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7. Hand and Wrist MCQs

Practice Set 197 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 3921

Topic: Nerve & Tendon

In the context of diagnosing carpal tunnel syndrome, what specific pressure-related physical examination finding, when positive, suggests median nerve compression?

. Increased thenar atrophy with resisted opposition.
. Pain and tingling in the median nerve distribution with sustained wrist flexion (Phalen's test).
. Weakness in finger abduction (Froment's sign).
. Decreased sensation over the ulnar side of the hand.
. Positive Tinel's sign at Guyon's canal.

Correct Answer & Explanation

. Pain and tingling in the median nerve distribution with sustained wrist flexion (Phalen's test).

Explanation

Phalen's test involves sustained wrist flexion, which increases pressure within the carpal tunnel, directly compressing the median nerve. A positive test elicits pain, numbness, or tingling in the median nerve distribution, indicating nerve irritation due to pressure. While thenar atrophy can occur in severe, chronic cases, it's not a 'pressure-related' finding itself but a consequence. Froment's sign is for ulnar nerve palsy. Decreased ulnar sensation and Tinel's at Guyon's canal relate to ulnar nerve compression.

Question 3922

Topic: 7. Hand and Wrist

In a patient presenting with suspected thoracic outlet syndrome (TOS), what pressure-related finding in a diagnostic test would most strongly support a neurogenic TOS diagnosis?

. Elevated venous pressure in the ipsilateral arm during abduction.
. Reduced arterial flow velocity in the subclavian artery during overhead maneuvers.
. Evidence of median nerve compression at the carpal tunnel.
. Decreased nerve conduction velocity across the brachial plexus with provocative positioning.
. Increased intracompartmental pressure in the deltoid muscle.

Correct Answer & Explanation

. Decreased nerve conduction velocity across the brachial plexus with provocative positioning.

Explanation

Neurogenic TOS is characterized by compression of the brachial plexus. A key diagnostic finding, when present, is a decrease in nerve conduction velocity (NCV) or a significant drop in compound muscle action potential (CMAP) amplitude across the brachial plexus, especially with provocative positioning (e.g., hyperabduction), which increases pressure on the nerves. While vascular TOS involves arterial or venous compression (and associated pressure changes or flow reductions), those are not characteristic of neurogenic TOS. Carpal tunnel syndrome is a separate diagnosis. Intracompartmental pressure in the deltoid is irrelevant to TOS.

Question 3923

Topic: 7. Hand and Wrist

In the assessment of a wrist fracture, the distal radius and ulna, if a cast is applied, what critical 'pressure point' should be carefully padded to prevent nerve compression or skin breakdown?

. The palmar crease.
. The styloid processes of the radius and ulna.
. The dorsal aspect of the wrist.
. The olecranon process.
. The carpal tunnel.

Correct Answer & Explanation

. The styloid processes of the radius and ulna.

Explanation

The styloid processes of the radius and ulna are prominent bony points at the wrist. When a cast is applied, these areas are highly susceptible to excessive pressure, which can lead to skin breakdown, pressure sores, or nerve compression (e.g., superficial radial nerve around the radial styloid). Meticulous padding around these bony prominences is therefore crucial. The olecranon is at the elbow, and the carpal tunnel is a canal, not a surface pressure point in this context. Palmar crease should be clear for finger motion, but not typically a primary 'pressure point' for breakdown like styloids.

Question 3924

Topic: Nerve & Tendon

Which of the following physical examination maneuvers aims to increase pressure on a peripheral nerve to elicit symptoms and aid in diagnosis?

. Straight Leg Raise (SLR) test for sciatica.
. Finkelstein's test for De Quervain's tenosynovitis.
. Tinel's sign for nerve entrapment.
. McMurray test for meniscal injury.
. Anterior drawer test for ACL laxity.

Correct Answer & Explanation

. Tinel's sign for nerve entrapment.

