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7. Hand and Wrist MCQs

Practice Set 199 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 3961

Topic: 7. Hand and Wrist

A patient sustained a Colles fracture and underwent closed reduction and casting. One year later, they complain of chronic pain at the distal radioulnar joint (DRUJ), limited forearm rotation, and a prominent ulnar head. What is the most likely cause?

. Scapholunate advanced collapse (SLAC) wrist
. Malunion of the distal radius with positive ulnar variance
. Carpal tunnel syndrome
. Nonunion of the distal radius
. Flexor tendon rupture

Correct Answer & Explanation

. Malunion of the distal radius with positive ulnar variance

Explanation

Chronic DRUJ pain, limited forearm rotation (pronation/supination), and a prominent ulnar head after a Colles fracture strongly indicate malunion of the distal radius, specifically with positive ulnar variance (radial shortening). This malunion alters the mechanics of the DRUJ, leading to impingement, arthritis, and instability. SLAC wrist is related to chronic scapholunate dissociation. Carpal tunnel would present with median nerve symptoms. Nonunion is very rare in the distal radius. Flexor tendon rupture is specific to loss of active flexion.

Question 3962

Topic: Wrist & Carpus

When assessing a Colles fracture on lateral radiographs, what measurement quantifies the normal volar angulation of the distal radial articular surface relative to the shaft?

. Radial inclination
. Ulnar variance
. Radial length
. Volar tilt (or Palmar tilt)
. Carpo-radial distance

Correct Answer & Explanation

. Volar tilt (or Palmar tilt)

Explanation

Volar tilt (also known as palmar tilt) quantifies the normal volar angulation of the distal radial articular surface relative to the longitudinal axis of the radial shaft on a lateral radiograph. Normal volar tilt is typically around 11-12 degrees. In a Colles fracture, this tilt is lost or reversed, resulting in dorsal tilt.

Question 3963

Topic: Wrist & Carpus
Which type of Colles fracture, according to Frykman's classification, carries the worst prognosis for post-traumatic arthritis?
. Type I
. Type II
. Type III
. Type IV
. Type VIII

Correct Answer & Explanation

. Type III

Explanation

Frykman Type IV fracture (intra-articular involving the radiocarpal joint, with an ulnar styloid fracture) carries a worse prognosis for post-traumatic arthritis among the initial types because it involves the radiocarpal articular surface, which is crucial for pain-free motion. More generally, any fracture with significant intra-articular involvement (Types III, IV, V, VI, VII, VIII) has a higher risk of post-traumatic arthritis, but Type IV specifically combines radiocarpal articular involvement with ulnar styloid involvement, indicating a more severe injury with potential DRUJ impact. Type VIII (intra-articular DRUJ only, with ulnar styloid) also has a poor prognosis for DRUJ arthritis. However, Type IV typically signifies significant articular disruption of the main radiocarpal joint.

Question 3964

Topic: 7. Hand and Wrist

A patient is undergoing closed reduction of a Colles fracture. What maneuver is used to correct the dorsal displacement of the distal fragment?

. Exaggerated supination followed by wrist extension
. Strong traction, then exaggeration of deformity, followed by volar translation of the distal fragment
. Ulnar deviation with forearm pronation
. Radial deviation with forearm supination
. Direct pressure on the radial styloid

Correct Answer & Explanation

. Strong traction, then exaggeration of deformity, followed by volar translation of the distal fragment

Explanation

After applying strong traction to disimpact the fracture, the reduction maneuver typically involves exaggerating the deformity (dorsiflexing the wrist to unlock the fragments), then applying a volar translational force to the distal fragment while simultaneously correcting other deformities (supination, ulnar deviation, palmar flexion). The key for dorsal displacement is the volar translation of the distal fragment. Wrist extension would worsen dorsal displacement.

Question 3965

Topic: 7. Hand and Wrist

What is the primary role of the radiolunate angle in assessing distal radius fractures?

