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7. Hand and Wrist MCQs

Practice Set 50 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 981

Topic: 7. Hand and Wrist

A 58-year-old patient presents 6 months after open reduction and internal fixation of a Galeazzi fracture. She complains of chronic pain on the ulnar side of her wrist, especially with pronation and ulnar deviation, and significantly limited forearm rotation. Radiographs show a healed radial shaft fracture but with 8mm of residual radial shortening and a positive ulnar variance. Which of the following is the most likely long-term complication causing her symptoms?

. Avascular necrosis of the lunate (Kienbock's disease).
. Radial nerve palsy.
. Ulnar impaction syndrome and distal radioulnar joint (DRUJ) arthritis.
. Flexor tendon rupture.
. Carpal tunnel syndrome.

Correct Answer & Explanation

. Ulnar impaction syndrome and distal radioulnar joint (DRUJ) arthritis.

Explanation

Correct Answer: CResidual radial shortening after a Galeazzi fracture leads to a positive ulnar variance, meaning the ulna is relatively longer than the radius. This altered length relationship is a common and significant complication. It causes the distal ulna to impinge on the lunate and triquetrum, leading to ulnar impaction syndrome. This condition is characterized by chronic ulnar-sided wrist pain, particularly with pronation and ulnar deviation, and can progress to degenerative changes and arthritis of the DRUJ and ulnocarpal joint. The limited forearm rotation is a direct consequence of the altered DRUJ mechanics and potential arthritis.Option A (Kienbock's disease) is associated with negative ulnar variance, not positive. Option B (Radial nerve palsy) is not a direct long-term consequence of radial shortening malunion. Option D (Flexor tendon rupture) is typically associated with hardware prominence or severe inflammatory conditions, not directly with positive ulnar variance. Option E (Carpal tunnel syndrome) is a median nerve compression neuropathy and, while possible, is not the most direct or common complication of this specific malunion pattern.

Question 982

Topic: Wrist & Carpus

A 9-year-old child sustains a fall and presents with a fracture of the distal radial diaphysis and associated dorsal dislocation of the distal ulna. Radiographs confirm a Galeazzi-type injury. Compared to the management of an adult with the same injury, what is the most common and often successful initial management approach for this child?

. Immediate open reduction and internal fixation (ORIF) of the radial shaft.
. External fixation of the forearm with dynamic traction.
. Closed reduction of the radial fracture and DRUJ, followed by long arm cast immobilization in supination.
. Ulnar head resection to prevent future impingement.
. Percutaneous pinning of the radial shaft and DRUJ.

Correct Answer & Explanation

. Closed reduction of the radial fracture and DRUJ, followed by long arm cast immobilization in supination.

Explanation

Correct Answer: CThe management of Galeazzi-type injuries differs significantly between children and adults. In children, due to their greater remodeling potential, thicker periosteum, and more resilient ligaments, closed reduction of both the radial shaft fracture and the distal radioulnar joint (DRUJ) is often successful. Once reduced, the forearm is typically immobilized in a long arm cast with the forearm in full supination (or neutral position) to help maintain reduction of the DRUJ by tightening the volar radioulnar ligaments. ORIF (Option A) is generally reserved for unstable or irreducible cases in children. External fixation (Option B) is rarely the primary definitive treatment for this injury in children. Ulnar head resection (Option D) is a salvage procedure for chronic DRUJ issues in adults and is never indicated acutely in children. Percutaneous pinning (Option E) might be used in some unstable pediatric cases, but closed reduction and casting is the initial attempt if possible.

Question 983

Topic: Wrist & Carpus

A 65-year-old patient presents with chronic, painful distal radioulnar joint (DRUJ) arthritis and severe positive ulnar variance following a malunited Galeazzi fracture treated 2 years prior. She has exhausted non-operative treatments including injections and therapy. Her radial shaft fracture is healed but shortened. Which of the following salvage procedures would be most appropriate to address her DRUJ pathology and improve forearm rotation?

. Scaphoidectomy and four-corner fusion.
. Proximal row carpectomy.
. Sauve-Kapandji procedure.
. Radial shortening osteotomy.
. Wrist arthrodesis.

Correct Answer & Explanation

. Sauve-Kapandji procedure.