Explanation

Tinel's sign involves percussion directly over a peripheral nerve (e.g., median nerve at the carpal tunnel, ulnar nerve at the cubital tunnel). This direct mechanical stimulation increases pressure on the nerve, and if the nerve is irritated or compressed, it elicits tingling or electric shock-like sensations in the nerve's distribution, thereby aiding in the diagnosis of nerve entrapment. The Straight Leg Raise test stretches the sciatic nerve. Finkelstein's test stretches tendons. McMurray and Anterior Drawer are tests for joint stability/meniscal injury.

Question 3925

Topic: 7. Hand and Wrist

A 65-year-old female with a history of chronic kidney disease (CKD) Stage IV (eGFR 25 mL/min) is scheduled for elective carpal tunnel release. Her serum potassium is 5.5 mEq/L pre-operatively. What is the most significant intraoperative concern related to her hyperkalemia?

. Increased risk of surgical site bleeding
. Cardiac arrhythmias (e.g., bradycardia, asystole)
. Increased risk of post-operative confusion
. Impaired wound healing
. Refractory hypertension

Correct Answer & Explanation

. Cardiac arrhythmias (e.g., bradycardia, asystole)

Explanation

Hyperkalemia, even moderate (5.5 mEq/L), is a significant concern in the perioperative setting, especially in patients with CKD, due to its potential to cause life-threatening cardiac arrhythmias. These can range from peaked T waves and prolonged PR intervals to QRS widening, bradycardia, and ultimately ventricular fibrillation or asystole. Therefore, addressing hyperkalemia pre-operatively or having a plan for intraoperative management is crucial. The other options are not direct and immediate life-threatening concerns related to hyperkalemia.

Question 3926

Topic: 7. Hand and Wrist

A 48-year-old male presents with worsening pain and numbness in his left hand, especially the thumb, index, and middle fingers, worse at night. Phalen's test and Tinel's sign at the wrist are positive. He also reports occasional weakness when gripping objects. What is the most accurate diagnostic test to confirm the diagnosis and guide management?

. Plain radiographs of the wrist.
. MRI of the cervical spine.
. Electromyography (EMG) and nerve conduction studies (NCS).
. Ultrasound of the median nerve.
. Blood tests for inflammatory markers.

Correct Answer & Explanation

. Electromyography (EMG) and nerve conduction studies (NCS).

Explanation

The patient's symptoms are classic for carpal tunnel syndrome (CTS), caused by compression of the median nerve at the wrist. While clinical examination (Phalen's, Tinel's) is highly suggestive, electromyography (EMG) and nerve conduction studies (NCS) are the most accurate diagnostic tests to confirm CTS, assess the severity of median nerve compression, rule out other neuropathies (e.g., cervical radiculopathy), and provide a baseline for monitoring. Plain radiographs are typically normal in CTS. MRI of the cervical spine would be considered if a cervical radiculopathy was suspected as a differential. Ultrasound can show median nerve swelling but is not as definitive for confirming nerve compression severity as EMG/NCS. Blood tests are not specific for CTS.

Question 3927

Topic: 7. Hand and Wrist

A 40-year-old male presents with right shoulder and arm pain, numbness in the C8-T1 distribution, and weakness of intrinsic hand muscles. He reports his symptoms worsen with overhead activities. Physical exam reveals tenderness over the supraclavicular fossa and a positive Adson's test. Which of the following is the most likely diagnosis?

. Cervical disc herniation.
. Rotator cuff tear.
. Pancoast tumor.
. Thoracic outlet syndrome (neurogenic type).
. Carpal tunnel syndrome.

Correct Answer & Explanation

. Thoracic outlet syndrome (neurogenic type).

Explanation

The constellation of shoulder/arm pain, C8-T1 numbness, intrinsic hand muscle weakness, worsening with overhead activities, and a positive Adson's test (suggesting subclavian artery compression) is highly indicative of neurogenic thoracic outlet syndrome. This condition involves compression of the brachial plexus and/or subclavian vessels as they pass through the thoracic outlet. Cervical disc herniation can mimic some symptoms but Adson's test is specific to TOS. Rotator cuff tears do not cause neurological deficits in the hand. Pancoast tumor can present with C8-T1 symptoms, but less commonly with relief from specific positioning or a positive Adson's test. Carpal tunnel syndrome affects median nerve distribution, not C8-T1.

