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7. Hand and Wrist MCQs

Practice Set 79 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 1561

Topic: Wrist & Carpus

A 65-year-old female sustains a dorsally displaced distal radius fracture (Colles type). A volar approach (modified Henry) is planned for open reduction and internal fixation. During the approach, the interval is developed between the flexor carpi radialis (FCR) and the radial artery. Which muscle must be incised and elevated from the radius to expose the fracture site?

. Pronator teres
. Pronator quadratus
. Flexor pollicis longus
. Brachioradialis
. Flexor digitorum superficialis

Correct Answer & Explanation

. Pronator teres

Explanation

In the modified Henry approach to the distal radius, the superficial interval is between the FCR tendon and the radial artery. In the deep dissection, the pronator quadratus muscle is encountered overlying the volar surface of the distal radius. It is incised along its radial border and elevated ulnarly (often as an L-shaped flap) to expose the fracture site.

Question 1562

Topic: 7. Hand and Wrist

A 42-year-old female presents with acute wrist pain and deformity after a fall on an outstretched hand. Radiographs reveal a highly comminuted, intra-articular fracture of the distal radius with a prominent volar marginal fragment and volar subluxation of the carpus.

Which of the following eponymous terms best describes this fracture pattern, and what is the optimal surgical approach for internal fixation?

. Colles fracture; dorsal approach
. Smith fracture; dorsal approach
. Volar Barton fracture; volar approach
. Chauffeur fracture; radial approach
. Die-punch fracture; dorsal approach

Correct Answer & Explanation

. Colles fracture; dorsal approach

Explanation

A volar shear fracture of the distal radius with concomitant volar radiocarpal subluxation is eponymously known as a Volar Barton fracture. Because the primary deforming force is volar shear, it is mechanically best treated by placing a volar buttress plate via a volar approach (typically the modified Henry approach between the FCR and radial artery) to directly counteract the shear forces and prevent volar carpal translation.

Question 1563

Topic: 7. Hand and Wrist

A 24-year-old male falls on an outstretched hand and sustains a proximal pole scaphoid fracture.

What is the rationale for using a dorsal surgical approach for internal fixation of this specific fracture pattern?

. It avoids the superficial branch of the radial nerve.
. It allows for direct visualization and preservation of the primary volar blood supply.
. It facilitates screw placement perpendicular to the fracture plane.
. It avoids division of the transverse carpal ligament.
. It prevents injury to the flexor carpi radialis tendon.

Correct Answer & Explanation

. It avoids the superficial branch of the radial nerve.

Explanation

Proximal pole scaphoid fractures are best fixed via a dorsal approach. This allows the surgeon to place the headless compression screw directly down the central axis of the scaphoid and perpendicular to the fracture plane, which is biomechanically superior for proximal pole lesions.

Question 1564

Topic: Nerve & Tendon

A 65-year-old female sustains a closed, displaced intra-articular distal humerus fracture (AO type 13-C3).

Preoperatively, she reports numbness and tingling in her ring and small fingers. What is the most appropriate intraoperative management of the ulnar nerve during open reduction and internal fixation (ORIF)?

. In situ decompression without any mobilization to preserve blood supply.
. Routine anterior submuscular transposition for all complex distal humerus fractures.
. Identification and mobilization of the nerve, leaving it in situ if there is no tension or impingement over the hardware.
. Excision of the medial epicondyle to definitively relieve tension on the nerve.
. Repair and tightening of the cubital tunnel retinaculum after hardware placement.

Correct Answer & Explanation

. Identification and mobilization of the nerve, leaving it in situ if there is no tension or impingement over the hardware.

Explanation

In the surgical management of distal humerus fractures, the ulnar nerve must be identified and protected. Current evidence suggests that routine transposition is not required and may increase the risk of devascularization and subsequent neuropathy. The nerve should be mobilized enough to allow safe fracture fixation and then left in situ, provided it rests comfortably without tension or direct impingement by the implants.

Question 1565

Topic: 7. Hand and Wrist

A 55-year-old female sustains a completely displaced, volarly angulated fracture of the distal radius (Smith fracture). In the emergency department, she complains of severe, progressively worsening burning pain in her hand and numbness in her thumb, index, and middle fingers. The pain is exacerbated by passive extension of her digits. What is the most appropriate immediate next step in management?

. Immediate closed reduction and splinting of the fracture, followed by frequent reassessment of her neurological status.
. Urgent surgical carpal tunnel release in the operating room prior to addressing the fracture.
. Administration of intravenous corticosteroids, high elevation, and observation for 24 hours.
. Emergent compartment pressure measurement of the volar forearm.
. Emergent open reduction and internal fixation with prophylactic carpal tunnel release.

Correct Answer & Explanation

. Immediate closed reduction and splinting of the fracture, followed by frequent reassessment of her neurological status.