. It assesses the congruity of the distal radioulnar joint (DRUJ).
. It measures the angle between the radial shaft and the articular surface on a lateral view.
. It evaluates the alignment between the distal radius and the lunate bone.
. It determines the amount of radial shortening.
. It predicts the risk of median nerve compression.

Correct Answer & Explanation

. It evaluates the alignment between the distal radius and the lunate bone.

Explanation

The radiolunate angle is measured on a lateral radiograph and evaluates the alignment between the distal radius and the lunate bone. In a normal wrist, the axis of the radius and the lunate should be collinear, or the lunate should be slightly volar tilted relative to the radius. Disruption of this relationship (e.g., dorsal angulation of the lunate relative to the radius) indicates carpal malalignment and often accompanies a dorsally angulated distal radius fracture or carpal instability. Volar tilt assesses the angle between the radial shaft and the articular surface.

Question 3966

Topic: Wrist & Carpus

Which complication is most characteristic of a malunited Colles fracture with excessive radial shortening and positive ulnar variance?

. Radial nerve palsy
. Scaphoid nonunion
. Ulnar impaction syndrome
. Flexor carpi ulnaris tendonitis
. Extensor indicis proprius rupture

Correct Answer & Explanation

. Ulnar impaction syndrome

Explanation

Excessive radial shortening and positive ulnar variance (where the ulna is relatively longer than the radius) following a Colles fracture can lead to ulnar impaction syndrome. This condition is characterized by chronic pain at the ulnar side of the wrist, particularly with pronation and ulnar deviation, due to increased load transmission through the TFCC and impaction of the ulnar head against the carpus (specifically the triquetrum and lunate). Radial nerve palsy, scaphoid nonunion, and tendon ruptures are not directly caused by ulnar impaction, though other tendon issues can occur.

Question 3967

Topic: 7. Hand and Wrist

When assessing radiographs for a Colles fracture, which view is most critical for evaluating articular congruence and intra-articular step-off?

. Anteroposterior (AP) view
. Lateral view
. Oblique view
. Traction view
. Carpal tunnel view

Correct Answer & Explanation

. Lateral view

Explanation

While both AP and lateral views are essential, the lateral view is most critical for evaluating articular congruence, particularly for assessing dorsal or volar displacement/angulation of the articular surface and identifying intra-articular step-off or gap. The AP view is best for assessing radial length, radial inclination, and ulnar variance. Oblique views can provide additional information, and traction views can aid in discerning fracture lines, but the lateral view is paramount for articular surface assessment in the sagittal plane.

Question 3968

Topic: Nerve & Tendon

Which clinical sign would raise immediate concern for potential median nerve compression following closed reduction and casting of a Colles fracture?

. Pain with passive finger flexion
. Inability to actively extend the thumb IP joint
. Numbness and tingling in the little finger
. Paresthesia in the thumb, index, and middle fingers with pain radiating proximally
. Warm, dry, red skin of the affected hand

Correct Answer & Explanation

. Paresthesia in the thumb, index, and middle fingers with pain radiating proximally

Explanation

Paresthesia (numbness and tingling) in the median nerve distribution (thumb, index, middle fingers, radial half of ring finger) combined with pain radiating proximally are classic signs of median nerve compression. While pain with passive finger flexion can be a sign of compartment syndrome, the specific nerve distribution points to median nerve. Inability to extend the thumb IP joint suggests EPL rupture. Numbness in the little finger points to ulnar nerve. Warm, dry, red skin might be seen in CRPS, but not typically in acute median nerve compression.

Question 3969

Topic: 7. Hand and Wrist

Regarding the surgical management of Colles fractures, which specific nerve is most at risk during a standard volar (Henry) approach to the distal radius?

