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7. Hand and Wrist MCQs

Practice Set 198 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 3941

Topic: 7. Hand and Wrist

Which condition is characterized by progressive, non-inflammatory thickening and shortening of the palmar fascia, leading to fixed flexion deformities of the fingers, most commonly the ring and small fingers?

. Trigger finger.
. Ganglion cyst.
. Carpal tunnel syndrome.
. Dupuytren's contracture.
. Flexor tenosynovitis.

Correct Answer & Explanation

. Dupuytren's contracture.

Explanation

Dupuytren's contracture is a fibromatosis characterized by progressive, non-inflammatory thickening and shortening of the palmar fascia, forming nodules and cords that lead to fixed flexion deformities of the fingers, predominantly the ring and small fingers. Trigger finger is a stenosing tenosynovitis. Ganglion cysts are fluid-filled sacs. Carpal tunnel syndrome is median nerve compression. Flexor tenosynovitis is inflammation of the tendon sheath.

Question 3942

Topic: 7. Hand and Wrist

Which of the following conditions might lead an orthopedic surgeon to specifically inquire about a history of 'lumps or bulges' in the groin or abdomen, indicating a potential hernia, before proceeding with elective hip surgery?

. Previous knee arthroscopy.
. History of stable angina.
. Chronic low back pain.
. Frequent constipation and straining during bowel movements.
. Diagnosis of carpal tunnel syndrome.

Correct Answer & Explanation

. Frequent constipation and straining during bowel movements.

Explanation

Frequent constipation and straining during bowel movements significantly increase intra-abdominal pressure, which is a known risk factor for hernia formation and exacerbation. Therefore, an orthopedic surgeon should inquire about such a history before elective hip surgery to identify any occult or symptomatic hernias that could complicate the peri-operative period (e.g., pain, incarceration, need for urgent surgery). Addressing a known hernia electively before major orthopedic surgery can prevent a post-operative crisis. Other options are generally not directly related to hernia risk.

Question 3943

Topic: 7. Hand and Wrist

What is the most critical anatomical structure to protect during surgical excision of a ganglion cyst from the dorsal aspect of the wrist?

. Radial artery
. Ulnar nerve
. Superficial branch of the radial nerve
. Median nerve
. Posterior interosseous nerve

Correct Answer & Explanation

. Superficial branch of the radial nerve

Explanation

Ganglion cysts on the dorsal aspect of the wrist are often in close proximity to the superficial branch of the radial nerve (SBRN). Damage to this nerve during excision can lead to painful neuromas or sensory deficits over the dorsum of the hand and thumb, which can be debilitating. The radial artery is typically on the volar side. The ulnar and median nerves are also volar or medial. The posterior interosseous nerve is a deep motor nerve and is less at risk during superficial ganglion excision.

Question 3944

Topic: 7. Hand and Wrist

Which intrinsic muscle of the hand is primarily responsible for opposition of the thumb?

. Adductor pollicis
. Flexor pollicis brevis
. Abductor pollicis brevis
. Opponens pollicis
. First dorsal interossei

Correct Answer & Explanation

. Opponens pollicis

Explanation

The Opponens Pollicis muscle is solely responsible for the complex motion of opposition of the thumb, bringing the thumb across the palm to touch the fingertips. The Abductor Pollicis Brevis abducts the thumb, and the Flexor Pollicis Brevis flexes it. The Adductor Pollicis adducts the thumb. The First Dorsal Interossei flex and abduct the index finger.

Question 3945

Topic: 7. Hand and Wrist

A patient presents with a painful, swollen index finger. On examination, the finger is held in slight flexion, and there is tenderness along the flexor tendon sheath, particularly at the A1 pulley. Passive extension of the finger is painful. What is the most likely diagnosis?

. Mallet finger
. Trigger finger (stenosing tenosynovitis)
. De Quervain's tenosynovitis
. Flexor tenosynovitis (Kanavel's signs)
. Gamekeeper's thumb

Correct Answer & Explanation

. Flexor tenosynovitis (Kanavel's signs)

Explanation

The description (finger held in slight flexion, uniform tenderness along the flexor sheath, pain with passive extension, fusiform swelling) matches Kanavel's cardinal signs of flexor tenosynovitis, a surgical emergency due to infection. Mallet finger is a disruption of the extensor tendon at the DIP joint. Trigger finger involves catching/locking of a digit due to a nodule in the flexor tendon at the A1 pulley. De Quervain's tenosynovitis affects the abductor pollicis longus and extensor pollicis brevis at the radial styloid. Gamekeeper's thumb is an injury to the ulnar collateral ligament of the thumb MCP joint.