Explanation

Acute carpal tunnel syndrome is a known complication of displaced distal radius fractures due to fracture displacement increasing pressure within the carpal tunnel, or from a fracture hematoma. The initial and most effective treatment is prompt, anatomically aligned closed reduction of the fracture, which usually relieves the pressure on the median nerve. If severe symptoms persist unchanged after an adequate reduction, urgent surgical decompression is indicated.

Question 1566

Topic: 7. Hand and Wrist
A 6-year-old boy falls on an outstretched hand and sustains a Bado Type I Monteggia fracture-dislocation. On examination, he is unable to extend his thumb and digits at the metacarpophalangeal joints, but active wrist extension is preserved, accompanied by radial deviation. Which nerve is most likely injured?
. Median nerve
. Ulnar nerve
. Anterior interosseous nerve
. Radial nerve proper
. Posterior interosseous nerve

Correct Answer & Explanation

. Posterior interosseous nerve

Explanation

The posterior interosseous nerve (PIN) is commonly injured in Monteggia fracture-dislocations, particularly Bado types I (anterior) and III (lateral). The PIN innervates the extensor carpi ulnaris (ECU) and the extensor digitorum communis (EDC), but spares the extensor carpi radialis longus (ECRL), which is innervated by the radial nerve proper before it bifurcates. This results in preserved wrist extension but with a radial deviation bias, along with inability to extend the digits at the MCP joints.

Question 1567

Topic: 7. Hand and Wrist

A 62-year-old female undergoes open reduction and internal fixation of a distal radius fracture using a standard Henry (volar) approach. Post-operatively, she is unable to actively flex the interphalangeal joint of her thumb. Which structure was most likely subjected to excessive retraction during the procedure?

. Median nerve proper
. Palmar cutaneous branch of median nerve
. Superficial radial nerve
. Ulnar nerve
. Anterior interosseous nerve

Correct Answer & Explanation

. Median nerve proper

Explanation

In the volar Henry approach to the distal radius, deep retractors placed around the radius can inadvertently compress or stretch the anterior interosseous nerve (AIN) or the flexor pollicis longus (FPL) muscle belly. AIN palsy presents as weakness or loss of thumb interphalangeal flexion and index distal interphalangeal flexion (positive Kiloh-Nevin sign / inability to make an 'OK' sign).

Question 1568

Topic: 7. Hand and Wrist

A 55-year-old female presents with a non-displaced distal radius fracture treated with a well-molded short arm cast. Two days later, she reports severe, progressively worsening numbness and tingling in her thumb, index, and middle fingers, as well as worsening pain. What is the most appropriate next step in management?

. Urgent carpal tunnel release
. Split the cast and padding immediately
. Administer oral corticosteroids
. Order a nerve conduction study
. Prescribe gabapentin for neuropathic pain

Correct Answer & Explanation

. Urgent carpal tunnel release

Explanation

Acute carpal tunnel syndrome can occur following a distal radius fracture, exacerbated by fracture hematoma and a tight cast. The initial step should always be to bi-valve or completely split the cast and all underlying padding to relieve extrinsic pressure. If symptoms persist despite decompression of the cast, surgical carpal tunnel release is indicated.

Question 1569

Topic: Nerve & Tendon

A 15-year-old gymnast sustains a medial epicondyle fracture that is displaced 15 mm into the joint, necessitating open reduction and internal fixation. During the surgical approach, the ulnar nerve is identified. According to current orthopedic literature, what is the most appropriate management of the ulnar nerve?

. Routine anterior sub-cutaneous transposition
. Leave the nerve in situ and perform fracture fixation
. Routine anterior sub-muscular transposition
. Routine epineurotomy to prevent post-operative swelling
. Resection of the medial intermuscular septum only

Correct Answer & Explanation

. Routine anterior sub-cutaneous transposition

Explanation

In the surgical treatment of pediatric medial epicondyle fractures, routine anterior transposition of the ulnar nerve is not recommended unless there is pre-existing significant nerve tension, instability, or the nerve impedes anatomical reduction. Standard practice involves identifying and protecting the nerve, leaving it in situ, and proceeding with fixation.

Question 1570

Topic: 7. Hand and Wrist
A 7-year-old girl falls from monkey bars and sustains a Bado Type III Monteggia fracture-dislocation. She exhibits a nerve palsy characterized by weakness in thumb and finger extension, but normal wrist extension with radial deviation. Which nerve is most likely injured?
. Anterior interosseous nerve
. Posterior interosseous nerve
. Superficial radial nerve
. Ulnar nerve
. Median nerve

Correct Answer & Explanation

. Posterior interosseous nerve

Explanation

Bado Type III Monteggia fractures are highly associated with Posterior Interosseous Nerve (PIN) injuries. PIN palsy causes weakness in finger/thumb extensors and ECU, leading to radial deviation during wrist extension.

