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7. Hand and Wrist MCQs

Practice Set 146 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 2901

Topic: Wrist & Carpus

A patient presents 3 months after a distal radius fracture with persistent ulnar-sided wrist pain, clicking, and instability of the distal radioulnar joint (DRUJ). Clinical examination reveals excessive dorsal-palmar translation of the ulna relative to the radius. Radiographs confirm appropriate healing of the distal radius fracture but show mild positive ulnar variance. The TFCC appears attenuated on MRI. What is the MOST appropriate next step in surgical management?

. Ulnar shortening osteotomy
. Distal ulna resection (Darrach procedure)
. DRUJ arthrodesis
. Reconstruction of the DRUJ ligaments/TFCC
. Proximal row carpectomy

Correct Answer & Explanation

. Ulnar shortening osteotomy

Explanation

The patient presents with chronic, symptomatic DRUJ instability following a distal radius fracture, with excessive translation and an attenuated TFCC, and mild positive ulnar variance. The primary goal is to restore DRUJ stability. Reconstruction of the DRUJ ligaments (e.g., using a tendon graft or capsular plication) along with repair of the TFCC is the most appropriate approach to restore the anatomical constraints of the DRUJ. Ulnar shortening osteotomy addresses positive ulnar variance and can indirectly improve TFCC tension, but it may not fully stabilize a grossly unstable DRUJ with attenuated ligaments. Distal ulna resection (Darrach) or DRUJ arthrodesis (Sauve-Kapandji) are salvage procedures for severe arthritis or painful, irreducible instability. Proximal row carpectomy is for midcarpal arthritis.

Question 2902

Topic: 7. Hand and Wrist

A 40-year-old construction worker presents with chronic wrist pain and stiffness. Radiographs demonstrate severe collapse and sclerosis of the lunate, significant carpal collapse (DISI pattern), and early radiocarpal arthritis (Lichtman Stage IV Kienbock's disease). He has failed all conservative measures. Which of the following is the MOST appropriate surgical intervention?

. Radial shortening osteotomy
. Lunate excision with tendon interposition
. Proximal row carpectomy (PRC)
. Wrist arthrodesis
. Vascularized bone graft to the lunate

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

The patient has Lichtman Stage IV Kienbock's disease, characterized by severe lunate collapse, carpal collapse, and established radiocarpal arthritis. At this stage, procedures aimed at revascularization or decompression (like radial shortening osteotomy or vascularized bone graft) are no longer indicated because the degenerative changes are too advanced. Proximal row carpectomy (PRC) is a common salvage procedure for symptomatic end-stage carpal arthritis, including Kienbock's disease, with an intact capitate head. It involves removing the scaphoid, lunate, and triquetrum, converting the radiocarpal joint into a radiocapitate joint. This provides good pain relief and preserves some motion. Wrist arthrodesis is also a salvage option, providing pain relief at the expense of all motion. Lunate excision alone is not stable.

Question 2903

Topic: Nerve & Tendon

A 25-year-old male complains of progressive weakness in his forearm flexors (excluding the flexor carpi ulnaris and ulnar half of the FDP) and numbness in his thumb, index, middle, and radial ring fingers. Examination reveals tenderness along the medial aspect of the distal humerus, just proximal to the medial epicondyle. Radiographs reveal a supracondylar spur (ligament of Struthers). What is the MOST likely diagnosis?

. Cubital tunnel syndrome
. Radial tunnel syndrome
. Anterior interosseous nerve syndrome
. Pronator syndrome
. Thoracic outlet syndrome

Correct Answer & Explanation

. Cubital tunnel syndrome

Explanation

The patient's symptoms (weakness in specific forearm flexors and median nerve distribution numbness, excluding ulnar-innervated muscles) are indicative of median nerve compression in the forearm. The presence of a supracondylar spur and tenderness proximal to the medial epicondyle, along with symptoms encompassing both motor and sensory aspects of the median nerve (unlike pure AIN syndrome), points strongly to Pronator Syndrome due to compression by the ligament of Struthers (a fibrous band connecting the supracondylar spur to the medial epicondyle). This ligament, along with the pronator teres, can compress the median nerve. Anterior interosseous nerve (AIN) syndrome is a pure motor deficit, affecting FPL, FDP to index/middle, and pronator quadratus, without sensory symptoms. Cubital tunnel syndrome affects the ulnar nerve. Radial tunnel syndrome affects the PIN. Thoracic outlet syndrome presents with more diffuse symptoms.