Question 3946

Topic: 7. Hand and Wrist

Which nerve is typically involved in Carpal Tunnel Syndrome?

. Radial nerve
. Ulnar nerve
. Median nerve
. Axillary nerve
. Musculocutaneous nerve

Correct Answer & Explanation

. Median nerve

Explanation

Carpal Tunnel Syndrome (CTS) results from compression of the median nerve as it passes through the carpal tunnel at the wrist. This leads to characteristic symptoms of numbness, tingling, and pain in the thumb, index finger, middle finger, and radial half of the ring finger, often worse at night. The radial and ulnar nerves pass outside the carpal tunnel.

Question 3947

Topic: Wrist & Carpus
A patient with suspected avascular necrosis of the lunate (Kienböck's disease) presents. Which classification system is commonly used to stage this condition?
. Watson classification
. Lichtman classification
. Mayo classification
. Garcia-Elias classification
. Herbert classification

Correct Answer & Explanation

. Lichtman classification

Explanation

The Lichtman classification is the most commonly used staging system for Kienböck's disease (avascular necrosis of the lunate). It categorizes the disease into four stages based on radiographic findings, including sclerosis, collapse, fragmentation, and secondary degenerative changes, guiding treatment decisions. Watson classification is for scapholunate dissociation. Mayo classification is for elbow instability. Herbert classification is for scaphoid fractures. Garcia-Elias is not a widely recognized orthopedic classification.

Question 3948

Topic: 7. Hand and Wrist

What is the typical mechanism of injury for a Colles fracture?

. Direct blow to the dorsal aspect of the wrist
. Fall onto a pronated hand with the wrist in flexion
. Axial load through the thumb
. Fall onto an outstretched hand (FOOSH) with the wrist in dorsiflexion
. Rotational force to the forearm

Correct Answer & Explanation

. Fall onto an outstretched hand (FOOSH) with the wrist in dorsiflexion

Explanation

The typical mechanism of injury for a Colles fracture is a fall onto an outstretched hand (FOOSH) with the wrist in dorsiflexion (extension). This forces the distal radius dorsally and typically results in dorsal angulation and displacement. A fall onto a pronated hand with the wrist in flexion would typically result in a Smith's fracture (reverse Colles), with volar displacement and angulation.

Question 3949

Topic: 7. Hand and Wrist

Which radiographic measurement is typically decreased in a Colles fracture?

. Ulnar variance
. Radial length (or radial height)
. Radial inclination
. Volar tilt
. Carpal height ratio

Correct Answer & Explanation

. Radial length (or radial height)

Explanation

In a typical Colles fracture with dorsal displacement and impaction, radial length (or radial height) is decreased due to compression of the distal radius. Radial inclination is also often decreased, and volar tilt becomes dorsal tilt (a negative volar tilt). Ulnar variance becomes positive (ulna appears longer relative to the radius). Carpal height ratio can also be affected, often decreased.

Question 3950

Topic: Wrist & Carpus

What is the primary anatomical purpose of the pronator quadratus muscle in relation to volar plating of the distal radius?

. It stabilizes the distal radioulnar joint (DRUJ).
. It is a key landmark for identifying the radial artery.
. It protects the flexor tendons from hardware irritation.
. It contributes to wrist extension.
. It prevents dorsal displacement of the distal fragment.

Correct Answer & Explanation

. It protects the flexor tendons from hardware irritation.

Explanation

The pronator quadratus muscle is typically reflected from lateral to medial during a volar approach for distal radius plating. After plate application, it is usually repaired over the plate. Its primary purpose in this context is to provide a soft tissue coverage for the volar locking plate and screws, thus protecting the overlying flexor tendons (especially FPL and FDP) from direct contact and irritation by the hardware. While it contributes to pronation and DRUJ stability, its role in protecting tendons from hardware is crucial in volar plating.

Question 3951

Topic: Wrist & Carpus
Which type of fracture would be classified as a Frykman Type II?
. Extra-articular distal radius fracture without ulnar styloid fracture
. Extra-articular distal radius fracture with ulnar styloid fracture
. Intra-articular distal radius fracture involving the radiocarpal joint only
. Intra-articular distal radius fracture involving both radiocarpal and DRUJ with ulnar styloid fracture
. Intra-articular distal radius fracture involving both radiocarpal and DRUJ without ulnar styloid fracture

Correct Answer & Explanation

. Extra-articular distal radius fracture with ulnar styloid fracture

Explanation

The Frykman classification system categorizes distal radius fractures based on articular involvement and the presence of an ulnar styloid fracture: Type I: Extra-articular, no ulnar styloid. Type II: Extra-articular, with ulnar styloid. Type III: Intra-articular (radiocarpal), no ulnar styloid. Type IV: Intra-articular (radiocarpal), with ulnar styloid. Type V: Intra-articular (radiocarpal + DRUJ), no ulnar styloid. Type VI: Intra-articular (radiocarpal + DRUJ), with ulnar styloid. Type VII: Intra-articular (DRUJ only), no ulnar styloid. Type VIII: Intra-articular (DRUJ only), with ulnar styloid. Therefore, Frykman Type II is an extra-articular distal radius fracture with an associated ulnar styloid fracture.