Question 3928

Topic: 7. Hand and Wrist

A 32-year-old male presents with right shoulder pain, paresthesias in the medial forearm and hand, and a palpable mass in the supraclavicular fossa. Further workup reveals a cervical rib. Compression of which neurovascular structure is most likely causing the patient's symptoms?

. Radial nerve.
. Ulnar nerve.
. Median nerve.
. Brachial plexus (lower trunk) and subclavian artery.
. Long thoracic nerve.

Correct Answer & Explanation

. Brachial plexus (lower trunk) and subclavian artery.

Explanation

A cervical rib typically compresses the lower trunk of the brachial plexus (C8, T1 roots) and the subclavian artery as they pass through the thoracic outlet. This compression leads to symptoms in the medial forearm and hand (ulnar nerve distribution), weakness of intrinsic hand muscles, and potentially vascular symptoms such as diminished radial pulse or pallor. The radial, ulnar, median, and long thoracic nerves are individual nerves that may be affected by specific conditions, but the overall presentation with a cervical rib points to compression of the broader neurovascular bundle, specifically the lower trunk of the brachial plexus and subclavian artery at the thoracic outlet.

Question 3929

Topic: 7. Hand and Wrist

A 30-year-old male sustains a complete transection of the median nerve at the wrist. Which of the following muscles would NOT be affected?

. Opponens pollicis
. Flexor pollicis brevis (superficial head)
. Abductor pollicis brevis
. Adductor pollicis
. Lumbricals to index and middle fingers

Correct Answer & Explanation

. Adductor pollicis

Explanation

A complete transection of the median nerve at the wrist would affect the thenar muscles (Opponens pollicis, Abductor pollicis brevis, superficial head of Flexor pollicis brevis) and the lumbricals to the index and middle fingers. The Adductor pollicis muscle is primarily innervated by the ulnar nerve, specifically the deep branch. Therefore, it would not be affected by a median nerve transection at the wrist.

Question 3930

Topic: Nerve & Tendon

Which of the following nerve compressions typically causes numbness and tingling in the thumb, index, and middle fingers, especially at night?

. Cubital tunnel syndrome
. Guyon's canal syndrome
. Radial tunnel syndrome
. Carpal tunnel syndrome
. Pronator teres syndrome

Correct Answer & Explanation

. Carpal tunnel syndrome

Explanation

Carpal tunnel syndrome is caused by compression of the median nerve within the carpal tunnel. Its classic symptoms include numbness, tingling, and pain in the median nerve distribution (thumb, index, middle, and radial half of the ring finger), often worse at night or with repetitive activities. Cubital tunnel syndrome (ulnar nerve at elbow) affects the small and ulnar half of the ring finger. Guyon's canal syndrome (ulnar nerve at wrist) affects similar fingers but typically spares the hypothenar muscles in early stages. Radial tunnel syndrome causes pain in the forearm, not numbness. Pronator teres syndrome is a proximal median nerve compression.

Question 3931

Topic: Nerve & Tendon

A patient presents with a painful trigger finger, where the finger catches or locks in flexion and then snaps straight. Which anatomical structure is primarily involved in this condition?

. Flexor digitorum profundus tendon
. Extensor digitorum communis tendon
. A1 pulley
. A2 pulley
. Lumbrical muscle

Correct Answer & Explanation

. A1 pulley

Explanation

Trigger finger (stenosing tenosynovitis) is caused by inflammation and thickening of the flexor tendon sheath and/or the flexor tendons themselves, specifically at the A1 pulley. This creates a disparity between the size of the tendon and the pulley, causing the tendon to catch as it attempts to glide through. The A1 pulley is located at the metacarpal head. Other pulleys (A2, etc.) are further distal, and the tendons and muscles listed are involved in finger movement but the A1 pulley is the site of pathology.

Question 3932

Topic: Nerve & Tendon

What is the primary anatomical structure involved in De Quervain's tenosynovitis?