. Radial nerve (superficial sensory branch)
. Ulnar nerve
. Median nerve
. Posterior interosseous nerve
. Anterior interosseous nerve

Correct Answer & Explanation

. Median nerve

Explanation

During a standard volar (Henry) approach to the distal radius, the median nerve is most at risk. It lies just ulnar (medial) to the flexor carpi radialis (FCR) tendon. Careful retraction of the FCR radially is essential to protect the median nerve. The superficial radial nerve is on the dorsal-radial aspect. The ulnar nerve is on the ulnar side. The posterior interosseous nerve is a motor branch of the radial nerve, located dorsally. The anterior interosseous nerve (a branch of the median nerve) is deep in the forearm but generally protected if the median nerve is safely retracted.

Question 3970

Topic: 7. Hand and Wrist

What is the primary function of the pronator quadratus muscle in the forearm, beyond its surgical relevance in plating?

. Wrist flexion
. Forearm supination
. Forearm pronation
. Finger extension
. Elbow flexion

Correct Answer & Explanation

. Forearm pronation

Explanation

The pronator quadratus is a deep muscle of the forearm, located distally, and its primary function is forearm pronation. It also helps to stabilize the distal radioulnar joint (DRUJ) during forearm rotation. While the muscle provides soft tissue coverage over a volar plate, its physiological role is pronation.

Question 3971

Topic: Wrist & Carpus

In the presence of an associated ulnar styloid fracture in a Colles fracture, when does it most significantly impact management decisions?

. Always, as it is an absolute indication for surgery.
. When it is large and leads to gross instability of the distal radioulnar joint (DRUJ).
. When it is smaller than 2mm, indicating minimal trauma.
. Only if associated with median nerve palsy.
. Never, as it heals spontaneously without intervention.

Correct Answer & Explanation

. When it is large and leads to gross instability of the distal radioulnar joint (DRUJ).

Explanation

An associated ulnar styloid fracture most significantly impacts management decisions when it is large, displaced, or, most critically, leads to gross instability of the distal radioulnar joint (DRUJ). The TFCC attaches to the ulnar styloid, so a displaced styloid fracture can destabilize the DRUJ. If the DRUJ is unstable after distal radius fixation, surgical management of the ulnar styloid (e.g., fixation or excision if comminuted) might be considered. Small, minimally displaced ulnar styloid fractures often heal well conservatively and don't typically affect the overall management of the distal radius fracture unless there's underlying DRUJ instability. It is not an absolute indication for surgery merely by its presence.

Question 3972

Topic: 7. Hand and Wrist

A 55-year-old female presents with severe wrist pain, paresthesias in the thumb, index, and middle fingers, and nocturnal awakening. Phalen's test and Tinel's sign are positive. Electromyography and nerve conduction studies confirm severe median nerve compression at the carpal tunnel. She has failed 6 months of conservative management including splinting, NSAIDs, and a corticosteroid injection. What is the most appropriate next step?

. Repeat corticosteroid injection
. Neurolysis of the median nerve proximal to the carpal tunnel
. Endoscopic carpal tunnel release
. Open carpal tunnel release
. Referral for occupational therapy and ergonomic assessment

Correct Answer & Explanation

. Open carpal tunnel release

Explanation

For severe carpal tunnel syndrome that has failed extensive conservative management, surgical decompression of the median nerve is indicated. Both open and endoscopic carpal tunnel release are effective. While endoscopic has a potentially faster return to work for some, open release is considered the gold standard, widely available, and highly successful. Given the 'severe' classification and failure of all conservative measures, surgical decompression is necessary. Repeat injections have diminishing returns and increased risk with severe compression. Neurolysis proximal to the carpal tunnel is not the primary treatment. Occupational therapy would be part of conservative care, which has already failed.

Question 3973

Topic: 7. Hand and Wrist

Which of the following is the most common carpal bone to be fractured?

. Lunate
. Capitate
. Scaphoid
. Trapezium
. Triquetrum

Correct Answer & Explanation

. Scaphoid

Explanation

The scaphoid is the most commonly fractured carpal bone. It typically occurs due to a fall on an outstretched hand (FOOSH) with the wrist hyperextended and radially deviated. Its unique blood supply (proximal pole receives blood supply distally) makes it prone to avascular necrosis and nonunion. Other carpal bones are fractured less frequently.

