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7. Hand and Wrist MCQs

Practice Set 261 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 5201

Topic: 7. Hand and Wrist

A pediatric patient is planned for a Woodward procedure to correct a severe Sprengel's deformity. During the inferior translation of the scapula, which of the following prophylactic surgical steps is often recommended to prevent a potentially devastating neurologic complication?

. Prophylactic release of the carpal tunnel
. Resection of the first rib
. Clavicle osteotomy or morcellization
. Release of the pectoralis major tendon
. Transposition of the ulnar nerve

Correct Answer & Explanation

. Clavicle osteotomy or morcellization

Explanation

Inferior displacement of the scapula stretches the brachial plexus against the clavicle, risking a brachial plexus palsy. A concurrent clavicle osteotomy (or morcellization) is often performed in severe cases to prevent this stretch injury.

Question 5202

Topic: 7. Hand and Wrist

A 28-year-old professional football player sustains a severe forced dorsiflexion injury to his great toe. MRI confirms a complete tear of the plantar plate from the base of the proximal phalanx with proximal retraction of the sesamoids. If left untreated, what is the most common long-term deformity associated with this injury?

. Hallux varus deformity
. Cock-up deformity of the hallux with loss of push-off strength
. Progressive flatfoot deformity
. Dorsal subluxation of the sesamoids
. Fixed plantarflexion contracture of the interphalangeal joint

Correct Answer & Explanation

. Cock-up deformity of the hallux with loss of push-off strength

Explanation

A complete plantar plate rupture (Turf Toe Grade 3) eliminates the plantar tether of the MTP joint. Left untreated, the unopposed extensor pull results in a cock-up deformity of the hallux, chronic MTP joint instability, and profound weakness during the push-off phase of gait.

Question 5203

Topic: Nerve & Tendon

A 6-year-old boy sustains an extension-type supracondylar humerus fracture. He is unable to make an 'OK' sign with his thumb and index finger. Which nerve is most likely injured, and what is its typical course of recovery?

. Radial nerve; requires immediate exploration
. Ulnar nerve; typically recovers spontaneously within 3-4 months
. Anterior interosseous nerve; typically recovers spontaneously within 2-3 months
. Median nerve (main trunk); requires surgical decompression
. Musculocutaneous nerve; typically recovers spontaneously within 6 months

Correct Answer & Explanation

. Anterior interosseous nerve; typically recovers spontaneously within 2-3 months

Explanation

Correct Answer: Anterior interosseous nerve; typically recovers spontaneously within 2-3 monthsThe anterior interosseous nerve (AIN), a branch of the median nerve, is the most commonly injured nerve in extension-type supracondylar humerus fractures. It innervates the flexor pollicis longus and the flexor digitorum profundus to the index finger, which are required to make the 'OK' sign. These injuries are typically neuropraxias that resolve spontaneously within 2 to 3 months, and observation is the standard of care.

Question 5204

Topic: Nerve & Tendon

A 6-year-old boy sustains an extension-type supracondylar humerus fracture. On physical examination, he is unable to flex the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger. Which nerve is most likely injured?

. Radial nerve
. Ulnar nerve
. Anterior interosseous nerve
. Posterior interosseous nerve
. Musculocutaneous nerve

Correct Answer & Explanation

. Anterior interosseous nerve

Explanation

Correct Answer: Anterior interosseous nerveThe anterior interosseous nerve (AIN), a motor branch of the median nerve, is the most commonly injured nerve in extension-type supracondylar humerus fractures. It innervates the flexor pollicis longus (FPL), the flexor digitorum profundus (FDP) to the index and middle fingers, and the pronator quadratus. Injury leads to the inability to make an 'OK' sign (loss of thumb IP and index DIP flexion). The radial nerve is the second most commonly injured, particularly with posteromedial displacement, while the ulnar nerve is more commonly injured in flexion-type fractures or iatrogenically during medial pin placement.

Question 5205

Topic: 7. Hand and Wrist

A 6-year-old boy sustains a displaced extension-type supracondylar humerus fracture. Which nerve is most commonly injured in this specific fracture pattern, and what is the typical clinical finding?

