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7. Hand and Wrist MCQs

Practice Set 193 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 3841

Topic: 7. Hand and Wrist

In a patient with chronic DRUJ instability after a Galeazzi fracture that was primarily treated with radial ORIF, what is the initial non-surgical intervention often attempted before considering revision surgery for the DRUJ?

. Long-term systemic corticosteroids
. Activity modification and physiotherapy focusing on dynamic stabilization and strengthening
. Repeated closed reduction attempts without immobilization
. Application of a custom-made wrist-hand orthosis for indefinite wear
. Intra-articular steroid injections into the DRUJ

Correct Answer & Explanation

. Activity modification and physiotherapy focusing on dynamic stabilization and strengthening

Explanation

For chronic, symptomatic DRUJ instability after Galeazzi fixation, especially if there's no severe malunion or mechanical block, initial non-surgical management typically involves activity modification and a focused physiotherapy program. This aims to improve dynamic stabilization of the DRUJ through strengthening the surrounding musculature (e.g., pronator quadratus, ECU) and improving proprioception. If this fails or if there are significant anatomical issues, surgical options are then considered.

Question 3842

Topic: 7. Hand and Wrist

Which of the following describes a key anatomical relationship disturbed in a Galeazzi fracture, contributing to DRUJ instability?

. The relationship between the radial head and the capitellum.
. The normal length relationship between the radius and the ulna.
. The stability of the scaphoid-lunate articulation.
. The integrity of the proximal radioulnar joint.
. The alignment of the carpal bones relative to the distal ulna.

Correct Answer & Explanation

. The normal length relationship between the radius and the ulna.

Explanation

A primary disturbance in a Galeazzi fracture is the normal length relationship between the radius and the ulna. The radial shaft fracture allows for radial shortening, disrupting the precise length and tension balance between the two bones, particularly affecting the DRUJ and the interosseous membrane. Restoration of this length is critical for DRUJ stability.

Question 3843

Topic: 7. Hand and Wrist

A young girl presents with disproportionate short stature. Clinical and radiographic evaluation of her extremities is shown below. Which of the following best describes the findings in the appendicular skeleton of patients with this condition?



. Long, slender tubular bones with arachnodactyly
. Short, small tubular bones with broad feet
. Asymmetric limb shortening with bowing
. Proximal focal femoral deficiency
. Polydactyly and syndactyly

Correct Answer & Explanation

. Short, small tubular bones with broad feet

Explanation

Correct Answer: Short, small tubular bones with broad feetPatients with Spondyloepiphyseal Dysplasia typically present with short, small tubular bones in the hands and broad feet, as demonstrated in the provided clinical and radiographic images.

Question 3844

Topic: 7. Hand and Wrist

A young girl with a known chondrodysplasia presents for evaluation. Clinical and radiographic images of her hands and feet are shown below. Which of the following best describes the extremity manifestations typical of this condition?


. Arachnodactyly with narrow feet
. Short small tubular bones with broad feet
. Polydactyly with syndactyly
. Macrodactyly with clubfoot
. Madelung deformity with pes cavus

Correct Answer & Explanation

. Short small tubular bones with broad feet

Explanation

Correct Answer: Short small tubular bones with broad feetThe images demonstrate short small tubular bones in the hands and broad feet, which are characteristic extremity findings in patients with spondyloepiphyseal dysplasia.

Question 3845

Topic: 7. Hand and Wrist

A young girl with disproportionate short stature presents for evaluation. Clinical and radiographic images of her hands and feet are shown below. Which of the following best describes the findings in the appendicular skeleton of patients with this condition?


. Arachnodactyly with thin cortices
. Short, small tubular bones with broad feet
. Polydactyly and syndactyly
. Madelung deformity of the wrist
. Severe bowing of the radius and ulna

Correct Answer & Explanation

. Short, small tubular bones with broad feet

Explanation

Correct Answer: Short, small tubular bones with broad feetThe images demonstrate short, small tubular bones in the hands and broad feet, which are characteristic appendicular findings in patients with Spondyloepiphyseal Dysplasia. Arachnodactyly is seen in Marfan syndrome, and Madelung deformity is associated with Leri-Weill dyschondrosteosis.

Question 3846

Topic: 7. Hand and Wrist

A young female patient with a short trunk and short stature presents for evaluation. Clinical and radiographic images of her hands and feet are provided.



What is the predominant finding in the appendicular skeleton shown in these images?