Question 3974

Topic: 7. Hand and Wrist
Regarding avascular necrosis of the lunate (Kienböck's disease), which of the following statements is most accurate?
. It is more common in females and typically affects the dominant wrist.
. Radiographs in early stages typically show carpal collapse and sclerosis.
. Ulnar positive variance is considered a predisposing factor.
. Conservative management with casting is the definitive treatment for advanced stages.
. Radial shortening osteotomy is a common surgical treatment aimed at decompressing the lunate.

Correct Answer & Explanation

. Radial shortening osteotomy is a common surgical treatment aimed at decompressing the lunate.

Explanation

Kienböck's disease is avascular necrosis of the lunate. Radial shortening osteotomy (or ulnar lengthening osteotomy) is a common surgical treatment, particularly in patients with ulnar negative variance, aimed at decompressing the lunate by altering the load-bearing across the wrist joint. It is more common in males and affects the dominant or non-dominant wrist equally. Early radiographs may be normal or show subtle density changes; carpal collapse and sclerosis are signs of later stages. Ulnar negative variance (ulna shorter than radius) is a predisposing factor, as it increases compressive forces on the lunate. Conservative management is usually ineffective in advanced stages.

Question 3975

Topic: 7. Hand and Wrist

A 28-year-old male presents with chronic pain and instability of his wrist following a fall onto his outstretched hand. Radiographs show a widening of the scapholunate interval ('Terry Thomas sign') and a dorsal intercalated segment instability (DISI) pattern. What is the most appropriate management for this chronic injury?

. Immobilization in a short arm cast.
. Wrist arthroscopy for debridement.
. Scapholunate ligament repair with capsulodesis.
. Proximal row carpectomy.
. Wrist fusion.

Correct Answer & Explanation

. Scapholunate ligament repair with capsulodesis.

Explanation

The patient presents with chronic scapholunate dissociation (widened scapholunate interval, DISI pattern) after a traumatic event. For chronic, symptomatic, but reducible scapholunate instability without significant arthritis, scapholunate ligament repair (often with augmentation or capsulodesis) is the preferred approach to restore carpal kinematics and prevent progression to scapholunate advanced collapse (SLAC) wrist. Immobilization alone is for acute, stable injuries. Arthroscopy for debridement might provide temporary relief but doesn't address the instability. Proximal row carpectomy or wrist fusion are salvage procedures for advanced arthritis (SLAC wrist) and are not indicated for reducible instability without significant arthritis.

Question 3976

Topic: Nerve & Tendon

A 50-year-old male presents with chronic insidious onset numbness and tingling in his ulnar two fingers and medial forearm. He describes worsening symptoms with prolonged elbow flexion. Physical examination reveals a positive Tinel's sign at the cubital tunnel and weakness in intrinsic hand muscles. What is the most appropriate initial management?

. Immediate cubital tunnel release.
. Oral corticosteroids.
. Elbow extension splinting, activity modification, and nerve gliding exercises.
. Observation with serial neurological exams.
. NSAIDs and heat therapy.

Correct Answer & Explanation

. Elbow extension splinting, activity modification, and nerve gliding exercises.

Explanation

This patient presents with cubital tunnel syndrome (ulnar nerve compression at the elbow). Initial management is always conservative for mild to moderate symptoms. This includes elbow extension splinting, activity modification (avoiding prolonged elbow flexion, leaning on the elbow), and nerve gliding exercises. Surgical decompression (cubital tunnel release) is reserved for failed conservative management, severe nerve compression, or progressive neurological deficits. Oral corticosteroids and NSAIDs may offer temporary symptomatic relief but do not address the underlying compression. Observation alone is insufficient if symptoms are significant.

Question 3977

Topic: 7. Hand and Wrist

A 70-year-old female presents with chronic wrist pain and weakness, particularly with gripping. Radiographs show severe pancarpal osteoarthritis, with marked narrowing of the radioscaphoid and capitolunate joints. She has failed conservative management. What is the most appropriate surgical intervention?