Question 2904

Topic: Hand Trauma & Infection

A 28-year-old skier falls, landing on his outstretched thumb. He presents with pain and swelling at the ulnar aspect of the thumb metacarpophalangeal (MCP) joint. Examination reveals significant instability (greater than 30-35 degrees of valgus laxity compared to the contralateral side) with a positive stress test, even with the MCP joint in 30 degrees of flexion. Palpation reveals a soft tissue mass at the ulnar base of the thumb. What is the MOST likely diagnosis and treatment?

. Thumb MCP joint sprain; Thumb spica splint
. Gamekeeper's thumb with a Stener lesion; Surgical repair of the UCL
. Thumb carpometacarpal (CMC) joint dislocation; Closed reduction
. Thumb extensor tendon rupture; Extensor tendon repair
. Thumb collateral ligament calcification; NSAIDs and rest

Correct Answer & Explanation

. Thumb MCP joint sprain; Thumb spica splint

Explanation

The patient's history (skiing fall, valgus stress to thumb), examination findings (pain, swelling, significant valgus laxity at the MCP joint, soft tissue mass consistent with a displaced UCL), and mechanism are classic for a Gamekeeper's thumb (acute rupture of the ulnar collateral ligament, UCL) with a Stener lesion. A Stener lesion occurs when the avulsed distal end of the UCL displaces superficial to the adductor aponeurosis, preventing healing with conservative treatment. Surgical repair of the UCL is indicated for Stener lesions or acute complete ruptures with significant instability to restore stability and function. Conservative management with splinting is only appropriate for partial tears or stable complete tears without a Stener lesion. CMC joint dislocation is at the base of the thumb. Extensor tendon rupture would involve active extension loss. Collateral ligament calcification is chronic.

Question 2905

Topic: Nerve & Tendon

A 35-year-old carpenter presents with a painful mass in the palm of his hand, at the base of his ring finger. The finger locks in flexion and requires passive extension with an audible 'click'. Examination reveals a tender nodule at the A1 pulley level. What is the MOST appropriate initial management?

. Surgical release of the A1 pulley
. Corticosteroid injection into the tendon sheath
. Rest and splinting of the finger
. Physical therapy with massage and stretching
. Oral NSAIDs

Correct Answer & Explanation

. Surgical release of the A1 pulley

Explanation

The patient's symptoms (painful locking, palpable nodule, clicking) are classic for trigger finger (stenosing tenosynovitis). The initial management typically involves conservative measures. A corticosteroid injection into the flexor tendon sheath at the level of the A1 pulley is highly effective in reducing inflammation and often resolving symptoms, especially after the first injection. If conservative management fails or symptoms recur, surgical release of the A1 pulley is definitive. Rest, splinting, physical therapy, and NSAIDs may offer some temporary relief but are less effective than an injection in the short term. Surgical release is considered a definitive treatment after failed conservative options.

Question 2906

Topic: Nerve & Tendon

A 40-year-old patient undergoes an open carpal tunnel release. Post-operatively, he complains of persistent numbness in the median nerve distribution and new weakness of his intrinsic hand muscles. On examination, he has a positive Froment's sign and Wartenberg's sign. What is the MOST likely iatrogenic injury?

. Incomplete release of the transverse carpal ligament
. Injury to the ulnar nerve
. Injury to the recurrent motor branch of the median nerve
. Injury to the palmar cutaneous branch of the median nerve
. Flexor digitorum superficialis tendon laceration

Correct Answer & Explanation

. Incomplete release of the transverse carpal ligament

Explanation

The patient's persistent median nerve symptoms suggest incomplete release or nerve irritation. However, the new symptoms of Froment's sign (indicating adductor pollicis weakness, an ulnar-innervated muscle) and Wartenberg's sign (indicating abduction of the small finger due to unopposed extensor digiti minimi, another ulnar nerve finding) strongly point to an iatrogenic injury to the ulnar nerve during open carpal tunnel release. While the median nerve is the target, the ulnar nerve is in close proximity, especially Guyon's canal, and can be injured. Incomplete release would cause persistent median nerve symptoms but not new ulnar nerve signs. Injury to the recurrent motor branch affects thenar muscles. Injury to the palmar cutaneous branch causes pain/numbness proximal to the incision, but no motor deficit. FDS laceration is a tendon injury, not nerve.