. Arachnodactyly with joint hypermobility
. Short, small tubular bones and broad feet
. Polydactyly and syndactyly
. Severe osteopenia with cortical thinning

Correct Answer & Explanation

. Short, small tubular bones and broad feet

Explanation

Correct Answer: Short, small tubular bones and broad feetThe images demonstrate short, small tubular bones in the hands and broad feet, which are characteristic appendicular findings in patients with Spondyloepiphyseal dysplasia.

Question 3847

Topic: 7. Hand and Wrist

In addition to the spine and large joints, which of the following appendicular skeletal deformities is frequently observed at birth in patients with spondyloepiphyseal dysplasia congenita?

. Polydactyly
. Clubfoot (talipes equinovarus)
. Radial clubhand
. Syndactyly
. Congenital pseudarthrosis of the tibia

Correct Answer & Explanation

. Clubfoot (talipes equinovarus)

Explanation

Clubfoot (talipes equinovarus) is a common presenting orthopedic manifestation in newborns with SEDC, occurring in up to 30% of patients. It typically requires early intervention.

Question 3848

Topic: Nerve & Tendon

Which of the following nerves is most commonly injured with a supracondylar humerus fracture in a child?

. Radial nerve
. Ulnar nerve
. Median nerve
. Anterior interosseous nerve (AIN)
. Musculocutaneous nerve

Correct Answer & Explanation

. Anterior interosseous nerve (AIN)

Explanation

The anterior interosseous nerve (AIN), a motor branch of the median nerve, is the most commonly injured nerve in supracondylar humerus fractures, particularly in extension-type injuries. AIN injury manifests as inability to make an 'OK' sign (flexion of IP joint of thumb and DIP joint of index finger). While the median nerve itself and the radial nerve can be injured, the AIN is specifically highlighted due to its vulnerability in this common pediatric fracture.

Question 3849

Topic: 7. Hand and Wrist

A 50-year-old female presents with numbness and tingling in her thumb, index, middle finger, and radial half of the ring finger, particularly at night. Phalen's test and Tinel's sign at the wrist are positive. What is the most appropriate initial non-operative treatment?

. Surgical carpal tunnel release
. Corticosteroid injection into the carpal tunnel
. Night splinting in a neutral wrist position
. Physical therapy with nerve gliding exercises
. Activity modification and ergonomic assessment

Correct Answer & Explanation

. Night splinting in a neutral wrist position

Explanation

This presentation is classic for carpal tunnel syndrome. The most appropriate initial non-operative treatment is night splinting in a neutral wrist position to reduce pressure on the median nerve. While corticosteroid injections can offer temporary relief and are often used as a next step, night splinting is generally the first-line non-invasive approach. Physical therapy and activity modification are also important adjuncts. Surgical release is reserved for failed conservative management or severe cases.

Question 3850

Topic: 7. Hand and Wrist

What is the most common cause of radial nerve palsy in the upper extremity?

. Humerus shaft fracture
. Supracondylar humerus fracture
. Elbow dislocation
. Carpal tunnel syndrome
. Wrist ganglion

Correct Answer & Explanation

. Humerus shaft fracture

Explanation

Radial nerve palsy is most commonly associated with humerus shaft fractures, particularly in the middle or distal third, where the nerve courses in the spiral groove. The nerve can be entrapped or directly transected. While other injuries can cause radial nerve involvement, humerus shaft fractures are the classic association. Supracondylar fractures more commonly affect the AIN/median nerve. Carpal tunnel syndrome affects the median nerve.

Question 3851

Topic: 7. Hand and Wrist
A 6-year-old boy sustains a severe extension-type III supracondylar humerus fracture. After closed reduction and percutaneous pinning, the hand is pink with a palpable radial pulse, but the child is unable to flex the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger. Which specific nerve structure has been injured?
. Posterior interosseous nerve
. Ulnar nerve
. Anterior interosseous nerve
. Superficial radial nerve
. Musculocutaneous nerve

Correct Answer & Explanation

. Anterior interosseous nerve

Explanation

The Anterior Interosseous Nerve (AIN), a branch of the median nerve, is the most commonly injured nerve in extension-type supracondylar humerus fractures. It provides motor innervation to the flexor pollicis longus (thumb IP flexion), flexor digitorum profundus to the index/middle fingers, and pronator quadratus. Weakness in the 'OK' sign indicates an AIN palsy.