. Ulnar nerve; inability to cross the fingers
. Radial nerve; inability to extend the wrist
. Anterior interosseous nerve; inability to flex the interphalangeal joint of the thumb
. Median nerve; numbness in the little finger
. Musculocutaneous nerve; weak elbow flexion

Correct Answer & Explanation

. Anterior interosseous nerve; inability to flex the interphalangeal joint of the thumb

Explanation

Correct Answer: Anterior interosseous nerve; inability to flex the interphalangeal joint of the thumbThe anterior interosseous nerve (AIN) is the most commonly injured nerve in extension-type supracondylar humerus fractures. It is a motor nerve, and injury results in the inability to flex the IP joint of the thumb and the DIP joint of the index finger (inability to make an 'OK' sign).

Question 5206

Topic: Nerve & Tendon

A 5-year-old boy sustained a lateral condyle fracture of the humerus that was treated nonoperatively. Two years later, he presents with a nonunion. Which of the following is the most common long-term neurological complication associated with this specific nonunion?

. Acute radial nerve palsy
. Tardy ulnar nerve palsy
. Anterior interosseous nerve syndrome
. Median nerve entrapment
. Complex regional pain syndrome

Correct Answer & Explanation

. Tardy ulnar nerve palsy

Explanation

Nonunion of a lateral condyle fracture typically results in a progressive cubitus valgus deformity. This progressive valgus stretch on the medial side of the elbow commonly leads to a tardy ulnar nerve palsy years later.

Question 5207

Topic: 7. Hand and Wrist

A 55-year-old female presents with severe, burning pain, swelling, and skin color changes in her right hand 6 weeks after sustaining a distal radius fracture treated in a cast. Radiographs reveal the findings shown.

According to current evidence, which of the following interventions initiated at the time of injury could have significantly reduced the risk of developing this condition?

. Early surgical fixation
. Vitamin C 500 mg daily for 50 days
. Gabapentin 300 mg three times daily
. Immediate initiation of bisphosphonates
. Prophylactic sympathetic nerve block

Correct Answer & Explanation

. Vitamin C 500 mg daily for 50 days

Explanation

The clinical and radiographic presentation (patchy osteopenia/Sudeck's atrophy) is classic for Complex Regional Pain Syndrome (CRPS). High-quality evidence demonstrates that Vitamin C (500 mg daily for 50 days) significantly reduces the incidence of CRPS after distal radius fractures.

Question 5208

Topic: 7. Hand and Wrist

A 55-year-old woman is 6 weeks post-closed reduction and casting of a distal radius fracture. She presents with severe burning pain, hypersensitivity, and erythema of the hand.

Which of the following radiographic findings is most characteristic of her condition?

. Subperiosteal bone resorption
. Patchy periarticular osteopenia
. Diffuse osteosclerosis
. Sunburst periosteal reaction
. Punched-out lytic lesions

Correct Answer & Explanation

. Patchy periarticular osteopenia

Explanation

Complex Regional Pain Syndrome (CRPS), formerly known as Sudeck's atrophy or algodystrophy, is characterized by patchy periarticular osteopenia on radiographs. This results from localized rapid bone turnover associated with vasomotor instability.

Question 5209

Topic: 7. Hand and Wrist

A 55-year-old woman is 6 weeks post-operative from a distal radius fracture open reduction and internal fixation. She presents with severe, burning pain, allodynia, skin color changes, and edema in the affected hand.

According to the Budapest Criteria, which of the following is an absolute requirement to make the diagnosis?

. A positive three-phase bone scan showing diffuse periarticular uptake
. Continuing pain which is disproportionate to any inciting event
. Identifyable nerve injury documented on electromyography
. Favorable clinical response to a sympathetic nerve block
. Presence of localized, patchy osteoporosis on radiographs

Correct Answer & Explanation

. Continuing pain which is disproportionate to any inciting event

Explanation

The Budapest Criteria for Complex Regional Pain Syndrome (CRPS) strictly require the presence of continuing pain that is disproportionate to any inciting event. Objective tests like bone scans and sympathetic blocks can support the diagnosis but are not required criteria.

Question 5210

Topic: Wrist & Carpus

Regarding the clinical scenario of Complex Regional Pain Syndrome (Sudeck's atrophy) following a distal radius fracture, which of the following prophylactic therapies has been shown in clinical trials to reduce its incidence?

. Gabapentin 300mg TID for 4 weeks
. Vitamin C 500mg daily for 50 days
. Pregabalin 75mg BID for 6 weeks
. Oral bisphosphonates for 3 months post-injury
. Prophylactic stellate ganglion blocks

Correct Answer & Explanation

. Vitamin C 500mg daily for 50 days

Explanation

Daily supplementation with 500 mg of Vitamin C for 50 days following a distal radius fracture has been shown in prospective randomized trials to significantly reduce the risk of developing CRPS.