Question 2907

Topic: Hand Trauma & Infection

A 55-year-old male presents with acute, severe pain and swelling in the small finger. He reports injecting a small amount of an illicit substance into the finger 24 hours prior. Examination reveals intense erythema, warmth, and tenderness, with exquisite pain on passive extension of the finger. He has a fever and elevated inflammatory markers. What is the MOST appropriate immediate management?

. Oral antibiotics and wound care
. Intravenous antibiotics and observation
. Incision and drainage of the flexor tendon sheath
. Splinting and rest
. Needle aspiration of the infection

Correct Answer & Explanation

. Oral antibiotics and wound care

Explanation

This patient presents with classic signs of acute suppurative flexor tenosynovitis (Kanavel's signs: uniform swelling, flexed posture, tenderness along tendon sheath, pain on passive extension), likely exacerbated by illicit substance injection, which introduces virulent bacteria directly into the sheath. This is a surgical emergency that requires immediate incision and drainage of the flexor tendon sheath to prevent tendon necrosis, rupture, and spread of infection. Intravenous antibiotics are crucial but are adjunctive to surgical decompression. Oral antibiotics, observation, splinting, or needle aspiration are insufficient and can lead to devastating consequences, including amputation. Early surgical intervention is paramount.

Question 2908

Topic: Nerve & Tendon

A 15-year-old competitive gymnast presents with chronic posteromedial elbow pain. She complains of pain with elbow extension, especially during overhead activities. Radiographs show hypertrophy of the posteromedial olecranon and loose bodies within the olecranon fossa. What is the MOST appropriate surgical intervention?

. Ulnar collateral ligament (UCL) reconstruction
. Loose body removal and olecranon osteophyte excision
. Medial epicondylectomy
. Cubital tunnel release
. Posterior interosseous nerve decompression

Correct Answer & Explanation

. Ulnar collateral ligament (UCL) reconstruction

Explanation

The patient's symptoms of chronic posteromedial elbow pain, especially with elbow extension in an overhead athlete, along with radiographic findings of olecranon hypertrophy and loose bodies, are classic for posterior impingement of the elbow (often called 'thrower's elbow' or valgus extension overload syndrome). This occurs as the olecranon impinges on the olecranon fossa during terminal extension, exacerbated by valgus stress. The MOST appropriate surgical intervention is arthroscopic or open loose body removal and excision of the olecranon osteophyte (debridement of the posteromedial olecranon) to eliminate the impingement. UCL reconstruction is for valgus instability, not primary impingement (though they can coexist). Medial epicondylectomy and cubital tunnel release address ulnar nerve compression. Posterior interosseous nerve decompression is for radial tunnel syndrome.

Question 2909

Topic: 7. Hand and Wrist

A 30-year-old female presents with chronic wrist pain and weakness, particularly with gripping. She reports a history of fall 1 year ago. Examination reveals tenderness over the ulnar aspect of the wrist, a positive fovea sign, and a positive piano key sign (ulnar head ballotment test). MRI reveals disruption of the distal radioulnar ligament (DRUL) component of the TFCC. What is the MOST appropriate surgical intervention?

. Ulnar shortening osteotomy
. Arthroscopic debridement of the TFCC
. Repair or reconstruction of the DRUL
. Distal ulna resection (Darrach procedure)
. Wrist arthrodesis

Correct Answer & Explanation

. Ulnar shortening osteotomy

Explanation

The patient's symptoms (chronic ulnar-sided wrist pain, weakness, positive fovea sign, positive piano key sign) and MRI findings (disruption of DRUL) are highly suggestive of chronic distal radioulnar joint (DRUJ) instability due to a traumatic TFCC injury, specifically affecting the peripheral attachments of the TFCC. For symptomatic DRUJ instability in a younger, active patient without significant degenerative changes, surgical repair or reconstruction of the distal radioulnar ligaments (DRUL) is the preferred treatment to restore stability and function. Ulnar shortening osteotomy addresses ulnar positive variance and can relieve impingement but does not directly repair the DRUL. Arthroscopic debridement is for stable, central TFCC tears. Darrach procedure and wrist arthrodesis are salvage procedures for end-stage arthritis or irreducible instability.

Question 2910

Topic: Nerve & Tendon

A 55-year-old woman develops progressive bilateral numbness and tingling in her ring and small fingers after undergoing cervical spine fusion for myelopathy. She has no new neck pain. Examination reveals decreased sensation in the ulnar nerve distribution and weakness of intrinsic hand muscles. Nerve conduction studies confirm bilateral ulnar neuropathy at the elbow. What is the MOST likely cause of her symptoms?