Question 3852

Topic: 7. Hand and Wrist

A 14-year-old girl presents with progressive wrist pain, decreased extension, and a prominent ulnar head. Radiographs reveal palmar and ulnar tilt of the distal radial articular surface with relative overgrowth of the ulna. The primary tethering structure responsible for this specific deformity is the:

. Triangular fibrocartilage complex
. Dorsal radiocarpal ligament
. Palmar radioulnar ligament
. Transverse carpal ligament
. Vickers ligament

Correct Answer & Explanation

. Vickers ligament

Explanation

The patient has Madelung deformity, which involves premature closure of the volar-ulnar portion of the distal radial physis. The Vickers ligament (an abnormally thickened and shortened radiolunate ligament) acts as a primary volar tether that tethers the lunate to the radius, restricting growth and causing the characteristic palmar and ulnar inclination of the distal radius.

Question 3853

Topic: 7. Hand and Wrist

A 4-year-old girl is evaluated for congenital gigantism isolated to the middle and index fingers of her right hand. Biopsy of the overgrown tissues shows prominent fibrofatty infiltration surrounding the median nerve. Which gene mutation is most likely responsible for this condition?

. NF1
. PTEN
. AKT1
. PIK3CA
. FBN1

Correct Answer & Explanation

. PIK3CA

Explanation

True macrodactyly usually follows a peripheral nerve territory (most commonly the median nerve) and is characterized by marked fibrofatty overgrowth within and around the nerve. It is now known to be part of the PIK3CA-related overgrowth spectrum (PROS). Somatic mosaic mutations in the PIK3CA gene drive this asymmetric tissue overgrowth.

Question 3854

Topic: 7. Hand and Wrist

A 35-year-old male presents with chronic radial-sided wrist pain, reduced grip strength, and limited range of motion following a missed scaphoid fracture 1 year prior. Radiographs show a scaphoid waist nonunion with associated carpal collapse (SNAC wrist Stage I). MRI demonstrates avascular necrosis (AVN) of the proximal pole fragment. What is the most appropriate surgical management?

. Excision of the radial styloid.
. Immobilization in a long arm thumb spica cast.
. Vascularized bone graft and internal fixation.
. Proximal row carpectomy.
. Wrist arthrodesis.

Correct Answer & Explanation

. Vascularized bone graft and internal fixation.

Explanation

For a symptomatic scaphoid nonunion, especially with avascular necrosis (AVN) of the proximal pole and early signs of carpal collapse (SNAC wrist Stage I), the goal is to achieve union. A vascularized bone graft (Option C) is often considered the treatment of choice in these cases because it brings its own blood supply to the avascular fragment, enhancing healing potential. This is combined with internal fixation (e.g., screw) for stability. Excision of the radial styloid (Option A) might be done for impingement but doesn't address the nonunion or AVN. Immobilization (Option B) is unlikely to achieve union in a chronic, symptomatic nonunion with AVN. Proximal row carpectomy (Option D) and wrist arthrodesis (Option E) are salvage procedures for advanced carpal collapse and arthritis (SNAC wrist Stage II-IV), not for trying to preserve wrist motion and achieve union in Stage I.

Question 3855

Topic: Wrist & Carpus
A 55-year-old active, healthy male sustains a high-energy fall onto an outstretched hand, resulting in a significantly comminuted, displaced intra-articular distal radius fracture (Frykman Type VIII). There is severe metaphyseal comminution and displacement of both radial styloid and dorsal ulnar corner fragments. What is the most appropriate definitive surgical approach to restore optimal function?
. Closed reduction and casting.
. External fixation alone.
. Volar locking plate fixation.
. Dorsal locking plate fixation.
. Combined volar and dorsal plating.

Correct Answer & Explanation

. Combined volar and dorsal plating.

Explanation

A Frykman Type VIII fracture indicates a comminuted intra-articular fracture involving both the radiocarpal and distal radioulnar joints. Given the high-energy mechanism, significant comminution, and displacement of both radial styloid and dorsal ulnar corner fragments, a highly stable fixation is required to restore anatomical alignment and allow early range of motion. While volar locking plates (Option 2) are the workhorse for most unstable distal radius fractures, a severely comminuted intra-articular fracture with significant dorsal comminution and dorsal ulnar corner involvement may not be adequately stabilized by a volar plate alone, especially if dorsal translation is an issue. Dorsal plating (Option 3) alone can be associated with extensor tendon irritation. In cases of severe comminution and instability with combined dorsal and volar displacement/damage, a combined volar and dorsal plating (Option 4) approach often provides superior stability and allows for more aggressive early rehabilitation, leading to better functional outcomes.

