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7. Hand and Wrist MCQs

Practice Set 73 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 1441

Topic: 7. Hand and Wrist

A 34-year-old female is involved in a high-speed motor vehicle collision and sustains a traumatic proximal forearm amputation. She successfully undergoes debridement and closure, and six weeks later, is fitted with her temporary prosthesis. In order to optimize her outcomes upon returning to work as a secretary, which of the following is recommended?

. Obtaining formal functional capacity testing
. Waiting for final prosthesis fitting prior to full release
. Minimize use of her prosthetic while at work
. Allowing return to work when full elbow range of motion is seen
. Offer outpatient psychological counseling

Correct Answer & Explanation

. Obtaining formal functional capacity testing

Explanation

Upper extremity trauma has serious, acute psychological effects that can linger long after the physical injury. These effects may negatively affect patient-reported outcomes, and may also be associated with worsening pain complaints. Coping and stress management techniques can be reviewed with formal psychological counseling, and should be offered to all patients who have underwent an amputation.Richards et al surveyed 34 patients who had emergency upper extremity surgery and found high levels of psychological distress in patients, including 29% with high levels of both depression and post-traumatic stress disorder (PTSD). They also found that disability was strongly related to pain, depression, and PTSD symptoms.Mallette et al assessed the attitudes of hand surgery patients and hand surgeons regarding psychologic influences on illness and compared their attitudes with those of the general population. They found that surgeons underestimated the openness of patients to discuss psychological issues and that patients believed in the strong effect of psychologic factors on healing and pain.Illustration A shows a myoelectric prosthesis in a military veteran. Incorrect Answers:

Question 1442

Topic: 7. Hand and Wrist
Figures 1 and 2 are the radiographs of a 36-year-old man who has had left wrist pain for the past 6 months following a fall onto his outstretched arm. Examination reveals a positive ballottement test, dorsal and ulnar carpal tenderness, and a painful snap with ulnar deviation, pronation, and axial compression. Injury to what ligament is the cause of this patient's pain?
. Short radiolunate
. Dorsal scapholunate interosseous
. Volar lunotriquetral interosseous
. Radioscaphocapitate

Correct Answer & Explanation

. Volar lunotriquetral interosseous

Explanation

EXPLANATION: The radiographs reveal a volarly tilted lunate on the lateral view (Figure 1) and an incongruous lunotriquetral articulation on the AP gripped view (Figure 2). The patient has what appears to be radiographic findings of volar intercalated segmental instability (VISI), a type of carpal instability, dissociative. An injury to the volar lunotriquetral ligament is the most important contributor to this type of instability. An injury to the dorsal scapholunate ligament typically leads to a dorsal intercalated segmental instability. Isolated injuries to the dorsal radiocarpal ligament and the radioscaphocapitate ligament do not lead to VISI, although combined injuries may lead to instability between the radius and the proximal row.

Question 1443

Topic: Nerve & Tendon
What nerve is most at risk during placement of the anterolateral portal in elbow arthroscopy?
. Median
. Ulnar
. Radial
. Posterior interosseous
. Anterior interosseous

Correct Answer & Explanation

. Radial

Explanation

DISCUSSION: The radial nerve is only 4 mm from the anterolateral portal, while the median nerve is 11 mm away from the anteromedial portal. The ulnar nerve is only at risk on the medial side of the elbow. Anterior and posterior interosseous nerves are more distal within the forearm and are not in danger during portal placement.

Question 1444

Topic: 7. Hand and Wrist
Based on the radiographic findings shown in Figure 41, which of the following wrist ligaments is most likely disrupted?
. Short radiolunate
. Long radiolunate
. Scapholunate
. Ulnolunate
. Lunotriquetral

Correct Answer & Explanation

. Scapholunate

Explanation

DISCUSSION: The radiograph shows a diastasis of the scapholunate interval, caused by certain failure of the scapholunate interosseous ligament. The lunotriquetral interosseous ligament stabilizes the lunotriquetral joint. The long radiolunate ligament originates in the volar radius and inserts in the lunate. The short radiolunate ligament originates on the ulnar margin of the radius and inserts on the ulnar margin of the lunate. The ulnolunate ligament originates at the ulnar styloid base and inserts on the volar aspect of the lunate.

Question 1445

Topic: 7. Hand and Wrist
A 28-year-old painter has had increasing pain in his hand and forearm after sustaining a paint injection wound to the tip of his left index finger 24 hours ago. Management should consist of
. hospital admission and IV antibiotics.
. emergent surgical debridement.
. oral antibiotics, splinting, and elevation.
. nonsteroidal anti-inflammatory drugs and splinting.
. oral antibiotics and a tetanus shot.