. Recurrence of cervical myelopathy
. Thoracic outlet syndrome
. Post-operative positioning-related ulnar nerve compression
. Brachial plexus injury
. Delayed-onset cubital tunnel syndrome

Correct Answer & Explanation

. Recurrence of cervical myelopathy

Explanation

New onset bilateral ulnar neuropathy after cervical spine surgery strongly suggests post-operative positioning-related ulnar nerve compression at the elbow. During prolonged surgery, especially in positions like prone or lateral decubitus, the ulnar nerve can be compressed at the cubital tunnel if the elbows are not adequately padded and positioned. While pre-existing cubital tunnel syndrome can be exacerbated, or a brachial plexus injury can occur, the bilateral and specific ulnar nerve distribution points most directly to intraoperative positioning. Recurrence of cervical myelopathy would typically involve a broader set of neurologic symptoms, often including new neck pain or upper motor neuron signs. Thoracic outlet syndrome is usually unilateral or has different provocative maneuvers. This is a common and important iatrogenic complication to recognize.

Question 2911

Topic: 7. Hand and Wrist

A 60-year-old diabetic male develops a chronic, non-healing ulcer on the tip of his small finger following a minor cut. He also has a fixed flexion deformity of the small finger PIP joint and a palpable cord in the palm. He has undergone debridement and wound care for 3 months with no improvement. What is the MOST appropriate next step in management?

. Continue with conservative wound care and antibiotic treatment
. Perform a tenolysis of the flexor tendon
. Consider amputation of the small finger
. Surgical release of the Dupuytren's contracture
. Vascular assessment for peripheral artery disease

Correct Answer & Explanation

. Continue with conservative wound care and antibiotic treatment

Explanation

The patient presents with a chronic, non-healing ulcer on the small fingertip, combined with a fixed flexion deformity of the PIP joint and a palpable Dupuytren's cord. A severe Dupuytren's contracture can lead to skin breakdown and ulceration, particularly at the fingertip, due to constant pressure, skin attenuation, and impaired circulation. When a chronic ulcer associated with a severe contracture fails conservative wound care, surgical release of the Dupuytren's contracture (fasciectomy or fasciotomy) is indicated to relieve tension on the skin, allow for better wound healing, and improve function. Amputation is a salvage procedure and should be considered if the ulcer is intractable despite contracture release, or if there is severe osteomyelitis. Vascular assessment is important but the primary pathology driving the ulcer is the contracture. Tenolysis is for adhesions, not contracture-related skin breakdown.

Question 2912

Topic: 7. Hand and Wrist

A 35-year-old female presents with chronic numbness and tingling in her thumb, index, and middle fingers. She has mild thenar atrophy. Electromyography shows slowing across the carpal tunnel. She is a full-time sign language interpreter and requires maximal hand function. She has tried night splinting and two corticosteroid injections, with only temporary relief. What is the MOST appropriate next step?

. Third corticosteroid injection
. Oral gabapentin
. Endoscopic carpal tunnel release
. Physical therapy with nerve gliding exercises
. Long-term observation

Correct Answer & Explanation

. Third corticosteroid injection

Explanation

The patient has symptomatic carpal tunnel syndrome with objective evidence of nerve compression (EMG slowing) and mild thenar atrophy, signifying motor involvement. She has failed conservative management, including two corticosteroid injections. For persistent symptoms and objective nerve compromise despite conservative measures, especially in a patient requiring maximal hand function, surgical decompression via carpal tunnel release (either open or endoscopic) is indicated. A third injection is unlikely to provide durable relief given previous failures. Gabapentin is for neuropathic pain but doesn't address the compression. Physical therapy is often adjunct. Long-term observation risks irreversible nerve damage and further atrophy.

Question 2913

Topic: 7. Hand and Wrist

A 50-year-old male presents with a painful, palpable mass along the dorsal aspect of his thumb at the radial styloid. He describes pain with grasping and pinching, and a positive Finkelstein's test. He is a new father and reports frequently lifting his infant. What is the MOST likely diagnosis and initial treatment?