Explanation

Correct Answer: CFor chronic, painful DRUJ arthritis and severe positive ulnar variance resulting from a malunited Galeazzi fracture, salvage procedures are often necessary. The Sauve-Kapandji procedure is a well-established option. It involves arthrodesis (fusion) of the distal radioulnar joint combined with a pseudoarthrosis (creation of a false joint) of the ulna proximal to the fusion. This allows for forearm rotation while maintaining the distal ulna for cosmetic appearance and some stability. Another common salvage procedure is the Darrach procedure (excision of the distal ulna or ulnar head), which also aims to relieve impingement and restore rotation.Option A (Scaphoidectomy and four-corner fusion) and Option B (Proximal row carpectomy) are procedures for midcarpal or radiocarpal arthritis, not primarily for DRUJ pathology. Option D (Radial shortening osteotomy) would worsen the positive ulnar variance; an ulnar shortening osteotomy might be considered if the radial fracture was anatomically healed and the primary issue was ulnar length, but not for irreducible DRUJ arthritis. Option E (Wrist arthrodesis) fuses the entire wrist, sacrificing all wrist motion, which is a more extensive procedure typically reserved for diffuse pancarpal arthritis or severe instability not amenable to other options, and it doesn't specifically address DRUJ rotation.

Question 984

Topic: 7. Hand and Wrist

A 35-year-old male undergoes ORIF of a Galeazzi fracture via a volar (Henry) approach. Postoperatively, he presents with an inability to flex the interphalangeal joint of his thumb and the distal interphalangeal joints of his index and middle fingers. He also has difficulty pronating his forearm against resistance. Sensation is intact. Which of the following nerves was most likely injured during the surgical procedure?

. Ulnar nerve
. Median nerve (main trunk)
. Superficial radial nerve
. Posterior interosseous nerve (PIN)
. Anterior interosseous nerve (AIN)

Correct Answer & Explanation

. Anterior interosseous nerve (AIN)

Explanation

Correct Answer: EThe clinical presentation described—inability to flex the interphalangeal joint of the thumb (due to loss of flexor pollicis longus, FPL) and the distal interphalangeal joints of the index and middle fingers (due to loss of the radial half of flexor digitorum profundus, FDP)—along with difficulty pronating the forearm (due to loss of pronator quadratus, PQ), with intact sensation, is pathognomonic for an anterior interosseous nerve (AIN) palsy. The AIN is a purely motor branch of the median nerve. It is the most commonly injured nerve during a volar (Henry) approach to the distal radial shaft, as it lies directly on the interosseous membrane and can be damaged by retraction, direct trauma, or entrapment.Option A (Ulnar nerve) injury would affect the ulnar two FDPs (ring and small fingers), most intrinsic hand muscles, and sensation to the ulnar side of the hand. Option B (Median nerve main trunk) injury would cause the described motor deficits plus sensory loss in the median nerve distribution. Option C (Superficial radial nerve) is a sensory nerve, so its injury would not cause these motor deficits. Option D (Posterior interosseous nerve) injury would result in a 'wrist drop' and inability to extend the fingers at the MCP joints, as it innervates the wrist and finger extensors.

Question 985

Topic: 7. Hand and Wrist

A 28-year-old male presents with a distal radial shaft fracture after a motorcycle accident. Initial AP and lateral radiographs of the forearm are shown. While the radial fracture is evident, the distal radioulnar joint (DRUJ) appears equivocal for dislocation on these standard views. Which additional radiographic finding or view would be most helpful to confirm DRUJ involvement and thus diagnose a Galeazzi fracture?

. A stress view of the wrist in radial deviation.
. A comparison view of the contralateral uninjured forearm.
. An oblique view of the elbow to assess the radial head.
. A carpal tunnel view to evaluate the median nerve space.
. A scapholunate interval measurement.

Correct Answer & Explanation

. A comparison view of the contralateral uninjured forearm.

Explanation

Correct Answer: BIn cases where DRUJ involvement is equivocal on standard AP and lateral radiographs of the injured forearm, obtaining a comparison view of the contralateral, uninjured forearm is extremely helpful. This allows the surgeon to assess the normal anatomical relationship between the distal radius and ulna for that specific patient, including the width of the DRUJ space and the alignment of the ulnar head within the sigmoid notch of the radius. Subtle widening of the DRUJ on the AP view or slight dorsal (or volar) displacement of the ulna on the lateral view, when compared to the uninjured side, can confirm DRUJ disruption. This is a critical step in diagnosing a Galeazzi fracture when the DRUJ dislocation is not grossly obvious.Option A (Stress view in radial deviation) is more relevant for ulnocarpal instability or TFCC tears, not primary DRUJ dislocation. Option C (Oblique elbow view) is for assessing the elbow joint and radial head, which is relevant for Monteggia or Essex-Lopresti injuries, not Galeazzi. Option D (Carpal tunnel view) is for assessing the carpal tunnel and is not directly useful for DRUJ stability. Option E (Scapholunate interval measurement) is for carpal instability, specifically scapholunate dissociation, and not directly for DRUJ assessment.