Correct Answer & Explanation

. emergent surgical debridement.

Explanation

DISCUSSION: The clinical presentation soon after injury may be surprisingly innocuous, but all high-pressure injection injuries of various materials are best treated by emergent surgical debridement of all foreign material from the flexor tendon sheath as well as the subcutaneous tissues. Subsequent hospital admission, IV antibiotics, and possible repeat debridements usually are necessary. The use of antibiotics alone is inadequate treatment of this severe injury.

Question 1446

Topic: 7. Hand and Wrist
A 22-year-old skier reports painful range of motion in the left thumb after falling forward on his outstretched hand while holding his ski pole. Examination of the left thumb reveals increased AP laxity and 45° of valgus laxity at the metacarpophalangeal (MCP) joint. Examination of the right thumb shows 25° of valgus laxity at the MCP joint. Radiographs are normal. Management should consist of
. primary repair of the ulnar collateral ligament.
. volar plate arthroplasty.
. pinning of the MCP joint for 6 weeks.
. a thumb spica cast.
. a hand-based thumb spica splint.

Correct Answer & Explanation

. primary repair of the ulnar collateral ligament.

Explanation

The patient has a complete tear of the ulnar collateral ligament as defined by MCP joint laxity of greater than 30° (or 15° greater laxity compared with the opposite side). Primary repair is the treatment of choice because displacement of the ligament superficial to the adductor aponeurosis (Stener lesion) must be corrected. Any volar plate injury can be addressed during repair of the ulnar collateral ligament.

Question 1447

Topic: 7. Hand and Wrist
A 32-year-old man sustained an injury to the right thumb metacarpophalangeal (MP) joint ulnar collateral ligament (UCL) and is undergoing surgical repair (Figure 1). What structure in the clinical photograph is blocking reduction of the ulnar collateral ligament?
. Extensor pollicis longus (EPL) tendon
. Adductor aponeurosis
. EPB and dorsal capsule
. Ulnar sesamoid bone and volar plate

Correct Answer & Explanation

. Adductor aponeurosis

Explanation

EXPLANATION: When the thumb MP UCL is torn from the proximal phalanx, the distal stump can be displaced superficial to the adductor aponeurosis, known as a Stener lesion. The adductor aponeurosis effectively blocks reduction of the ligament to the normal attachment site. The EPB and EPL tendons are dorsal to the UCL, and the ulnar sesamoid bone/volar plate are in a volar position in relation to the UCL. The dorsal capsule would also not block reduction of the UCL due to its anatomic location. The other responses do not block the UCL with this type of injury.

Question 1448

Topic: Nerve & Tendon
A 25-year-old professional baseball pitcher reports a 4-month history of gradually increasing medial elbow pain that occurs during the late cocking and acceleration phases of throwing. The pain occasionally refers distally along the ulnar aspect of the forearm. He denies any weakness; however, he notes occasional paresthesias. A nerve conduction velocity study demonstrates increased latency across the cubital tunnel. Management consisting of 6 weeks of rest and rehabilitation fails to provide relief as the symptoms returned when he resumed throwing. What is the best course of action?
. Further rehabilitation
. Corticosteroid injection
. Reconstruction of the medial collateral ligament
. Subcutaneous transposition of the ulnar nerve
. Arthroscopic debridement of medial osteophytes

Correct Answer & Explanation

. Subcutaneous transposition of the ulnar nerve

Explanation

DISCUSSION: In the thrower’s elbow, ulnar neuritis is felt to result from both chronic compression and traction on the nerve that occurs during the throwing motion. Occasionally, subluxation of the nerve also can lead to symptoms. If nonsurgical management fails to provide relief, transposition of the nerve to an anterior subcutaneous location is the surgical procedure of choice. The nerve is held in its new position by one or two fascial slings created from the fascia of the common flexor origin. REFERENCES: Schickendantz MS: Diagnosis and treatment of elbow disorders in the overhead athlete. Hand Clin 2002;18:65-75. Eaton RG, Crowe JF, Parkes JC III: Anterior transposition of the ulnar nerve using a non-compressing fasciodermal sling. J Bone Joint Surg Am 1980;62:820-825.