Question 1571

Topic: 7. Hand and Wrist

A 29-year-old man falls on an outstretched hand. Lateral radiographs of his wrist show the lunate displaced volarly and 'spilled' from the radius, while the capitate remains aligned with the radius. He reports severe pain and numbness in his index and middle fingers. What is the most appropriate management?

. Closed reduction and cast immobilization for 6 weeks
. Urgent open reduction, ligament repair, and carpal tunnel release
. Immediate EMG/NCS to confirm nerve compression
. Corticosteroid injection into the carpal tunnel
. Proximal row carpectomy

Correct Answer & Explanation

. Closed reduction and cast immobilization for 6 weeks

Explanation

This is a lunate dislocation, which frequently causes acute median nerve compression in the carpal tunnel. Urgent open reduction, ligamentous repair, and carpal tunnel release are required to prevent permanent nerve damage.

Question 1572

Topic: 7. Hand and Wrist

A 29-year-old male falls from a roof and sustains a dorsal perilunate dislocation. He presents with severe wrist pain, absent 2-point discrimination in the thumb and index finger, and weakness in thumb opposition. What is the most appropriate initial surgical management?

. Closed reduction and casting with outpatient nerve conduction studies
. Carpal tunnel release combined with open reduction of the carpus
. Immediate tendon transfer for thumb opposition restoration
. Proximal row carpectomy
. Open reduction via an isolated dorsal approach without nerve decompression

Correct Answer & Explanation

. Closed reduction and casting with outpatient nerve conduction studies

Explanation

Acute median neuropathy following a perilunate dislocation represents an acute carpal tunnel syndrome. It is a surgical emergency requiring immediate carpal tunnel release in conjunction with open reduction of the carpus.

Question 1573

Topic: 7. Hand and Wrist
A 7-year-old girl falls and sustains a Bado Type III Monteggia fracture-dislocation. On examination, she is unable to actively extend the MCP joints of her fingers, but wrist extension is preserved with radial deviation. Which nerve structure is injured?
. Anterior interosseous nerve
. Posterior interosseous nerve
. Superficial radial nerve
. Ulnar nerve
. Median nerve proper

Correct Answer & Explanation

. Posterior interosseous nerve

Explanation

Bado Type III injuries (lateral dislocation of the radial head) carry the highest risk of posterior interosseous nerve (PIN) palsy. PIN injury causes loss of finger and thumb extension, as well as loss of ulnar wrist extension (ECU), leading to radial deviation during active wrist extension.

Question 1574

Topic: 7. Hand and Wrist

A 55-year-old female presents with a completely displaced fracture of the distal radius. After a closed reduction and splinting, she complains of rapidly escalating pain and progressive loss of two-point discrimination in her thumb, index, and long fingers within 2 hours. What is the definitive management?

. Elevate the arm, split the cast, and observe for 24 hours
. Immediate open reduction, internal fixation, and carpal tunnel release
. Urgent EMG to confirm the severity of median nerve injury
. Administration of IV corticosteroids and mannitol
. Closed reduction under general anesthesia

Correct Answer & Explanation

. Elevate the arm, split the cast, and observe for 24 hours

Explanation

Progressive, severe median nerve neuropathy following reduction of a distal radius fracture signifies acute carpal tunnel syndrome. This is a surgical emergency requiring immediate carpal tunnel release and simultaneous rigid fracture stabilization.

Question 1575

Topic: 7. Hand and Wrist

A 28-year-old man falls on his outstretched hand. His wrist is diffusely swollen, and he holds his fingers in slight flexion. A lateral radiograph demonstrates the 'spilled teacup' sign. He reports severe, continuous numbness in his thumb, index, and middle fingers. What is the most appropriate initial management?

. Closed reduction in the emergency department and clinic follow-up in 1 week
. Splinting the wrist in slight flexion to relieve nerve tension
. Urgent open reduction, ligamentous repair, and carpal tunnel release
. Administration of high-dose oral corticosteroids and close observation
. Immediate EMG to map the extent of median nerve axonal loss

Correct Answer & Explanation

. Closed reduction in the emergency department and clinic follow-up in 1 week

Explanation

A volar lunate dislocation (spilled teacup sign) frequently compresses the median nerve. When presenting with acute carpal tunnel syndrome, urgent surgical intervention involving open reduction, ligament repair, and carpal tunnel release is mandated.

Question 1576

Topic: Nerve & Tendon

A 12-year-old boy sustains a traumatic elbow dislocation that is reduced in the emergency department. Post-reduction radiographs show widening of the medial joint space, and the medial epicondyle ossification center is completely absent from its normal anatomic position. He has new-onset numbness in his small finger. What is the most likely pathomechanism?