Question 986

Topic: Wrist & Carpus

After successful open reduction and internal fixation of a Galeazzi fracture and temporary K-wire stabilization of a persistently unstable distal radioulnar joint (DRUJ), what is a key principle of early postoperative rehabilitation?

. Immediate active forearm pronation and supination exercises to prevent stiffness.
. Strict immobilization of the forearm in a long arm cast until K-wires are removed (typically 4-6 weeks).
. Early passive range of motion of the wrist and elbow, avoiding any forearm rotation.
. Aggressive strengthening of the wrist flexors and extensors starting on postoperative day 1.
. Removal of the cast after 2 weeks and transition to a removable brace for full activity.

Correct Answer & Explanation

. Strict immobilization of the forearm in a long arm cast until K-wires are removed (typically 4-6 weeks).

Explanation

Correct Answer: BWhen the DRUJ has been stabilized with temporary K-wires following Galeazzi fracture fixation, the primary goal of early postoperative rehabilitation is to protect the healing capsuloligamentous structures of the DRUJ. This necessitates strict immobilization of the forearm, typically in a long arm cast or splint, in the position of DRUJ stability (e.g., supination for dorsal instability). The K-wires are usually maintained for 4-6 weeks to allow sufficient time for soft tissue healing. Premature or aggressive forearm rotation (Option A) would risk disrupting the healing DRUJ ligaments, leading to recurrent instability or pin complications. After K-wire removal and clinical assessment of DRUJ stability, a gradual and protected range of motion program for forearm rotation can be initiated.Option C is partially correct regarding wrist and elbow motion, but strict immobilization of the forearm is paramount. Option D (aggressive strengthening) is too early and risks disrupting fixation and healing. Option E (early cast removal and full activity) is far too aggressive and would almost certainly lead to failure of DRUJ stabilization and potential radial malunion.

Question 987

Topic: 7. Hand and Wrist

A 62-year-old female undergoes volar locking plate fixation for a distal radius fracture. At 6 months postoperatively, she returns with sudden inability to flex her thumb interphalangeal joint. The hardware is noted to be prominent at the watershed line. Which structure has most likely ruptured?

. Extensor pollicis longus
. Flexor carpi radialis
. Flexor pollicis longus
. Median nerve
. Flexor digitorum profundus to the index finger

Correct Answer & Explanation

. Flexor pollicis longus

Explanation

Volar locking plates placed distal to the watershed line of the distal radius create prominent hardware that can cause mechanical attrition. This most commonly results in delayed rupture of the flexor pollicis longus (FPL) tendon.

Question 988

Topic: 7. Hand and Wrist

A 55-year-old female treated nonoperatively in a cast for a minimally displaced Colles fracture presents at 6 weeks unable to actively extend her thumb interphalangeal joint. Tenodesis effect is absent for the thumb. What is the most likely etiology of this complication?

. Missed compartment syndrome of the forearm
. Tendon rupture due to mechanical attrition and focal ischemia
. Undiagnosed concurrent scaphoid fracture
. Secondary median nerve compression
. De Quervain's tenosynovitis

Correct Answer & Explanation

. Missed compartment syndrome of the forearm

Explanation

Extensor pollicis longus (EPL) rupture is a known complication of nondisplaced or minimally displaced distal radius fractures. It occurs secondary to mechanical attrition at Lister's tubercle and focal ischemia from fracture hematoma within the third extensor compartment.

Question 989

Topic: 7. Hand and Wrist

A 30-year-old male presents with a Chauffeur's fracture of the radial styloid after a motor vehicle accident. Due to the mechanism of avulsion, this specific fracture pattern is most frequently associated with a tear of which carpal ligament?

. Scapholunate interosseous ligament
. Lunotriquetral interosseous ligament
. Dorsal radiocarpal ligament
. Triangular fibrocartilage complex
. Ulnar collateral ligament

Correct Answer & Explanation

. Scapholunate interosseous ligament

Explanation

A Chauffeur's (radial styloid) fracture is caused by a direct blow or forced ulnar deviation and supination. It serves as a strong clinical marker for associated carpal ligament injuries, particularly tearing of the scapholunate interosseous ligament.