Question 1449

Topic: 7. Hand and Wrist

A 38-year-old left hand-dominant bodybuilder reports ecchymosis in the left axilla and anterior brachium after sustaining an injury while bench pressing 3 weeks ago. Coronal and axial MRI scans are shown in Figures 16a and 16b. What treatment method yields the best long-term results? Review Topic

. Physical therapy and nonsteroidal anti-inflammatory drugs
. Local corticosteroid injection and physical therapy
. Open repair of the long head of the biceps
. Open repair of the sternocostal portion of the pectoralis major tendon
. Open repair of the clavicular portion of the pectoralis major tendon

Correct Answer & Explanation

. Physical therapy and nonsteroidal anti-inflammatory drugs

Explanation

The MRI scans show a rupture of the sternocostal portion of the pectoralis major tendon. This is the most common site of rupture and bench pressing is the most common etiology. Surgical repair yields better functional outcomes and patient satisfaction for tears not only at the tendon/bone interface but also at the myotendinous junction.

Question 1450

Topic: Wrist & Carpus

A 55-year-old female presents with a complex intra-articular distal radius fracture. CT imaging reveals a small, displaced volar ulnar corner (volar lunate facet) fragment. Failure to adequately reduce and stabilize this specific fragment is most likely to result in which of the following complications?

. Dorsal intercalated segment instability (DISI)
. Volar radiocarpal subluxation or dislocation
. Rupture of the extensor pollicis longus (EPL) tendon
. Nonunion of the radial styloid
. Avascular necrosis of the scaphoid

Correct Answer & Explanation

. Dorsal intercalated segment instability (DISI)

Explanation

The volar ulnar corner (volar lunate facet) of the distal radius provides critical tethering support to the lunate via the short radiolunate ligament. If this fragment (often called the critical corner or tear-drop fragment) escapes fixation, the lunate and the entire carpus are at high risk for catastrophic volar subluxation or dislocation.

Question 1451

Topic: Wrist & Carpus

A 55-year-old female undergoes volar locked plating for a distal radius fracture. Six months postoperatively, she is unable to actively flex the interphalangeal joint of her thumb. Which aspect of surgical technique is most highly associated with this complication?

. Placement of the plate proximal to the watershed line
. Prominence of the plate distal to the watershed line
. Over-penetration of dorsal locking screws
. Radial-sided plate prominence
. Ulnar-sided plate prominence

Correct Answer & Explanation

. Placement of the plate proximal to the watershed line

Explanation

Iatrogenic rupture of the flexor pollicis longus (FPL) tendon is a known complication of volar plating. It is directly associated with plate prominence volar and distal to the anatomic watershed line of the distal radius.

Question 1452

Topic: Nerve & Tendon
A right-hand-dominant 45-year-old man sustains an injury to the anterior aspect of his right elbow while trying to lift a heavy load 3 days ago. He has ecchymosis in the anterior and medial elbow regions and has difficulty with resisted forearm supination with the elbow in a flexed position. A diagnosis of an acute distal biceps tendon rupture is made and surgical treatment is chosen. The anatomic relationship of the distal biceps tendon to the median nerve and recurrent radial artery within the antecubital fossa is such that the biceps tendon travels
. lateral (radial) to the median nerve and posterior (deep) to the recurrent radial artery.
. lateral (radial) to the median nerve and anterior (superficial) to the recurrent radial artery.
. medial (ulnar) to the median nerve and posterior (deep) to the recurrent radial artery.
. medial (ulnar) to the median nerve and anterior (superficial) to the recurrent radial artery.

Correct Answer & Explanation

. lateral (radial) to the median nerve and posterior (deep) to the recurrent radial artery.

Explanation

During surgical repair of a distal biceps tendon rupture, regardless of the surgical approach or technique, an understanding of the regional anatomy is important. The tendon passes distally into the antecubital fossa. The antecubital fossa is defined by the brachioradialis radially and the pronator teres ulnarly. A sheath surrounds the biceps tendon as it passes through the antecubital fossa toward its insertion on the radial tuberosity. The lateral antebrachial cutaneous nerve lies superficially in the subcutaneous tissue of the antecubital fossa. The nerve parallels the brachioradialis. While still superficial, the tendon is contiguous with the lacertus fibrosus that becomes confluent medially with the fascia overlying the flexor-pronator mass. The brachial artery lies just beneath the lacertus fibrosus at the level of the elbow flexion crease. The tendon travels just lateral (radial) to the median nerve within the antecubital fossa and passes posterior (deep) to the recurrent radial artery before it attaches to the radial tuberosity. Full forearm supination allows visualization of the tendinous insertion on the radial tuberosity.

