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7. Hand and Wrist MCQs

Practice Set 41 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 801

Topic: 7. Hand and Wrist

A 29-year-old, 7 months pregnant woman presents with new-onset bilateral thumb numbness, worse at night, and a positive Durkan test. She has no weakness or thenar atrophy. What is the most appropriate initial management strategy for her condition?

. Immediate bilateral carpal tunnel release surgery.
. Electromyography and nerve conduction studies to confirm diagnosis before any treatment.
. Referral for corticosteroid injections into the carpal tunnel.
. Conservative treatment with wrist splinting and activity modification.
. Prescription of oral diuretics to reduce edema.

Correct Answer & Explanation

. Conservative treatment with wrist splinting and activity modification.

Explanation

Correct Answer: DThe discussion states that "most women with this problem can be treated conservatively with the expectation that symptoms will improve and/or resolve following delivery." Conservative measures typically include wrist splinting (especially at night), activity modification, and patient education. Given the absence of weakness or thenar atrophy, conservative management is the appropriate initial approach.Option A is incorrectbecause surgical intervention is generally reserved for cases that fail conservative management or present with severe, progressive neurological deficits, which are not described here as initial presentation.Option B is incorrectbecause while NCS/EMG can confirm the diagnosis, the clinical presentation (nocturnal symptoms, positive Durkan, pregnancy) is highly suggestive, and conservative treatment can be initiated without immediate electrodiagnostic studies, especially given the self-limiting nature post-pregnancy.Option C is incorrectbecause while corticosteroid injections can be used, they are often considered after initial conservative measures like splinting, and their use in pregnancy requires careful consideration.Option E is incorrectbecause while edema is the cause, oral diuretics are not the standard or primary treatment for carpal tunnel syndrome, especially in pregnancy, and could have other implications.

Question 802

Topic: 7. Hand and Wrist

In evaluating a patient for carpal tunnel syndrome, both the Phalen test (wrist flexion) and the Durkan test (direct median nerve compression) can be performed. Compared to the Phalen test, what is a key advantage of the Durkan test as described in the case?

. The Durkan test is less painful for the patient.
. The Durkan test is performed with the wrist in extension, reducing carpal tunnel pressure.
. The Durkan test has generally higher sensitivity and specificity.
. The Durkan test is primarily used to assess thenar muscle strength.
. The Durkan test requires less patient cooperation.

Correct Answer & Explanation

. The Durkan test has generally higher sensitivity and specificity.

Explanation

Correct Answer: CThe discussion explicitly compares the Durkan and Phalen tests, stating that the "sensitivity and specificity [of the Durkan test] are generally thought to be less than that for the Durkan test" when referring to Phalen's. This implies that the Durkan test has generally higher sensitivity and specificity compared to the Phalen test, making option C correct.Option A is incorrectas the case does not provide information on the relative pain levels of the tests.Option B is incorrectas the Durkan test involves direct compression, not wrist extension. The Phalen test involves wrist flexion, which increases pressure.Option D is incorrectas the Durkan test assesses sensory symptoms (paresthesias/pain) in the median nerve distribution, not thenar muscle strength.Option E is incorrectas both tests require patient cooperation to report symptoms accurately.

Question 803

Topic: 7. Hand and Wrist

The 29-year-old pregnant patient reports that her numbness in the thumbs is "worst at night and wakes her up from sleep." This specific characteristic of carpal tunnel syndrome symptoms is most likely due to which of the following?

. Increased activity during the day causing nerve fatigue.
. Nocturnal changes in blood pressure leading to nerve ischemia.
. Fluid shifts and prolonged wrist flexion during sleep increasing carpal tunnel pressure.
. Psychological factors exacerbating symptoms during periods of rest.
. Increased sympathetic nervous system activity at night.

Correct Answer & Explanation

. Fluid shifts and prolonged wrist flexion during sleep increasing carpal tunnel pressure.

