

Question 2827

Topic: Wrist & Carpus

Following volar plate fixation of a distal radius fracture, which tendon is most at risk for attrition and eventual rupture if screws prominently penetrate the dorsal cortex?

. Extensor digitorum communis
. Extensor pollicis brevis
. Extensor pollicis longus
. Extensor carpi radialis longus
. Extensor indicis proprius

Correct Answer & Explanation

. Extensor digitorum communis

Explanation

The extensor pollicis longus (EPL) tendon wraps around Lister's tubercle on the dorsal radius. It is uniquely vulnerable to attrition and rupture if dorsal screw penetration occurs during volar plating.

Question 2828

Topic: 7. Hand and Wrist

A 28-year-old female sustains an intra-articular distal radius fracture with a 3 mm articular step-off. If left unreduced, which of the following is the most likely long-term clinical consequence?

. Extensor pollicis longus rupture
. Carpal tunnel syndrome
. Post-traumatic radiocarpal arthritis
. Distal radioulnar joint instability
. Atrophic nonunion

Correct Answer & Explanation

. Extensor pollicis longus rupture

Explanation

Articular incongruity of greater than 2 mm in the distal radius is a primary indication for operative intervention. Failure to restore joint congruity is strongly associated with the development of early post-traumatic radiocarpal arthritis.

Question 2829

Topic: 7. Hand and Wrist

A 65-year-old female presents with a non-displaced distal radius fracture treated successfully in a cast. Six weeks later, she suddenly develops the inability to actively extend her thumb interphalangeal joint. What is the most likely cause?

. Flexor pollicis longus rupture
. Extensor pollicis longus tendon rupture
. Posterior interosseous nerve palsy
. Trigger thumb
. De Quervain's tenosynovitis

Correct Answer & Explanation

. Flexor pollicis longus rupture

Explanation

Extensor pollicis longus (EPL) tendon rupture classically occurs weeks after a non-displaced distal radius fracture. It is caused by mechanical attrition from fracture callus at Lister's tubercle or local ischemia in the third dorsal compartment.

Question 2830

Topic: 7. Hand and Wrist



A patient undergoes internal fixation for a complex distal radius fracture using a volar locking plate. Postoperatively, he has persistent numbness and tingling in the thumb, index, and middle fingers. Which of the following is the most likely cause?

. Ulnar nerve compression at Guyon's canal
. Posterior interosseous nerve injury
. Median nerve traction or contusion
. Complex regional pain syndrome
. Cervical radiculopathy

Correct Answer & Explanation

. Ulnar nerve compression at Guyon's canal

Explanation

Median neuropathy is the most common neurologic complication following distal radius fractures and their surgical treatment. It is often due to fracture hematoma, post-injury swelling, or iatrogenic traction during surgery.

Question 2831

Topic: Wrist & Carpus

A 55-year-old woman sustained a distal radius fracture. To minimize the risk of developing complex regional pain syndrome (CRPS), which of the following oral medications has been shown in prospective studies to be beneficial?

. Gabapentin
. Vitamin C
. Ibuprofen
. Pregabalin
. Amitriptyline

Correct Answer & Explanation

. Gabapentin

Explanation

Daily administration of 500 mg of Vitamin C for 50 days post-injury has been shown in some prospective studies to significantly reduce the incidence of CRPS following distal radius fractures.

Question 2832

Topic: Wrist & Carpus

In a patient with a distal radius fracture, which radiographic parameter is considered unacceptable for non-operative management and warrants surgical intervention?

. Radial shortening of < 2 mm
. Dorsal tilt of 5 degrees
. Intra-articular step-off > 2 mm
. Radial inclination of 20 degrees
. Volar tilt of neutral

Correct Answer & Explanation

. Radial shortening of < 2 mm

Explanation

An intra-articular step-off of > 2 mm is generally considered unacceptable as it significantly increases the risk of post-traumatic arthritis, making it an indication for operative fixation.

Question 2833

Topic: 7. Hand and Wrist

A 40-year-old woman is treated with a volar locking plate for a comminuted intra-articular distal radius fracture.

At 6 weeks postoperatively, she complains of an inability to actively flex the interphalangeal joint of her thumb. What is the most likely cause?

. Median nerve neuropraxia
. Adhesions of the flexor pollicis longus (FPL)
. FPL tendon rupture from prominent distal hardware
. Extensor pollicis longus (EPL) rupture
. Anterior interosseous nerve injury

Correct Answer & Explanation

. Median nerve neuropraxia

Explanation

Volar plate prominence distal to the watershed line can cause mechanical attrition and subsequent rupture of the flexor pollicis longus (FPL) tendon.

Question 2834

Topic: Wrist & Carpus

A 60-year-old female presents with an inability to flex the interphalangeal joint of her thumb 6 months after undergoing volar locked plating of a distal radius fracture.

Radiographs show the plate is positioned distal to the watershed line. Attritional rupture of which of the following tendons has most likely occurred?