Question 5211

Topic: 7. Hand and Wrist

A 55-year-old woman is 6 weeks post-closed reduction and casting of a distal radius fracture. She reports agonizing, burning pain in her hand, out of proportion to her injury. Examination shows a swollen, erythematous, and diaphoretic hand with restricted finger motion.

Which of the following prophylactic measures has been shown to reduce the incidence of this condition following distal radius fractures?

. Early prophylactic sympathetic nerve block
. Oral vitamin C 500 mg daily for 50 days
. Routine administration of gabapentin
. Prophylactic bisphosphonate therapy
. Extended immobilization for 8 weeks

Correct Answer & Explanation

. Oral vitamin C 500 mg daily for 50 days

Explanation

Vitamin C (500 mg daily for 50 days) has been shown in some studies to significantly decrease the risk of developing Complex Regional Pain Syndrome (CRPS) following distal radius fractures. CRPS is characterized by autonomic dysfunction, hyperalgesia, and spotty osteopenia.

Question 5212

Topic: Wrist & Carpus

A 55-year-old female sustains a distal radius fracture treated with open reduction and internal fixation. To prevent the development of the condition shown in the clinical image below, what pharmacological prophylaxis should be initiated?

. Gabapentin 300mg daily
. Vitamin C 500mg daily for 50 days
. Ibuprofen 400mg every 8 hours
. Prednisone 20mg daily for 14 days
. Amitriptyline 25mg nightly

Correct Answer & Explanation

. Vitamin C 500mg daily for 50 days

Explanation

The image demonstrates trophic skin changes and swelling consistent with Complex Regional Pain Syndrome (CRPS). Studies have shown that Vitamin C (500 mg daily for 50 days) significantly reduces the incidence of CRPS following distal radius fractures. Other medications listed are used for treatment, not proven primary prophylaxis.

Question 5213

Topic: 7. Hand and Wrist

A 42-year-old female presents with severe, burning pain, allodynia, and swelling of her right hand 6 weeks following a casted distal radius fracture. If a three-phase technetium-99m bone scan is ordered, what is the classic finding indicative of her suspected diagnosis?

. Decreased uptake in all three phases
. Focal increased uptake limited exclusively to the fracture site
. Diffuse, periarticular increased uptake in the delayed phase
. "Cold" defects corresponding to areas of skin necrosis
. Increased uptake in the axial skeleton but normal appendicular uptake

Correct Answer & Explanation

. Diffuse, periarticular increased uptake in the delayed phase

Explanation

The diagnosis is Complex Regional Pain Syndrome (CRPS). The classic finding on a three-phase bone scan for CRPS is diffuse, increased periarticular uptake in the affected limb during the delayed (third) phase. The initial blood flow and blood pool phases may also show asymmetric flow.

Question 5214

Topic: 7. Hand and Wrist

Which radiographic finding is most characteristic of advanced Sudeck's atrophy (Complex Regional Pain Syndrome) in the hand and wrist?

. Subperiosteal bone resorption at the radial aspect of the middle phalanges
. Patchy, severe periarticular osteopenia
. Diffuse cortical thickening of the metacarpals
. Punched-out lytic lesions in the carpal bones
. Acro-osteolysis of the distal phalanges

Correct Answer & Explanation

. Patchy, severe periarticular osteopenia

Explanation

Sudeck's atrophy (CRPS) classically manifests radiographically as patchy, periarticular demineralization (osteopenia) due to localized hyperemia and disuse. Subperiosteal resorption is seen in hyperparathyroidism, while acro-osteolysis is associated with scleroderma or hyperparathyroidism.

Question 5215

Topic: 7. Hand and Wrist

A subset of patients with multiple myeloma may develop Carpal Tunnel Syndrome or macroglossia. This specific clinical presentation is most directly related to which complication of the disease?

. Hyperviscosity syndrome
. Severe hypercalcemia
. AL Amyloidosis
. Cryoglobulinemia
. Hyperuricemia

Correct Answer & Explanation

. AL Amyloidosis

Explanation

Primary (AL) amyloidosis is caused by the tissue deposition of misfolded monoclonal immunoglobulin light chains produced by the clonal plasma cells in multiple myeloma. Deposition in the transverse carpal ligament leads to carpal tunnel syndrome, and deposition in the tongue causes macroglossia.

Question 5216

Topic: 7. Hand and Wrist

A 45-year-old female presents with ongoing severe burning pain, allodynia, and distinct color and temperature asymmetry in her right hand, 8 weeks after closed reduction and casting of a distal radius fracture.