Question 3856

Topic: 7. Hand and Wrist
A 45-year-old construction worker presents with chronic radial-sided wrist pain, particularly with grip and forearm rotation, after a fall onto an outstretched hand 5 years prior. Physical exam reveals tenderness over the scaphoid and lunate. Radiographs show widening of the scapholunate interval (Terry Thomas sign) and proximal migration of the capitate into the scapholunate gap. What is the most appropriate diagnosis and long-term management strategy?
. Scaphoid nonunion advanced collapse (SNAC) wrist; scaphoid excision and four-corner fusion.
. Scapholunate advanced collapse (SLAC) wrist; scaphoid excision and four-corner fusion.
. Isolated scapholunate ligament tear; primary repair or reconstruction.
. De Quervain's tenosynovitis; corticosteroid injection and splinting.
. Pisotriquetral arthritis; pisiform excision.

Correct Answer & Explanation

. Scapholunate advanced collapse (SLAC) wrist; scaphoid excision and four-corner fusion.

Explanation

The patient's symptoms (chronic radial-sided wrist pain, grip/rotation pain, tenderness over scaphoid/lunate) and radiographic findings (widening of the scapholunate interval, proximal migration of the capitate into the scapholunate gap) are classic for Scapholunate Advanced Collapse (SLAC) wrist. This condition is a progressive degenerative arthritis of the wrist that follows an untreated or unrepaired chronic scapholunate dissociation. Option 1 (SLAC wrist; scaphoid excision and four-corner fusion) is the correct answer. The described clinical and radiographic features are pathognomonic for SLAC wrist. In advanced stages (Stage II or III, indicated by capitate migration), scaphoid excision and four-corner fusion (fusion of lunate, triquetrum, capitate, and hamate) is a well-established and effective procedure to relieve pain while preserving some wrist motion.

Question 3857

Topic: 7. Hand and Wrist
A 35-year-old male, a professional tennis player, presents with chronic wrist pain and stiffness. MRI reveals collapse of the lunate, sclerosis, fragmentation, and carpal height loss, consistent with Kienbock's disease Lichtman Stage IIIB. He has failed conservative management, including activity modification and immobilization. Which of the following surgical options is most appropriate given the advanced stage of the disease?
. Radial shortening osteotomy.
. Proximal row carpectomy (PRC).
. Lunate revascularization with a vascularized bone graft.
. Denervation of the wrist.
. Capitate shortening osteotomy.

Correct Answer & Explanation

. Radial shortening osteotomy.

Explanation

Lichtman Stage IIIB Kienbock's disease is characterized by lunate collapse, sclerosis, fragmentation, and carpal height loss, but without significant pan-carpal degenerative changes. In this stage, the goal is to offload the lunate to prevent further collapse and pain. A radial shortening osteotomy (Option A) is indicated when there is a positive ulnar variance or neutral variance, effectively decompressing the lunate. It is a well-established treatment for early to mid-stage Kienbock's disease before diffuse arthrosis sets in. Proximal row carpectomy (PRC) (Option B) is typically reserved for Lichtman Stage IV disease, where pan-carpal arthritis has developed. Lunate revascularization (Option C) is more appropriate for earlier stages (Lichtman I or II) before significant collapse and fragmentation. Denervation (Option D) is a palliative procedure for pain relief but does not address the underlying pathology or prevent progression. Capitate shortening osteotomy (Option E) may be considered in cases of negative ulnar variance but is less common and typically less effective for IIIB disease than radial shortening.

Question 3858

Topic: 7. Hand and Wrist

A 40-year-old carpenter presents with chronic left wrist pain and weakness following a fall onto his outstretched hand 2 years prior. Radiographs reveal a scaphoid nonunion with a humpback deformity and dorsal intercalated segmental instability (DISI) pattern. MRI confirms avascular necrosis of the proximal pole fragment. He has failed conservative treatment. What is the most appropriate surgical management for this condition?

. Open reduction and internal fixation of the scaphoid with a headless compression screw.
. Excision of the proximal pole of the scaphoid.
. Radial styloidectomy and wrist denervation.
. Vascularized bone graft to the scaphoid nonunion and internal fixation.
. Proximal row carpectomy (PRC).

Correct Answer & Explanation

. Vascularized bone graft to the scaphoid nonunion and internal fixation.