. Flexor carpi radialis
. Flexor pollicis longus
. Abductor pollicis longus
. Extensor pollicis longus
. Flexor digitorum profundus to the index finger

Correct Answer & Explanation

. Flexor carpi radialis

Explanation

Volar plates placed distal to the watershed line can impinge on the flexor tendons, most commonly the flexor pollicis longus (FPL). This prominent hardware leads to tenosynovitis and subsequent attritional tendon rupture.

Question 2835

Topic: Wrist & Carpus

A 45-year-old male sustains a distal radius fracture. Closed reduction and cast application are performed. Which of the following radiographic parameters is generally considered the maximum acceptable threshold for radial shortening to minimize the risk of symptomatic distal radioulnar joint (DRUJ) arthrosis?

. 1 mm
. 3 mm
. 5 mm
. 7 mm
. 10 mm

Correct Answer & Explanation

. 1 mm

Explanation

Acceptable radiographic parameters for distal radius fractures include radial shortening of less than 5 mm, dorsal tilt of less than 10 degrees, and intra-articular step-off of less than 2 mm. Shortening >5 mm significantly alters DRUJ kinematics and increases load transmission through the ulna.

Question 2836

Topic: Wrist & Carpus

A 55-year-old woman is evaluated 8 weeks following a nondisplaced distal radius fracture treated in a short arm cast. She suddenly loses the ability to actively extend the interphalangeal joint of her thumb. Radiographs reveal a healed fracture. What is the most appropriate surgical treatment?

. Direct end-to-end repair of the ruptured tendon
. Extensor indicis proprius (EIP) to extensor pollicis longus (EPL) tendon transfer
. Extensor carpi radialis longus (ECRL) to EPL tendon transfer
. Palmaris longus interposition graft
. Thumb interphalangeal joint arthrodesis

Correct Answer & Explanation

. Direct end-to-end repair of the ruptured tendon

Explanation

Attritional rupture of the Extensor Pollicis Longus (EPL) can occur after nondisplaced distal radius fractures due to ischemia or mechanical friction at Lister's tubercle. Because the tendon ends are degenerated and retracted, direct repair is unfeasible; an EIP to EPL transfer is the standard treatment.

Question 2837

Topic: Wrist & Carpus

A 62-year-old woman sustains a nondisplaced Colles fracture treated in a short arm cast. Six weeks later, she reports sudden loss of ability to extend her thumb. Which of the following is the most appropriate management?

. Primary end-to-end repair of the ruptured tendon
. Extensor indicis proprius (EIP) to extensor pollicis longus (EPL) tendon transfer
. Exploration and release of the first dorsal compartment
. Corticosteroid injection into the third dorsal compartment
. Observation and physical therapy

Correct Answer & Explanation

. Primary end-to-end repair of the ruptured tendon

Explanation

Nondisplaced distal radius fractures can lead to EPL tendon rupture due to attrition or watershed ischemia within the third dorsal compartment. Because the tendon ends are typically retracted and frayed, an EIP to EPL transfer is the standard treatment rather than primary repair.

Question 2838

Topic: Wrist & Carpus

What is the maximum acceptable limit for intra-articular step-off when evaluating the reduction of a distal radius fracture to minimize the risk of post-traumatic radiocarpal arthrosis?

. 0 mm
. 2 mm
. 4 mm
. 5 mm
. 7 mm

Correct Answer & Explanation

. 0 mm

Explanation

An intra-articular step-off greater than 2 mm is highly correlated with the development of early post-traumatic radiocarpal arthritis. Surgical intervention is generally indicated if a step-off of 2 mm or greater cannot be reduced closed.

Question 2839

Topic: 7. Hand and Wrist

A 65-year-old woman with pre-existing cervical spondylosis falls forward and strikes her chin. She presents with bilateral upper extremity weakness (hands worse than shoulders) and relatively preserved lower extremity strength. What is the most likely diagnosis?

. Anterior cord syndrome
. Brown-Sรฉquard syndrome
. Central cord syndrome
. Posterior cord syndrome
. Conus medullaris syndrome

Correct Answer & Explanation

. Anterior cord syndrome

Explanation

Central cord syndrome classically occurs after a hyperextension injury in a patient with a stenotic cervical canal. It presents with disproportionate upper extremity weakness, particularly affecting fine motor function in the hands.

Question 2840

Topic: 7. Hand and Wrist

A 65-year-old man with cervical spondylosis sustains a hyperextension injury. He presents with profound weakness in his hands and arms, but is able to ambulate with mild lower extremity weakness. He has preserved perianal sensation. Which of the following best describes his expected prognosis for neurologic recovery?

. Full recovery of hand intrinsic function is expected within 6 months
. Lower extremity strength typically recovers first, followed by upper extremity, with hand intrinsics recovering last
. Bowel and bladder function are permanently lost
. Surgical intervention within 24 hours is mandatory for any chance of functional recovery
. Hand intrinsic function recovers first, followed by proximal muscle groups

Correct Answer & Explanation

. Full recovery of hand intrinsic function is expected within 6 months

Explanation

This is a classic presentation of central cord syndrome. Recovery typically occurs in a predictable pattern: lower extremities recover first, followed by bowel/bladder, then proximal upper extremities, with fine motor hand intrinsic function recovering last and often incompletely.

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