Question 1453

Topic: Wrist & Carpus
The development of complex regional pain syndrome (CRPS) following distal radius fracture is associated with what factor?
. Diabetes
. Fibromyalgia
. Nonsurgical fracture management
. Male gender

Correct Answer & Explanation

. Fibromyalgia

Explanation

CRPS is an uncommon complication following distal radius fractures; its incidence is reported to range between 1% and 37%. Two recent studies have evaluated for risk factors in the development of CRPS following distal radius fractures. Female gender, concomitant fracture of the distal ulna, and surgical treatment were all associated with an increased likelihood of CRPS, as was fibromyalgia. Older age was identified as conferring both an increased and a decreased risk for CRPS in the two studies.

Question 1454

Topic: 7. Hand and Wrist
Figures 1 through 3 show the MRI images and a radiograph obtained from a 31-year-old woman who has a 1-year history of diffuse right wrist pain that is gradually worsening. She denies fever or chills and also denies a history of injury. Her examination reveals no swelling, no erythema, an 80-degree arc of active wrist flexion and extension, and dorsal wrist tenderness. The most likely diagnosis is
. scapholunate advanced collapse (SLAC) wrist with cystic capitate changes.
. idiopathic avascular necrosis (AVN) of the capitate.
. capitate osteomyelitis.
. aneurysmal bone cyst in the capitate.

Correct Answer & Explanation

. idiopathic avascular necrosis (AVN) of the capitate.

Explanation

EXPLANATION: Based on the clinical presentation of chronic, progressive wrist pain in a young adult without trauma or infection, and the characteristic imaging findings of the capitate, the most likely diagnosis is idiopathic avascular necrosis of the capitate (Preiser disease or similar pathology).

Question 1455

Topic: 7. Hand and Wrist
A 54-year-old woman with idiopathic carpal tunnel syndrome undergoes open carpal tunnel release with a flexor tenosynovectomy. The pathology from the tenosynovium is likely to show
. fibrosis and edema.
. polymorphonuclear cells.
. negatively birefringent crystals.
. macrophages and lymphocytes.
. fibrinous degeneration of collagen fibers.

Correct Answer & Explanation

. fibrosis and edema.

Explanation

DISCUSSION: The tenosynovium excised at the time of a carpal tunnel release for idiopathic carpal tunnel syndrome rarely shows signs of acute or chronic inflammation. Fibrosis, edema, and vascular sclerosis are the most common histologic findings. A tenosynovectomy with a carpal tunnel release usually is not necessary in the treatment of idiopathic carpal tunnel syndrome.

Question 1456

Topic: 7. Hand and Wrist
A 32-year-old amateur bowler has progressive pain in the lateral aspect of the proximal forearm and elbow. Nonsurgical management consisting of a tennis elbow brace, nonsteroidal anti-inflammatory drugs, and activity modification has failed to provide relief. Examination reveals tenderness in the lateral aspect of the proximal forearm and exacerbation of symptoms with resisted finger extension. Radiographs of the elbow reveal no abnormalities. Which of the following studies will aid in diagnosis?
. MRI of the elbow and forearm
. Bone scan
. Electrodiagnostic studies
. Radial tunnel injection
. Radiographs of the wrist

Correct Answer & Explanation

. Radial tunnel injection

Explanation

DISCUSSION: It is often difficult to accurately discern between lateral epicondylitis and radial tunnel syndrome. Neither MRI nor a bone scan is likely to reveal abnormalities. Electrodiagnostic studies are often inconclusive, and radial tunnel syndrome often presents without motor weakness. The symptoms of radial tunnel syndrome are expected to improve with an injection of lidocaine into the radial tunnel; therefore, this is the test of choice in this clinical scenario.

Question 1457

Topic: 7. Hand and Wrist
A 34-year-old woman has pain at the base of the thumb that worsens with pinching activities. Nonsurgical treatment has failed to provide relief. Examination reveals that the basilar joint is hypermobile, tender, and painful when stressed. A radiograph of the trapeziometacarpal joint shows normal contour with widening when compared with the opposite side. Management should consist of:
. Trapeziometacarpal arthrodesis
. Osteotomy of the thumb metacarpal
. Arthrotomy and joint debridement
. Ligament reconstruction using one half of the flexor carpi radialis
. Trapezium resection, tendon interposition, and reconstruction of the ligament

Correct Answer & Explanation

. Ligament reconstruction using one half of the flexor carpi radialis

Explanation

Painful instability of the thumb carpometacarpal (CMC) joint as manifested by idiopathic hypermobility of the basal joint is not uncommon, particularly in women. Extra-articular ligament reconstruction to stabilize the thumb CMC joint by routing a portion of the flexor carpi radialis (FCR) through the base of the thumb metacarpal is recommended for patients in stage I and stage II disease (i.e., patients having zero to only slight cartilage attrition).