According to the most widely accepted clinical criteria for diagnosing this condition, which of the following is required?

. A positive triple-phase bone scan demonstrating asymmetric periarticular uptake
. Presence of continuing pain disproportionate to any inciting event along with at least three out of four symptom categories
. A documented decrease in sympathetic nerve activity on quantitative sudomotor axon reflex testing (QSART)
. Complete resolution of pain following a stellate ganglion block
. Radiographic evidence of severe patchy osteopenia (Sudeck's atrophy)

Correct Answer & Explanation

. Presence of continuing pain disproportionate to any inciting event along with at least three out of four symptom categories

Explanation

The Budapest criteria are the standard for diagnosing Complex Regional Pain Syndrome (CRPS). They require continuing pain disproportionate to the inciting event, at least one symptom in three of four categories (sensory, vasomotor, sudomotor/edema, motor/trophic), and at least one sign in two of the same categories.

Question 5217

Topic: 7. Hand and Wrist

A 45-year-old woman develops severe, burning pain, allodynia, and trophic skin changes in her right hand 8 weeks after sustaining a minimally displaced distal radius fracture treated in a cast.

According to the Budapest criteria, the diagnosis of Complex Regional Pain Syndrome (CRPS) is made. What is the cornerstone of initial management?

. Sympathetic ganglion block
. Surgical sympathectomy
. Physical therapy combined with neuromodulatory medications
. Spinal cord stimulation
. Intravenous bisphosphonates

Correct Answer & Explanation

. Physical therapy combined with neuromodulatory medications

Explanation

The cornerstone of initial management for CRPS is aggressive physical and occupational therapy to maintain range of motion and function. This is typically combined with pharmacological management such as gabapentin, pregabalin, or tricyclic antidepressants.

Question 5218

Topic: 7. Hand and Wrist

A 42-year-old female presents 3 months post-carpal tunnel release with severe burning pain, allodynia, asymmetric sweating, and decreased ROM in her digits.

According to the Budapest criteria, which additional clinical sign must be present to establish a clinical diagnosis of Complex Regional Pain Syndrome (CRPS)?

. Elevated ESR and CRP
. Patchy osteopenia on plain radiographs
. Evidence of a specific peripheral nerve injury
. Vasomotor changes, such as temperature asymmetry or skin color changes
. A positive triple-phase bone scan

Correct Answer & Explanation

. Vasomotor changes, such as temperature asymmetry or skin color changes

Explanation

The Budapest criteria require at least one symptom in three of four categories: sensory, vasomotor, sudomotor/edema, and motor/trophic. She currently lacks documentation of vasomotor changes to meet the clinical diagnostic threshold.

Question 5219

Topic: 7. Hand and Wrist

A 35-year-old man undergoes an open reduction and internal fixation of a distal radius fracture. Postoperatively, he develops severe, burning pain, edema, and trophic skin changes in the affected hand.

EMG and nerve conduction studies reveal a distinct, partial injury to the median nerve. Which of the following best classifies this patient's condition?

. CRPS Type I
. CRPS Type II
. Neuropathic osteoarthropathy
. Sudeck's atrophy
. Factitious disorder

Correct Answer & Explanation

. CRPS Type II

Explanation

CRPS Type II (formerly known as causalgia) is distinguished from CRPS Type I by the presence of a distinct, identifiable peripheral nerve injury. Type I occurs without a definable nerve lesion.

Question 5220

Topic: 7. Hand and Wrist

A 9-year-old boy presents with an awkward, waddling gait and generalized muscle weakness. Plain radiographs of the lower extremities are obtained.

If this patient has Camurati-Engelmann disease, which of the following best describes the expected pattern of bone involvement?

. Endosteal and periosteal thickening primarily affecting the diaphyses, sparing the epiphyses
. Epiphyseal stippling and irregular metaphyseal ossification
. Medullary expansion with cortical thinning of the metaphyses, resulting in an Erlenmeyer flask deformity
. Eccentric lytic lesions in the metaphyses with surrounding sclerosis
. Symmetrical involvement of the skull base, maxilla, and short tubular bones of the hands

Correct Answer & Explanation

. Endosteal and periosteal thickening primarily affecting the diaphyses, sparing the epiphyses

Explanation

Camurati-Engelmann disease (Progressive Diaphyseal Dysplasia) is characterized by bilateral, symmetrical cortical thickening of the long bone diaphyses. It classically spares the metaphyses and epiphyses.

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