Question 3952

Topic: 7. Hand and Wrist

A patient with a Colles fracture is treated with closed reduction and casting. One week later, they complain of worsening pain, difficulty extending their thumb, and a 'giving way' sensation. On examination, there is tenderness over Lister's tubercle. What is the most likely diagnosis?

. Median nerve palsy
. Flexor pollicis longus (FPL) rupture
. Extensor pollicis longus (EPL) tenosynovitis or impending rupture
. Infection in the casted arm
. Acute carpal tunnel syndrome

Correct Answer & Explanation

. Extensor pollicis longus (EPL) tenosynovitis or impending rupture

Explanation

Pain, difficulty extending the thumb, and tenderness over Lister's tubercle one week after a Colles fracture suggests Extensor Pollicis Longus (EPL) tenosynovitis or impending rupture. The EPL tendon makes a sharp turn around Lister's tubercle, and swelling, hematoma, or subtle displacement can cause irritation and compromise its integrity. An actual EPL rupture typically presents as a sudden inability to extend the IP joint of the thumb actively. FPL rupture would affect thumb flexion. Median nerve palsy causes sensory changes and thenar weakness, not necessarily specific thumb extension issues in this pattern. Infection would have systemic signs. Acute carpal tunnel would cause median nerve distribution symptoms.

Question 3953

Topic: 7. Hand and Wrist

When performing a volar approach for distal radius plating, the median nerve is most at risk of injury in which position?

. Laterally, during dissection towards the radial artery.
. Medially, near the flexor carpi ulnaris tendon.
. Deep to the pronator quadratus muscle.
. Superficially, just ulnar to the flexor carpi radialis tendon.
. Distally, in the carpal tunnel itself during plate insertion.

Correct Answer & Explanation

. Superficially, just ulnar to the flexor carpi radialis tendon.

Explanation

The median nerve typically lies superficially, just ulnar (medial) to the flexor carpi radialis (FCR) tendon in the distal forearm. During a standard Henry approach or similar volar approach, care must be taken to retract the FCR tendon radially to protect the median nerve from direct injury during incision and subsequent dissection. The radial artery is more lateral. The pronator quadratus covers the bone. The carpal tunnel is distal, but the initial approach and retraction put the nerve at highest superficial risk.

Question 3954

Topic: Wrist & Carpus

What is the acceptable range for post-reduction volar tilt in a Colles fracture?

. 0 to 5 degrees dorsal tilt
. 10 to 20 degrees volar tilt
. Any degree of dorsal tilt is acceptable if radial length is restored
. -5 to 10 degrees (dorsal to slight volar)
. Strictly 11 degrees volar tilt

Correct Answer & Explanation

. -5 to 10 degrees (dorsal to slight volar)

Explanation

Acceptable post-reduction parameters for volar tilt generally range from neutral (0 degrees) to slight volar angulation (up to 10-15 degrees volar tilt). Some sources might accept a small degree of dorsal tilt (e.g., up to 5 degrees dorsal, or -5 degrees volar) in older, lower-demand patients, but beyond that, it signifies instability or malreduction with increased risk of functional impairment. The typical volar tilt of a normal distal radius is around 11-12 degrees. Therefore, -5 to 10 degrees is the most reasonable acceptable range, encompassing neutral or mild dorsal as potentially acceptable in certain contexts, and avoiding excessive dorsal tilt.

Question 3955

Topic: 7. Hand and Wrist

What is the main advantage of a volar locking plate over traditional K-wire fixation for an unstable, comminuted Colles fracture in an elderly patient?

. Volar locking plates are less invasive and have a lower infection risk.
. Volar locking plates allow for immediate, unrestricted weight-bearing on the wrist.
. Volar locking plates provide superior rotational stability and better maintenance of reduction, especially in osteoporotic bone, allowing earlier mobilization.
. K-wire fixation is contraindicated in elderly patients due to poor bone quality.
. K-wires are more likely to cause extensor tendon irritation.

Correct Answer & Explanation

. Volar locking plates provide superior rotational stability and better maintenance of reduction, especially in osteoporotic bone, allowing earlier mobilization.