. Extensor Carpi Ulnaris tendon
. Extensor Pollicis Longus tendon
. Abductor Pollicis Longus and Extensor Pollicis Brevis tendons in the first dorsal compartment
. Flexor Carpi Radialis tendon
. Flexor Pollicis Longus tendon

Correct Answer & Explanation

. Abductor Pollicis Longus and Extensor Pollicis Brevis tendons in the first dorsal compartment

Explanation

De Quervain's tenosynovitis is an inflammatory condition affecting the tendons of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) as they pass through the first dorsal compartment of the wrist. It causes pain on the radial side of the wrist, exacerbated by gripping or thumb movements, and a positive Finkelstein's test.

Question 3933

Topic: Nerve & Tendon

Which of the following statements regarding the treatment of mallet finger is true?

. Surgical repair of the extensor tendon is always indicated.
. The DIP joint should be immobilized in flexion for 6 weeks.
. Conservative treatment involves continuous splinting of the DIP joint in extension for 6-8 weeks.
. It is caused by rupture of the flexor digitorum profundus tendon.
. Buddy taping to an adjacent finger is the most effective treatment.

Correct Answer & Explanation

. Conservative treatment involves continuous splinting of the DIP joint in extension for 6-8 weeks.

Explanation

Mallet finger is an injury to the extensor tendon at the distal interphalangeal (DIP) joint, resulting in an inability to fully extend the DIP joint. The standard conservative treatment involves continuous splinting of the DIP joint in full extension for 6-8 weeks (or longer), while allowing full PIP joint motion. Surgical repair is rarely indicated for closed injuries. Immobilizing in flexion would worsen the deformity. It's an extensor tendon injury, not flexor. Buddy taping is insufficient for effective immobilization of the DIP joint.

Question 3934

Topic: 7. Hand and Wrist

A 40-year-old construction worker presents with numbness and tingling in his thumb, index, middle, and radial half of the ring finger, worse at night and with repetitive hand activities. He also reports weakness in thumb abduction. Which of the following physical examination findings would be most specific for diagnosing Carpal Tunnel Syndrome?

. Positive Finkelstein's test.
. Pain with resisted wrist extension.
. Weakness in finger adduction.
. Positive Tinel's sign at the wrist and Phalen's test.
. Pain over the anatomical snuffbox.

Correct Answer & Explanation

. Positive Tinel's sign at the wrist and Phalen's test.

Explanation

The symptoms are classic for Carpal Tunnel Syndrome (CTS), caused by compression of the median nerve at the wrist. A positive Tinel's sign (tingling/pain with percussion over the median nerve at the wrist) and a positive Phalen's test (symptoms elicited by sustained wrist flexion) are highly specific and sensitive physical examination findings for CTS. Finkelstein's test is for De Quervain's tenosynovitis. Pain with resisted wrist extension can indicate lateral epicondylitis. Weakness in finger adduction is more indicative of ulnar nerve pathology. Pain over the anatomical snuffbox suggests scaphoid injury.

Question 3935

Topic: 7. Hand and Wrist

A 32-year-old female sustains a Colles fracture (extra-articular distal radius fracture with dorsal displacement). She is managed with closed reduction and casting. Which of the following is the most important radiographic parameter to assess immediately post-reduction to ensure adequate reduction and minimize complications?

. Radial inclination.
. Radial length.
. Palmar tilt (or volar tilt).
. Ulnar variance.
. Presence of an associated ulnar styloid fracture.

Correct Answer & Explanation

. Palmar tilt (or volar tilt).

Explanation

For a Colles fracture (dorsally displaced distal radius fracture), restoring the palmar tilt (or volar tilt) is the most critical radiographic parameter to assess post-reduction. Loss of palmar tilt or residual dorsal angulation significantly increases the risk of chronic pain, weakness, and altered wrist biomechanics (e.g., carpal instability, distal radioulnar joint issues). While radial length and inclination are also important, correction of dorsal angulation (restoring palmar tilt) is paramount for Colles fractures. Ulnar variance and ulnar styloid fracture are less critical for immediate functional outcome of the radius fracture itself.