Question 990

Topic: 7. Hand and Wrist

A 50-year-old female presents to the emergency department with a severely displaced extension-type distal radius fracture. She complains of acute, dense numbness in her thumb, index, and long fingers. What is the most appropriate initial step in management?

. Immediate operative carpal tunnel release
. Urgent closed reduction and splinting of the fracture
. Administration of systemic corticosteroids
. Urgent electromyography (EMG) testing
. Observation and elevation for 24 hours

Correct Answer & Explanation

. Urgent closed reduction and splinting of the fracture

Explanation

In the setting of acute carpal tunnel syndrome secondary to a displaced distal radius fracture, the initial step is prompt closed reduction and splinting to relieve pressure on the median nerve. If symptoms persist unchanged post-reduction, surgical decompression is required.

Question 991

Topic: Wrist & Carpus

To appropriately evaluate reduction of a distal radius fracture, the surgeon must understand normal radiographic parameters. Which of the following values most accurately represents the normal native anatomy of the distal radius?

. Radial inclination 22 degrees, Volar tilt 11 degrees, Radial height 12 mm
. Radial inclination 11 degrees, Volar tilt 22 degrees, Radial height 5 mm
. Radial inclination 15 degrees, Volar tilt 5 degrees, Radial height 22 mm
. Radial inclination 22 degrees, Dorsal tilt 11 degrees, Radial height 12 mm
. Radial inclination 30 degrees, Volar tilt 0 degrees, Radial height 15 mm

Correct Answer & Explanation

. Radial inclination 22 degrees, Volar tilt 11 degrees, Radial height 12 mm

Explanation

The standard radiographic parameters of the normal distal radius are approximately 22 degrees of radial inclination, 11 degrees of volar tilt, and 11 to 12 mm of radial height.

Question 992

Topic: Wrist & Carpus

A 35-year-old man undergoes volar plating of a distal radius fracture. Three months postoperatively, he develops sudden inability to actively flex the interphalangeal joint of his thumb. Which technical error most likely contributed to this complication?

. Plate placement distal to the watershed line
. Use of excessively long dorsal locking screws
. Failure to repair the pronator quadratus completely
. Inadequate reduction of the volar tilt
. Over-penetration of the drill bit into the DRUJ

Correct Answer & Explanation

. Plate placement distal to the watershed line

Explanation

Flexor pollicis longus (FPL) tendon rupture is a known complication of volar plating. It occurs due to tendon attrition over a prominent plate placed too distally (beyond the watershed line) on the radius.

Question 993

Topic: Wrist & Carpus

A 24-year-old falls onto an outstretched hand and sustains a Galeazzi fracture. Following open reduction and internal fixation of the radius, the distal radioulnar joint (DRUJ) remains unstable in supination. What is the most appropriate next step in management?

. Cast immobilization in maximal pronation
. Open reduction of the DRUJ with TFCC repair
. Transfixion pinning of the DRUJ in neutral or supination
. Darrach procedure
. Resection of the ulnar styloid

Correct Answer & Explanation

. Transfixion pinning of the DRUJ in neutral or supination

Explanation

If the DRUJ remains unstable after anatomic fixation of the radius in a Galeazzi fracture, it should be reduced and pinned using K-wires in the position of maximum stability (usually supination).

Question 994

Topic: 7. Hand and Wrist

A 30-year-old man presents with a comminuted fracture of the proximal third of the ulna with an associated anterior dislocation of the radial head. Following rigid plate fixation of the ulna, the radial head is stable but the patient exhibits a lack of active thumb and finger extension, while wrist extension remains intact but deviates radially. Which nerve is most likely injured?

. Anterior interosseous nerve
. Median nerve
. Posterior interosseous nerve
. Ulnar nerve
. Superficial sensory radial nerve

Correct Answer & Explanation

. Posterior interosseous nerve

Explanation

Bado Type I Monteggia fractures are most commonly associated with a posterior interosseous nerve (PIN) palsy. PIN palsy results in loss of active extension of the MCP joints and thumb, with preserved radial wrist extension.

Question 995

Topic: Wrist & Carpus

A 55-year-old woman sustains an extra-articular distal radius fracture treated with closed reduction and casting. Four weeks later, she reports a sudden pop and inability to actively extend her thumb interphalangeal joint. What is the most common management for this complication?