Explanation

Correct Answer: CNocturnal worsening of carpal tunnel syndrome symptoms is a classic presentation. During sleep, people often maintain positions of wrist flexion or extension, which can increase pressure within the carpal tunnel. Additionally, fluid shifts in the body can lead to increased edema in the extremities at night, further contributing to nerve compression. The case mentions "edematous hands" and symptoms being "worst at night and wake her up from sleep," aligning with this mechanism.Option A is incorrectas symptoms are typically worse at night, not due to daytime activity causing nerve fatigue.Option B is incorrectas while blood pressure changes occur, the primary mechanism for nocturnal CTS symptoms is mechanical compression from wrist position and fluid shifts, not primarily nerve ischemia from blood pressure changes.Option D is incorrectas while psychological factors can influence pain perception, the nocturnal worsening of CTS has a well-established physiological basis.Option E is incorrectas increased sympathetic activity is not the primary mechanism for nocturnal CTS symptoms.

Question 804

Topic: Nerve & Tendon

The patient's primary symptom is numbness in her thumbs bilaterally. Given a diagnosis of carpal tunnel syndrome, which of the following anatomical structures is primarily responsible for the sensory innervation of the thumb that is affected in this condition?

. Ulnar nerve
. Radial nerve
. Median nerve
. Anterior interosseous nerve
. Posterior interosseous nerve

Correct Answer & Explanation

. Median nerve

Explanation

Correct Answer: CCarpal tunnel syndrome is caused by compression of the median nerve. The median nerve provides sensory innervation to the palmar aspect of the thumb, index finger, middle finger, and the radial half of the ring finger. Therefore, numbness in the thumbs is a classic symptom of median nerve compression.Option A is incorrectas the ulnar nerve primarily innervates the little finger and the ulnar half of the ring finger.Option B is incorrectas the radial nerve primarily provides sensory innervation to the dorsal aspect of the thumb, index, middle, and radial half of the ring finger, but not the palmar aspect of the thumb which is typically affected in CTS.Option D is incorrectas the anterior interosseous nerve is a motor branch of the median nerve and does not provide sensory innervation to the thumb.Option E is incorrectas the posterior interosseous nerve is a motor branch of the radial nerve and does not provide sensory innervation to the thumb.

Question 805

Topic: 7. Hand and Wrist

A 29-year-old, 7 months pregnant woman with carpal tunnel syndrome has failed conservative management and is considering surgical intervention. Which of the following statements regarding carpal tunnel release surgery during pregnancy is most accurate?

. Surgical intervention is absolutely contraindicated due to high risks to the fetus.
. Surgery should be delayed until at least 6 months postpartum to ensure complete resolution of edema.
. It can be safely performed under the direction of an experienced anesthesiologist.
. The procedure carries a significantly higher risk of median nerve injury during pregnancy.
. Only endoscopic carpal tunnel release is considered safe during pregnancy.

Correct Answer & Explanation

. It can be safely performed under the direction of an experienced anesthesiologist.

Explanation

Correct Answer: CThe discussion explicitly addresses surgical intervention during pregnancy, stating: "If surgical intervention is required, it can be safely performed under the direction of an experienced anesthesiologist." This directly supports option C.Option A is incorrectas the case states surgery can be safely performed if needed, implying it is not absolutely contraindicated.Option B is incorrectas while many symptoms resolve postpartum, the statement does not mandate a 6-month delay if surgery is indicated and safe during pregnancy.Option D is incorrectas the case does not suggest a higher risk of median nerve injury during pregnancy, only that it can be safely performed.Option E is incorrectas the case does not specify a preference for endoscopic versus open release, only that surgery can be safely performed. The choice of technique would depend on surgeon preference and patient factors.

Question 806

Topic: 7. Hand and Wrist

The case describes a 29-year-old woman developing carpal tunnel syndrome during her 7th month of pregnancy. This presentation highlights pregnancy as a significant risk factor. Which of the following best describes the typical timing and underlying reason for the onset of carpal tunnel syndrome symptoms during pregnancy?

. Early pregnancy, due to rapid hormonal changes affecting nerve conduction.
. First trimester, primarily due to morning sickness-related dehydration.
. Later phases of pregnancy, related to whole body edema.
. Immediately postpartum, due to the sudden decrease in circulating fluid volume.
. Anytime during pregnancy, but only in women with pre-existing diabetes.

Correct Answer & Explanation

. Later phases of pregnancy, related to whole body edema.