. The medial epicondyle is incarcerated within the joint, compressing the ulnar nerve
. The ulnar nerve was completely transected by a sharp bone fragment during reduction
. The posterior interosseous nerve is stretched over the lateral condyle
. The median nerve is entrapped in a supracondylar fracture hematoma
. An acute compartment syndrome of the forearm has developed

Correct Answer & Explanation

. The medial epicondyle is incarcerated within the joint, compressing the ulnar nerve

Explanation

Incarceration of the medial epicondyle within the elbow joint is a classic complication of pediatric elbow dislocations. It presents with a widened medial joint space, an 'absent' medial epicondyle on standard views, and often ulnar neuropathy due to entrapment of the nerve with the bone fragment.

Question 1577

Topic: 7. Hand and Wrist
Figures 1 through 4 are the radiographs, sagittal-cut CT scan, and coronal T1 MR image of a 16-year-old boy who has wrist stiffness and pain after sustaining an injury 2 years ago. There is no bleeding from the proximal pole during surgery. Which procedure will most likely result in restoration of alignment and healing?
. 1,2 intercompartmental supraretinacular artery (ICSRA) graft
. Free-vascularized medial femoral condyle graft
. Iliac crest corticocancellous graft
. 4+5 extensor compartmental artery (ECA) vascularized bone graft

Correct Answer & Explanation

. Free-vascularized medial femoral condyle graft

Explanation

The imaging studies show an established scaphoid waist nonunion with a humpback deformity and carpal collapse. The proximal pole appears sclerotic and poorly perfused. Correction of alignment requires a volar approach with a structural bone graft. A free-vascularized medial femoral condyle graft provides both adequate bone graft to correct the deformity and revascularization of the scaphoid.

Question 1578

Topic: 7. Hand and Wrist
In an acute closed boutonniere injury, what is the most appropriate splinting technique for the proximal interphalangeal joint?
. Static splint in 30° of flexion
. Static splint in full extension
. Dynamic extension splint
. 30° extension block splint
. Buddy taping to the adjacent finger

Correct Answer & Explanation

. Static splint in full extension

Explanation

Rupture of the central slip of the extensor mechanism and a varying degree of lateral band volar migration are the pathologic entities in an acute boutonniere injury. Splinting the proximal interphalangeal joint in full extension allows reapproximation of the central slip to the base of the middle phalanx.

Question 1579

Topic: 7. Hand and Wrist
An 83-year-old woman reports pain in her left middle finger after a minor injury. Laboratory studies show a WBC count of 7,000/mm³, an erythrocyte sedimentation rate of 3 mm/h, a uric acid of 10.4 mg/dL, and a normal serum protein electrophoresis. Radiographs are shown in Figures 49a and 49b. A core biopsy specimen is shown in Figure 49c. In addition to treatment of the finger fracture, treatment should include:
. Colchicine and indomethacin
. Radiation therapy to the left hand
. Systemic chemotherapy
. IV antibiotics
. Through the wrist amputation

Correct Answer & Explanation

. Colchicine and indomethacin

Explanation

This clinical picture is most consistent with periarticular erosions from gout. The patient has multiple periarticular lytic lesions in the hand. The laboratory studies show an elevated serum uric acid level, and the biopsy specimen demonstrates acute and chronic inflammation with prominent clefts. Therefore, the preferred treatment is systemic control of her gout. Radiation therapy, chemotherapy, and/or amputation should be considered for a malignancy; however, the pathology does not demonstrate any evidence of pleomorphism, high nuclear-to-cytoplasmic ratio, nuclear atypia, or mitotic activity. Antibiotics for an infectious process is a consideration, but the minimal elevation in the WBC count and erythrocyte sedimentation rate does not support an infectious process.

Question 1580

Topic: 7. Hand and Wrist

A 70-year-old man with severe osteoarthritis of the right hip walks with a cane. To maximally decrease the joint reaction force across his right hip, in which hand should he hold the cane and what is the primary biomechanical reason?

. Right hand; to decrease the moment arm of the body weight
. Left hand; to decrease the force required by the right hip abductors
. Right hand; to increase the moment arm of the hip abductors
. Left hand; to increase the joint reaction force generated by the iliopsoas
. Right hand; to shift the center of gravity laterally over the right hip

Correct Answer & Explanation

. Right hand; to decrease the moment arm of the body weight

Explanation

Using a cane in the contralateral (left) hand reduces the joint reaction force across the affected (right) hip. The cane pushes down on the ground, creating an upward ground reaction force on the left side. This counter-torque supports the pelvis, drastically decreasing the force that the right hip abductor muscles must generate. Since abductor muscle force is the primary contributor to the hip joint reaction force, decreasing it leads to a significant decrease in the overall joint reaction force.

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