. Primary end-to-end repair of the ruptured tendon
. Extensor indicis proprius to extensor pollicis longus transfer
. Palmaris longus interposition graft
. Thumb interphalangeal joint arthrodesis
. Flexor digitorum superficialis transfer

Correct Answer & Explanation

. Extensor indicis proprius to extensor pollicis longus transfer

Explanation

Extensor pollicis longus (EPL) rupture at Lister's tubercle is a known complication of nondisplaced or minimally displaced distal radius fractures. Treatment of choice is an EIP to EPL tendon transfer because the ruptured ends are typically retracted and attenuated.

Question 996

Topic: 7. Hand and Wrist

A 32-year-old male is evaluated in the ER for a highly comminuted distal radius fracture with an associated scaphoid fracture. What is the most common direction of carpal displacement in a classic Barton's fracture?

. Dorsal dislocation with the dorsal radial articular rim
. Volar subluxation with the volar radial articular rim
. Radial deviation with the radial styloid
. Proximal migration of the lunate
. Isolated dislocation of the triquetrum

Correct Answer & Explanation

. Volar subluxation with the volar radial articular rim

Explanation

A classic Barton's fracture is a shear fracture of the distal radius articular surface. It most commonly involves the volar rim (volar Barton's), carrying the carpus with it into volar subluxation.

Question 997

Topic: Wrist & Carpus

A 25-year-old snowboarder falls and sustains a severely displaced intra-articular distal radius fracture. Which radiographic parameter is most predictive of developing symptomatic post-traumatic radiocarpal osteoarthrosis?

. Loss of radial inclination greater than 10 degrees
. Volar tilt of 5 degrees dorsal
. Intra-articular step-off greater than 2 mm
. Radial shortening of 3 mm
. Ulnar variance of +1 mm

Correct Answer & Explanation

. Intra-articular step-off greater than 2 mm

Explanation

The most critical radiographic factor correlating with the development of post-traumatic arthritis after a distal radius fracture is an intra-articular step-off of greater than 2 mm. Anatomic reduction of the articular surface is a primary goal of operative intervention.

Question 998

Topic: 7. Hand and Wrist

Following open reduction and internal fixation of a diaphyseal both-bone forearm fracture, anatomic restoration of the normal radial bow is essential. Failure to restore the radial bow most directly limits which motion?

. Elbow flexion
. Wrist flexion
. Forearm pronation and supination
. Wrist ulnar deviation
. Metacarpophalangeal extension

Correct Answer & Explanation

. Forearm pronation and supination

Explanation

The radius normally has a lateral bow that is critical for providing clearance around the ulna during forearm rotation. Failure to anatomically restore the magnitude and location of this bow results in significant loss of pronation and supination.

Question 999

Topic: 7. Hand and Wrist

A 55-year-old female falls on an outstretched hand, sustaining a displaced distal radius fracture. She complains of severe paresthesias in the median nerve distribution. The fracture is closed reduced in the emergency department, but dense numbness persists and her pain acutely worsens over the next hour. What is the most appropriate next step in management?

. Elevate the limb and re-evaluate in 24 hours
. Administer oral corticosteroids and splint the wrist in flexion
. Immediate operative fracture fixation and carpal tunnel release
. Perform a median nerve conduction study
. Schedule open reduction and internal fixation within 1 week

Correct Answer & Explanation

. Immediate operative fracture fixation and carpal tunnel release

Explanation

Acute carpal tunnel syndrome that does not improve or worsens after fracture reduction requires immediate surgical decompression and fracture fixation. Delaying treatment in the setting of progressive acute median neuropathy can lead to irreversible nerve damage.

Question 1000

Topic: Wrist & Carpus

A 30-year-old male sustains a Galeazzi fracture. After rigid open reduction and internal fixation of the radius, the distal radioulnar joint (DRUJ) remains unstable in pronation but is stable when the forearm is placed in full supination. What is the most appropriate intraoperative management of the DRUJ?

. Immobilize the forearm in a long arm cast in pronation
. Immobilize or percutaneously pin the DRUJ in supination
. Perform an open repair of the volar radioulnar ligament
. Perform a prophylactic Darrach procedure
. Perform an open reduction of the DRUJ through a dorsal approach

Correct Answer & Explanation

. Immobilize or percutaneously pin the DRUJ in supination

Explanation

If the DRUJ is reducible and stable in supination after radius fixation in a Galeazzi fracture, it should be immobilized or pinned in supination for 4 to 6 weeks. Pinning in the position of stability ensures joint congruence while the triangular fibrocartilage complex (TFCC) heals.

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