. Thumb carpometacarpal (CMC) arthritis; Corticosteroid injection
. De Quervain's tenosynovitis; Thumb spica splint and NSAIDs
. Scaphoid fracture; Short arm thumb spica cast
. Intersection syndrome; Activity modification
. Radial nerve entrapment; Physical therapy

Correct Answer & Explanation

. Thumb carpometacarpal (CMC) arthritis; Corticosteroid injection

Explanation

The patient's symptoms (pain at radial styloid, pain with grasping/pinching, positive Finkelstein's test) and history (new father, repetitive lifting) are classic for De Quervain's tenosynovitis. This condition involves stenosing tenosynovitis of the first dorsal compartment of the wrist, affecting the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons. Initial treatment is conservative and includes rest, activity modification, splinting (thumb spica splint to immobilize the thumb and wrist), NSAIDs, and often corticosteroid injections into the tendon sheath. CMC arthritis would involve the joint. Scaphoid fracture would have acute trauma and snuffbox tenderness. Intersection syndrome involves the crossing of the first and second dorsal compartments, more proximal. Radial nerve entrapment would have sensory or motor deficits.

Question 2914

Topic: 7. Hand and Wrist

A 45-year-old manual laborer presents with chronic right wrist pain. Radiographs reveal a scaphoid waist nonunion with severe radioscaphoid and capitolunate osteoarthritis. The radiolunate joint is completely spared. What is the most appropriate surgical treatment for this patient?

. Scaphoid excision and four-corner arthrodesis
. Proximal row carpectomy (PRC)
. Total wrist arthrodesis
. Radial styloidectomy and bone grafting
. Vascularized pedicled bone graft from the distal radius

Correct Answer & Explanation

. Scaphoid excision and four-corner arthrodesis

Explanation

This patient has Scaphoid Nonunion Advanced Collapse (SNAC) Stage III. SNAC staging dictates management: Stage I involves only the radial styloid; Stage II involves the entire radioscaphoid joint; Stage III involves the radioscaphoid and capitolunate joints; Stage IV involves the entire carpus including the radiolunate joint. Because the capitate head is arthritic in Stage III, a proximal row carpectomy (PRC) is contraindicated (as the arthritic capitate would articulate with the lunate fossa). Four-corner fusion (excision of the scaphoid and fusion of the capitate, lunate, hamate, and triquetrum) is the standard of care as it fuses the arthritic midcarpal joint while preserving motion through the healthy radiolunate joint.

Question 2915

Topic: Wrist & Carpus

A 55-year-old female presents with the inability to actively flex the interphalangeal joint of her thumb 9 months after undergoing volar locked plating for a distal radius fracture. Radiographs demonstrate that the volar plate is positioned distal to the watershed line of the distal radius. Which of the following tendons is most commonly ruptured in this specific scenario?

. Extensor pollicis longus (EPL)
. Flexor carpi radialis (FCR)
. Flexor pollicis longus (FPL)
. Flexor digitorum superficialis (FDS)
. Abductor pollicis longus (APL)

Correct Answer & Explanation

. Extensor pollicis longus (EPL)

Explanation

The clinical presentation describes a delayed rupture of the Flexor Pollicis Longus (FPL) tendon, which is a known complication of volar plating of the distal radius. According to the Soong grading classification, plates placed at or distal to the watershed line (Grade 2) are highly prominent and create friction against the overlying flexor tendons, most notably the FPL. EPL ruptures are more commonly associated with non-displaced distal radius fractures or dorsal screw penetration, not prominent volar plates.

Question 2916

Topic: Nerve & Tendon

A 35-year-old male sustains a complete, confirmed sharp laceration of the ulnar nerve at the level of the medial epicondyle. Upon physical examination 6 months later, the patient unexpectedly demonstrates intact active function of the first dorsal interosseous and adductor pollicis muscles, despite a profound sensory deficit in the little finger. Which of the following anatomical anomalies best explains this clinical finding?

. Riche-Cannieu anastomosis
. Martin-Gruber anastomosis
. Marinacci communication
. Berrettini anastomosis
. Bouvier anomaly

Correct Answer & Explanation

. Riche-Cannieu anastomosis

Explanation

A Martin-Gruber anastomosis is a motor nerve communication that crosses from the median nerve (or anterior interosseous nerve) to the ulnar nerve in the forearm. In patients with this anomaly, motor fibers destined for ulnar-innervated intrinsic muscles bypass an ulnar nerve injury at the elbow, traveling instead through the median nerve before crossing over to the distal ulnar nerve. This preserves intrinsic muscle function (like the adductor pollicis and first dorsal interosseous) despite a proximal ulnar nerve transection.

Question 2917

Topic: 7. Hand and Wrist

A 32-year-old carpenter presents with progressively worsening dorsal wrist pain. Radiographs reveal sclerosis and fragmentation of the lunate, a radioscaphoid angle of 65 degrees, and proximal migration of the capitate indicating carpal height collapse. Ulnar variance is neutral. What is the most appropriate surgical management?