Question 1458

Topic: 7. Hand and Wrist
Figures 1 and 2 show the postreduction radiographs obtained from a 32-year-old man who fell from a ladder onto his outstretched right arm. He reports right wrist pain and dense numbness in his radial digits. What is the most appropriate treatment option?
. Emergent surgery, including open carpal tunnel release, open reduction of the perilunate dislocation, repair of the scapholunate ligament, and intercarpal pinning
. Emergent surgery, including open carpal tunnel release, closed reduction of the perilunate dislocation, and casting
. Elective outpatient surgery, including open carpal tunnel release, open reduction of the perilunate dislocation, repair of the scapholunate ligament, and intercarpal pinning
. Emergent surgery, including open reduction of the perilunate dislocation, repair of the scapholunate ligament, and intercarpal pinning

Correct Answer & Explanation

. Emergent surgery, including open carpal tunnel release, open reduction of the perilunate dislocation, repair of the scapholunate ligament, and intercarpal pinning

Explanation

This patient sustained a lesser-arc perilunate dislocation. As a result of the injury, he also developed acute carpal tunnel syndrome. The closed reduction attempt was unsuccessful; therefore, this injury is best managed with emergent surgery, an open carpal tunnel release, an open reduction of the perilunate dislocation, scapholunate ligament repair, and intercarpal pinning. Outpatient surgery in a delayed fashion is not advised because of the acuity and severity of the carpal tunnel syndrome. Closed reduction and casting is not advised, because it commonly leads to continued carpal instability with subsequent dorsal intercalated segment instability deformity and scaphoid lunate advanced collapse wrist arthritis.

Question 1459

Topic: 7. Hand and Wrist

Figure 57a and 57b show the radiographs of a 57-year-old man who has pain in the ulnar side of the wrist and hand. Examination shows tenderness at the base of the hypothenar area. Additional diagnostic testing should include

. AP and lateral radiographs of the elbow
. Diagnositc arthroscopy
. Aspiration of joint fluid
. An erythrocyte sedimentation rate and CBC
. A diagnostic lidocaine injection

Correct Answer & Explanation

. AP and lateral radiographs of the elbow

Explanation

"The major symptom of dysfunction at the pisotriquetral joint is pain at the hypothenar eminence. It is often vague and poorly localized. The patient may complain of clicking or locking sensation with certain motions of the wrist. Careful clinical evaluation reveals that there is usually well localized tenderness to pressure over the pisiform. Side-to-side passive motion of the pisiform may reproduce pain and occasionally crepitus. Forced hyperextension of the wrist and resistance to palmar flexion and ulnar deviation, as well as to pronation and supination, may reproduce the symptoms. Excessive mobility of the pisiform is a common finding with pain often produced at the extremes of its mobility. A small injection of a local anesthetic agent into the isotriquetral joint at the ulnar aspect of the wrist with relief of symptoms helps confirm the diagnosis."

Question 1460

Topic: 7. Hand and Wrist
A 30-year-old man caught his dominant little finger on the straps of his windsurfing board 10 days ago. He reports swelling about the distal phalanx and has difficulty completely extending the distal interphalangeal joint. A radiograph is shown in Figure 47. What is the most appropriate treatment for this injury?
. Extension splinting of the proximal interphalangeal and distal interphalangeal joints
. Extension splinting of the distal interphalangeal joint
. Transarticular pinning of the distal interphalangeal joint
. Extension block pinning of the distal interphalangeal joint
. Open reduction and internal fixation of the distal phalanx

Correct Answer & Explanation

. Extension splinting of the distal interphalangeal joint

Explanation

DISCUSSION: The radiograph reveals a “bony mallet injury.” As the distal phalanx is not volarly subluxated, extension splinting, similar to a classic mallet injury without bony involvement, is appropriate. If there is volar subluxation associated with a large bony fragment, surgical intervention is appropriate. REFERENCES: Baratz ME, Schmidt CC, Hughes TB: Extensor tendon injuries, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green’s Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 192. Bendre AA, Hartigan BJ, Kalainov DM: Mallet finger. J Am Acad Orthop Surg 2005;13:336-344.

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