Question 3936

Topic: 7. Hand and Wrist
A 55-year-old female presents with persistent pain and stiffness in her right wrist after a fall 6 months ago. Radiographs show scapholunate advanced collapse (SLAC wrist) with significant degenerative changes. She is active and desires maximal pain relief and functional restoration. Which of the following surgical options is most appropriate for her condition?
. Scaphoid nonunion fixation.
. Wrist arthroscopy with debridement.
. Four-corner fusion (arthrodesis) with scaphoid excision.
. Proximal row carpectomy.
. Total wrist arthroplasty.

Correct Answer & Explanation

. Four-corner fusion (arthrodesis) with scaphoid excision.

Explanation

For advanced SLAC wrist with significant degenerative changes (often Stage II or III), a four-corner fusion (fusion of the capitate, hamate, triquetrum, and lunate) with scaphoid excision is a well-established and reliable procedure. It provides excellent pain relief while preserving some wrist motion. Scaphoid nonunion fixation would be for an acute nonunion. Wrist arthroscopy is for early arthritis. Proximal row carpectomy can be an option, but fusion is often preferred in active patients requiring more predictable pain relief and stability. Total wrist arthroplasty is reserved for older, low-demand patients due to concerns about wear and loosening.

Question 3937

Topic: 7. Hand and Wrist

A 55-year-old male develops numbness and tingling in his left hand, specifically affecting the thumb, index, middle, and radial half of the ring finger. Symptoms are worse at night and with repetitive hand activities. Phalen's test is positive. What is the most likely diagnosis?

. Ulnar nerve entrapment at the elbow (cubital tunnel syndrome).
. Radial nerve palsy (wrist drop).
. Carpal tunnel syndrome.
. Cervical radiculopathy (C6/C7).
. Thoracic outlet syndrome.

Correct Answer & Explanation

. Carpal tunnel syndrome.

Explanation

The symptoms described (numbness/tingling in the median nerve distribution, nocturnal exacerbation, worsening with activity, positive Phalen's test) are classic for carpal tunnel syndrome, which is compression of the median nerve at the wrist. Ulnar nerve entrapment affects the small finger and ulnar half of the ring finger. Radial nerve palsy affects the extensors and causes wrist drop. Cervical radiculopathy would likely involve neck pain and weakness. Thoracic outlet syndrome has broader neurovascular symptoms, often involving the entire arm.

Question 3938

Topic: 7. Hand and Wrist

Which bone is most commonly fractured in the wrist after a fall onto an outstretched hand?

. Triquetrum.
. Hamate.
. Lunate.
. Scaphoid.
. Pisiform.

Correct Answer & Explanation

. Scaphoid.

Explanation

The scaphoid is the most commonly fractured carpal bone, typically occurring after a fall onto an outstretched hand (FOOSH) with the wrist hyperextended and radially deviated. Due to its precarious blood supply, scaphoid fractures are prone to nonunion and avascular necrosis, especially if not recognized and treated appropriately.

Question 3939

Topic: Nerve & Tendon

What is the primary anatomical structure involved in De Quervain's tenosynovitis?

. Extensor carpi ulnaris.
. Flexor pollicis longus.
. Extensor pollicis brevis and abductor pollicis longus.
. Flexor digitorum profundus.
. Extensor digitorum communis.

Correct Answer & Explanation

. Extensor pollicis brevis and abductor pollicis longus.

Explanation

De Quervain's tenosynovitis is a painful condition affecting the tendons on the thumb side of the wrist, specifically involving stenosing tenosynovitis of the first dorsal compartment. This compartment contains the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons. Finkelstein's test is typically positive. The other tendons are located in different compartments or have different functions.

Question 3940

Topic: 7. Hand and Wrist

What is the most common site for a 'boxer's fracture'?

. Distal radius.
. Fifth metacarpal neck.
. First metacarpal base.
. Navicular bone.
. Hamate bone.

Correct Answer & Explanation

. Fifth metacarpal neck.

Explanation

A 'boxer's fracture' is a fracture of the neck of the fifth metacarpal bone, typically occurring from punching a hard object with a closed fist. It is often characterized by volar angulation and shortening. The distal radius is involved in Colles' fractures. First metacarpal base is a Bennett's or Rolando fracture. Navicular and hamate are carpal bones.

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