Explanation

Volar locking plates provide superior rotational stability and better maintenance of reduction, especially in comminuted fractures and osteoporotic bone, compared to K-wire fixation. This rigid fixation allows for earlier mobilization of the wrist and hand, which is crucial for preventing stiffness and improving functional outcomes in elderly patients. While K-wires are less invasive, they often provide less stable fixation, particularly in osteoporotic bone, and can lead to loss of reduction. K-wire fixation is not contraindicated in the elderly, but its indications are more limited. Dorsal hardware (plates or wires) is more likely to cause extensor tendon irritation than volar.

Question 3956

Topic: Wrist & Carpus

The 'watershed line' on the volar aspect of the distal radius is an important surgical consideration to prevent which complication?

. Radial artery injury
. Median nerve compression
. Flexor tendon irritation/rupture
. DRUJ instability
. Nonunion of the distal radius

Correct Answer & Explanation

. Flexor tendon irritation/rupture

Explanation

The 'watershed line' on the volar aspect of the distal radius represents the distal limit for volar plate placement. Placing the plate or screws distal to this line risks impingement on and subsequent irritation or rupture of the flexor tendons, particularly the flexor pollicis longus (FPL). This line marks the insertion of the volar capsule and ligaments. Avoiding distal plate placement past this line is critical for preventing tendon complications.

Question 3957

Topic: 7. Hand and Wrist

Which factor is LEAST likely to contribute to the development of Complex Regional Pain Syndrome (CRPS) Type I after a Colles fracture?

. Prolonged immobilization
. Excessive edema post-injury
. Psychological stress and anxiety
. Aggressive early physical therapy mobilization of the wrist
. Significant pain out of proportion to the injury

Correct Answer & Explanation

. Aggressive early physical therapy mobilization of the wrist

Explanation

Aggressive early physical therapy mobilization of the wrist is LEAST likely to contribute to CRPS Type I; in fact, early, gentle mobilization, within pain limits, is often part of CRPS prevention and management. Factors that are known to contribute to CRPS include prolonged immobilization, excessive edema, psychological factors, and severe pain. The pathophysiology of CRPS is complex, involving neuropathic, inflammatory, and sympathetic nervous system dysfunction.

Question 3958

Topic: 7. Hand and Wrist

Which of the following ligaments is most commonly injured in association with a Colles fracture, particularly if there is DRUJ instability?

. Scapholunate ligament
. Lunatotriquetral ligament
. Triangular fibrocartilage complex (TFCC)
. Radial collateral ligament
. Transverse carpal ligament

Correct Answer & Explanation

. Triangular fibrocartilage complex (TFCC)

Explanation

The Triangular Fibrocartilage Complex (TFCC) is most commonly injured in association with a Colles fracture, particularly when there is involvement of the distal radioulnar joint (DRUJ) or an associated ulnar styloid fracture. The TFCC is the primary stabilizer of the DRUJ. Scapholunate and lunatotriquetral ligaments relate to carpal instability. Radial collateral ligament is on the radial side of the wrist. Transverse carpal ligament forms the roof of the carpal tunnel.

Question 3959

Topic: 7. Hand and Wrist

A patient with a Colles fracture treated with a volar locking plate returns at 6 weeks with good union but complains of persistent numbness in the median nerve distribution, which was not present pre-operatively. What is the most likely cause?

. Infection around the plate
. CRPS Type I
. Carpal tunnel syndrome due to plate prominence or scar tissue
. Extensor pollicis longus rupture
. DRUJ instability

Correct Answer & Explanation

. Carpal tunnel syndrome due to plate prominence or scar tissue

Explanation

Persistent numbness in the median nerve distribution developing post-operatively after volar plating, when it was not present pre-operatively, strongly suggests carpal tunnel syndrome. This can be caused by scar tissue formation, plate prominence (especially if placed too distally or volarly), or swelling around the median nerve within the carpal tunnel. Infection would typically have other signs like pain, erythema, and discharge. CRPS has a broader symptom complex. EPL rupture causes loss of thumb extension. DRUJ instability relates to mechanical symptoms, not median nerve neuropathy directly.

Question 3960

Topic: 7. Hand and Wrist

In the surgical approach for a volar locking plate, the Flexor Carpi Radialis (FCR) tendon is commonly retracted in which direction?

. Ulnarly
. Dorsally
. Proximally
. Radially
. Distally

Correct Answer & Explanation

. Radially

Explanation

In the standard volar (Henry) approach to the distal radius, the incision is made between the Flexor Carpi Radialis (FCR) tendon and the radial artery. The FCR tendon is then retracted radially (laterally) to expose the underlying structures, specifically the median nerve which lies ulnar to the FCR, and then deeper, the pronator quadratus muscle and distal radius.

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