Explanation

Correct Answer: CThe discussion states that the etiology of pregnancy-induced carpal tunnel syndrome is "related to whole body edema during the later phases of pregnancy." The patient in the case is 7 months pregnant, which falls within the later phases. This makes option C the most accurate description.Option A is incorrectas the onset is typically in the later phases, not early pregnancy, and the primary mechanism is edema, not just hormonal changes affecting nerve conduction.Option B is incorrectas the first trimester is not the typical timing, and dehydration is not the primary cause; rather, it's edema.Option D is incorrectas symptoms typically improve or resolve postpartum, not worsen or begin immediately postpartum.Option E is incorrectas while diabetes is a risk factor for CTS, pregnancy-induced CTS can occur in women without pre-existing diabetes, and the timing is typically in the later phases, not just 'anytime'.

Question 807

Topic: 7. Hand and Wrist

Which of the following anatomic structures acts as the primary unyielding 'anvil' against which the ulnar artery is traumatized in the pathogenesis of Hypothenar Hammer Syndrome?

. Pisiform
. Hook of the hamate
. Tubercle of the trapezium
. Base of the fifth metacarpal
. Styloid process of the ulna

Correct Answer & Explanation

. Hook of the hamate

Explanation

In Hypothenar Hammer Syndrome (HHS), repetitive blunt trauma to the hypothenar eminence crushes the superficial palmar branch of the ulnar artery. The hook of the hamate acts as the bony anvil, causing intimal injury, subsequent thrombosis, or aneurysm formation.

Question 808

Topic: 7. Hand and Wrist

A 28-year-old female in her third trimester of pregnancy presents with bilateral numbness and tingling in her thumb, index, and long fingers, which awakens her at night. Which of the following is the most appropriate initial management?

. Immediate carpal tunnel release under local anesthesia
. Prescription of oral corticosteroids
. Fabrication of nocturnal neutral-position wrist splints
. Diuretic therapy to reduce systemic fluid retention
. Cervical spine MRI to rule out radiculopathy

Correct Answer & Explanation

. Fabrication of nocturnal neutral-position wrist splints

Explanation

Carpal tunnel syndrome in pregnancy typically peaks in the third trimester due to fluid retention and usually resolves postpartum. Nocturnal splinting in a neutral wrist position is the safest and most effective first-line conservative treatment.

Question 809

Topic: 7. Hand and Wrist
A 32-year-old pregnant patient (34 weeks gestation) has severe, refractory carpal tunnel syndrome with progressive thenar atrophy and profound motor weakness despite splinting and localized injections. If surgical intervention is deemed mandatory, which of the following anesthetic techniques is most appropriate?
. General anesthesia with volatile anesthetics
. Intravenous regional anesthesia (Bier block)
. Spinal anesthesia
. Wide-awake local anesthesia no tourniquet (WALANT)
. Axillary brachial plexus block with deep intravenous sedation

Correct Answer & Explanation

. Wide-awake local anesthesia no tourniquet (WALANT)

Explanation

When carpal tunnel release is strictly indicated during pregnancy, the WALANT technique is highly preferred. It avoids the systemic risks of sedation and general anesthesia, ensuring maximum safety for both the mother and the fetus.

Question 810

Topic: 7. Hand and Wrist

What is the anticipated natural history for the vast majority of patients who develop pregnancy-induced Carpal Tunnel Syndrome?

. Progression to permanent thenar atrophy requiring late surgical release
. Spontaneous resolution of symptoms within a few weeks to months postpartum
. Persistent nocturnal pain that responds only to systemic steroids postpartum
. Development of complex regional pain syndrome if not treated surgically before delivery
. Migration of symptoms to the contralateral hand immediately following delivery

Correct Answer & Explanation

. Spontaneous resolution of symptoms within a few weeks to months postpartum

Explanation

Carpal Tunnel Syndrome associated with pregnancy is primarily driven by transient hormonal and fluid volume changes. Most cases resolve spontaneously within weeks to a few months postpartum as normal fluid balance is restored.

Question 811

Topic: 7. Hand and Wrist

During the evaluation of a patient with suspected Hypothenar Hammer Syndrome, Allen's test demonstrates sluggish reperfusion when the radial artery is occluded, but immediate reperfusion when the ulnar artery is occluded. Which of the following best describes the structural pathology?