Explanation

This patient has a chronic scaphoid nonunion with several complicating factors: humpback deformity (indicating carpal collapse), dorsal intercalated segmental instability (DISI), and avascular necrosis (AVN) of the proximal pole. These factors significantly complicate healing and increase the risk of progression to scaphoid nonunion advanced collapse (SNAC) wrist. In the presence of AVN of the proximal pole and a humpback deformity, a simple screw fixation (Option A) is often insufficient due to poor bone quality and the need to correct the deformity and revascularize the fragment. A vascularized bone graft (VBG) (Option D) is the most appropriate surgical management in this scenario. The VBG provides live bone cells and blood supply to the avascular proximal pole, promotes healing of the nonunion, and helps maintain carpal height after reduction of the humpback deformity. Excision of the proximal pole (Option B) would further destabilize the wrist. Radial styloidectomy and wrist denervation (Option C) are palliative for pain relief but don't address the underlying nonunion or instability. Proximal row carpectomy (PRC) (Option E) is a salvage procedure typically reserved for SNAC wrist or advanced arthritis, not for a treatable nonunion with AVN.

Question 3859

Topic: 7. Hand and Wrist

A 38-year-old healthy male presents with chronic right arm and hand numbness, tingling, and weakness, exacerbated by overhead activities. Physical examination reveals a positive Adson's test, Wright's test, and Roos test. Nerve conduction studies show mild slowing across the brachial plexus, but no definitive focal nerve entrapment. MRI of the cervical spine is unremarkable. Given the clinical picture, what is the most likely diagnosis and the preferred surgical approach if conservative treatment fails?

. Cervical radiculopathy, requiring anterior cervical discectomy and fusion (ACDF).
. Ulnar nerve entrapment at the elbow, requiring ulnar nerve transposition.
. Median nerve entrapment at the wrist (carpal tunnel syndrome), requiring carpal tunnel release.
. Neurogenic thoracic outlet syndrome, requiring first rib resection and scalenectomy.
. Pancoast tumor, requiring biopsy and oncologic resection.

Correct Answer & Explanation

. Neurogenic thoracic outlet syndrome, requiring first rib resection and scalenectomy.

Explanation

This patient's symptoms (numbness, tingling, weakness in arm/hand, exacerbated by overhead activities) and positive provocative tests (Adson's, Wright's, Roos) are classic for neurogenic thoracic outlet syndrome (NTOS). NTOS occurs due to compression of the brachial plexus at the thoracic outlet (between the scalene muscles, first rib, and clavicle). The cervical spine MRI being unremarkable rules out cervical radiculopathy (Option A) as the primary cause. Nerve conduction studies often show equivocal or non-localizing findings in NTOS, making it a clinical diagnosis. Ulnar nerve entrapment (Option B) and carpal tunnel syndrome (Option C) would typically have more focal signs and symptoms and specific NCS findings. A Pancoast tumor (Option E) can cause similar symptoms but usually presents with Horner's syndrome and is ruled out by normal imaging. If conservative management fails for NTOS, the preferred surgical approach involves decompression of the thoracic outlet, most commonly by first rib resection and scalenectomy (Option D), which releases the brachial plexus from compressive structures.

Question 3860

Topic: 7. Hand and Wrist

Which of the following describes the most common mechanism of injury for a perilunate dislocation?

. A direct fall onto the palm with the wrist in radial deviation and flexion.
. A fall onto an outstretched hand with the wrist in dorsiflexion, ulnar deviation, and supination.
. A twisting injury of the wrist with the forearm pronated.
. A direct blow to the dorsal aspect of the wrist.
. Repetitive microtrauma from occupational activities.

Correct Answer & Explanation

. A fall onto an outstretched hand with the wrist in dorsiflexion, ulnar deviation, and supination.

Explanation

The most common mechanism for a perilunate dislocation is a fall onto an outstretched hand (FOOSH) with the wrist in dorsiflexion, ulnar deviation, and supination (Option B). This hyperdorsiflexion causes the carpus to fail dorsally around the relatively fixed lunate, which remains articulated with the radius. Options A, C, D, and E describe mechanisms for other wrist injuries or are less common for perilunate dislocations. For example, a fall onto the palm with radial deviation and flexion (Option A) could lead to other carpal injuries but not typically a perilunate. Repetitive microtrauma (Option E) is associated with conditions like Kienbock's disease or TFCC tears, not acute dislocations.

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