. Scaphoid excision and four-corner fusion.
. Wrist arthrodesis (fusion).
. Proximal row carpectomy.
. Total wrist arthroplasty.
. Radial styloidectomy.

Correct Answer & Explanation

. Wrist arthrodesis (fusion).

Explanation

For severe pancarpal osteoarthritis with diffuse involvement, especially in an older, lower-demand patient, wrist arthrodesis (fusion) is often the most appropriate surgical intervention. It provides reliable pain relief and stability, albeit at the cost of sacrificing motion. While total wrist arthroplasty (TWA) is an option to preserve motion, it has specific indications and potential complications (loosening, wear) that might make fusion a more predictable choice for severe, diffuse disease, particularly in patients not requiring extensive wrist motion. Scaphoid excision and four-corner fusion (or PRC) are for more localized patterns of arthritis (e.g., SLAC, SNAC wrist) where some healthy carpal bones remain. Radial styloidectomy is for localized impingement.

Question 3978

Topic: 7. Hand and Wrist

A 35-year-old male presents with persistent pain and tenderness over the dorsal aspect of his wrist following a fall onto an outstretched hand 6 weeks ago. Initial radiographs were reported as normal. What is the most appropriate next step in diagnosis?

. Repeat plain radiographs of the wrist
. CT scan of the wrist
. MRI of the wrist
. Bone scan
. Ultrasound of the wrist

Correct Answer & Explanation

. MRI of the wrist

Explanation

Given persistent wrist pain and tenderness, especially in the anatomical snuffbox (implied location, though not explicitly stated for scaphoid), after a fall, and normal initial radiographs, avascular necrosis (AVN) of the scaphoid or a missed scaphoid fracture is a significant concern. MRI is the most sensitive and specific imaging modality for detecting occult scaphoid fractures and early AVN of the scaphoid. Repeat radiographs might show changes but are less sensitive than MRI. CT is excellent for bone detail but less sensitive for early occult fractures or AVN. Bone scan can be sensitive but less specific. Ultrasound is not typically used for scaphoid fractures.

Question 3979

Topic: Wrist & Carpus

A 30-year-old construction worker falls from scaffolding, landing on his extended, ulnar-deviated wrist. Lateral radiographs of the wrist demonstrate that the lunate maintains its normal articulation with the distal radius, but the capitate is dorsally displaced relative to the lunate. What is the most likely diagnosis?

. Lunate dislocation
. Perilunate dislocation
. Scapholunate dissociation
. Barton's fracture
. Midcarpal dislocation

Correct Answer & Explanation

. Perilunate dislocation

Explanation

This describes a perilunate dislocation. On a lateral radiograph, the lunate maintains its 'teacup' articulation with the distal radius, but the capitate is dislocated dorsally out of the teacup. In contrast, a lunate dislocation (the end stage of perilunate instability) occurs when the lunate is tipped off the radius (volarly), appearing like a 'spilled teacup,' while the capitate remains aligned with the radius.

Question 3980

Topic: 7. Hand and Wrist

A 28-year-old male presents with chronic wrist pain and a 'clunking' sensation. Radiographs demonstrate a 'Terry Thomas' sign with a widened scapholunate interval. If isolated repair is considered, which portion of the scapholunate interosseous ligament (SLIL) is biomechanically the most critical for carpal stability?

. Volar portion
. Dorsal portion
. Proximal membranous portion
. Radioscaphocapitate portion
. Scaphotrapezial portion

Correct Answer & Explanation

. Dorsal portion

Explanation

The scapholunate interosseous ligament (SLIL) is composed of three distinct anatomical zones: dorsal, proximal (membranous), and volar. The dorsal portion is the thickest, strongest, and biomechanically most important restraint against scapholunate dissociation. In contrast, for the lunotriquetral (LT) ligament, the volar portion is the thickest and most critical for stability.

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