. Radial shortening osteotomy
. Lunate core decompression
. Proximal row carpectomy (PRC)
. Vascularized pedicled bone grafting
. Capitate shortening osteotomy

Correct Answer & Explanation

. Radial shortening osteotomy

Explanation

This patient has Lichtman Stage IIIb Kienbรถck's disease, defined by lunate fragmentation, fixed scaphoid rotation (>60 degrees), and carpal height collapse. Because carpal collapse and fixed scaphoid rotation have already occurred, joint leveling procedures (like a radial shortening osteotomy) or revascularization procedures are ineffective and contraindicated. Salvage procedures, such as a proximal row carpectomy (PRC) or limited intercarpal fusions (e.g., scaphocapitate fusion), are the treatments of choice for Stage IIIb.

Question 2918

Topic: 7. Hand and Wrist

A 24-year-old skier presents with acute right thumb pain after a fall. Examination shows 40 degrees of radial deviation of the thumb metacarpophalangeal (MCP) joint when tested in full extension, compared to 15 degrees on the uninjured side. An MRI confirms a complete rupture of the ulnar collateral ligament (UCL) with a Stener lesion. Which anatomic structure becomes interposed between the torn ends of the UCL in a true Stener lesion?

. Adductor pollicis aponeurosis
. Abductor pollicis brevis tendon
. Extensor pollicis longus tendon
. Flexor pollicis longus tendon
. Volar plate

Correct Answer & Explanation

. Adductor pollicis aponeurosis

Explanation

A Stener lesion occurs when the distal attachment of the thumb ulnar collateral ligament (UCL) completely avulses and displaces superficial and proximal to the adductor pollicis aponeurosis. The aponeurosis becomes interposed between the torn ends of the ligament, mechanically preventing the ligament from healing back to its insertion at the base of the proximal phalanx. This finding is an absolute indication for surgical repair, as conservative management will fail.

Question 2919

Topic: 7. Hand and Wrist

A 50-year-old man presents with an inability to form an 'OK' sign with his right thumb and index finger. Examination reveals an inability to actively flex the interphalangeal joint of his thumb and the distal interphalangeal joint of his index finger. Tenodesis effect is intact, demonstrating full passive flexion of these digits when the wrist is passively extended. There is no sensory deficit in the hand. Which of the following is the most likely diagnosis?

. Flexor tendon rupture (FPL and FDP)
. Anterior interosseous nerve (AIN) syndrome
. Pronator syndrome
. Cubital tunnel syndrome
. Posterior interosseous nerve (PIN) syndrome

Correct Answer & Explanation

. Flexor tendon rupture (FPL and FDP)

Explanation

The patient's presentation is classic for Anterior Interosseous Nerve (AIN) syndrome. The AIN is a pure motor branch of the median nerve that innervates the flexor pollicis longus (FPL), the flexor digitorum profundus (FDP) to the index and middle fingers, and the pronator quadratus. Weakness results in the characteristic 'flat pinch' or inability to make the 'OK' sign. An intact tenodesis effect rules out tendon ruptures. The lack of sensory deficits differentiates AIN syndrome from Pronator syndrome (which affects the main median nerve and includes sensory loss).

Question 2920

Topic: 7. Hand and Wrist

A 45-year-old male presents with chronic, progressive wrist pain 5 years after a fall on an outstretched hand. Radiographs demonstrate a scaphoid nonunion with advanced collapse (SNAC). There is significant arthritis at the radioscaphoid joint and the capitolunate joint, but the radiolunate joint is well preserved. Which of the following is the MOST appropriate surgical intervention?

. Proximal row carpectomy (PRC)
. Total wrist arthrodesis
. Scaphoid excision and four-corner fusion
. Radial styloidectomy
. Scaphoid ORIF with vascularized bone grafting

Correct Answer & Explanation

. Proximal row carpectomy (PRC)

Explanation

This patient has a Stage III SNAC wrist, characterized by osteoarthritis involving the radioscaphoid and capitolunate joints, while sparing the radiolunate articulation. Proximal row carpectomy (PRC) relies on a pristine capitate head articulating with the lunate fossa; therefore, capitolunate arthritis is an absolute contraindication for PRC. Scaphoid excision and four-corner fusion (capitate, lunate, hamate, and triquetrum) eliminates the arthritic joints while preserving some wrist motion, making it the gold standard for Stage III SNAC/SLAC wrists.

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