. The ulnar artery is patent and provides dominant flow.
. The radial artery is occluded at the wrist.
. There is an obstruction in the ulnar artery or superficial palmar arch.
. The deep palmar arch is functioning as the sole blood supply.
. The patient has a vasospastic disorder affecting both arteries symmetrically.

Correct Answer & Explanation

. There is an obstruction in the ulnar artery or superficial palmar arch.

Explanation

A positive (abnormal) Allen test for the ulnar artery means that releasing the ulnar artery while keeping the radial artery compressed fails to reperfuse the hand quickly. This indicates an occlusion or severe flow limitation in the ulnar artery.

Question 812

Topic: 7. Hand and Wrist

A pregnant patient with Carpal Tunnel Syndrome fails nocturnal splinting and requests further non-operative intervention to manage severe pain. Which of the following is true regarding local corticosteroid injections for this condition during pregnancy?

. They are strictly contraindicated due to high teratogenic risk.
. They can be safely administered and offer significant, often definitive, symptomatic relief until postpartum resolution.
. They are only safe if performed under fluoroscopic guidance.
. They routinely cause premature labor due to systemic absorption.
. They are ineffective because the syndrome is purely driven by relaxin, not inflammation.

Correct Answer & Explanation

. They can be safely administered and offer significant, often definitive, symptomatic relief until postpartum resolution.

Explanation

Local corticosteroid injections have minimal systemic absorption and are considered safe during pregnancy. They provide effective, albeit sometimes temporary, relief to bridge the patient until postpartum spontaneous resolution.

Question 813

Topic: 7. Hand and Wrist

In Hypothenar Hammer Syndrome, the ulnar artery is most vulnerable to trauma as it exits Guyon's canal. Which of the following correctly identifies the anatomical boundaries of Guyon's canal?

. Roof: flexor retinaculum; Floor: palmar carpal ligament; Radial: scaphoid; Ulnar: trapezium
. Roof: palmar carpal ligament; Floor: flexor retinaculum; Radial: hook of hamate; Ulnar: pisiform
. Roof: extensor retinaculum; Floor: TFCC; Radial: lunate; Ulnar: triquetrum
. Roof: superficial palmar fascia; Floor: pronator quadratus; Radial: radial styloid; Ulnar: ulnar styloid
. Roof: flexor retinaculum; Floor: interosseous membrane; Radial: capitate; Ulnar: hamate

Correct Answer & Explanation

. Roof: palmar carpal ligament; Floor: flexor retinaculum; Radial: hook of hamate; Ulnar: pisiform

Explanation

Guyon's canal is bounded volarly (roof) by the palmar carpal ligament and dorsally (floor) by the flexor retinaculum (transverse carpal ligament). The radial border is the hook of the hamate, and the ulnar border is the pisiform.

Question 814

Topic: 7. Hand and Wrist

When evaluating a patient for Carpal Tunnel Syndrome during pregnancy, a musculoskeletal ultrasound is performed. Which of the following sonographic findings at the wrist is most diagnostic of median nerve compression?

. Decreased echogenicity and decreased cross-sectional area of the median nerve
. Increased cross-sectional area of the median nerve proximal to the carpal tunnel inlet
. A completely bifid median nerve with a persistent median artery
. Loss of the transverse carpal ligament integrity
. Hypervascularity of the flexor digitorum superficialis muscle bellies

Correct Answer & Explanation

. Increased cross-sectional area of the median nerve proximal to the carpal tunnel inlet

Explanation

Diagnostic ultrasound for carpal tunnel syndrome typically shows an enlarged median nerve (increased cross-sectional area, usually >10 mm^2) just proximal to the inlet of the carpal tunnel, reflecting nerve edema from distal compression.

Question 815

Topic: 7. Hand and Wrist

A pregnant female presents with hand paresthesias. Which of the following clinical features would suggest a diagnosis of thoracic outlet syndrome rather than pregnancy-induced Carpal Tunnel Syndrome?

. Symptoms that are primarily worse at night
. Bilateral involvement of the hands
. Paresthesias involving the ulnar forearm and exacerbation with arm elevation
. A positive Phalen's maneuver at 30 seconds
. Resolution of symptoms following a local wrist corticosteroid injection

Correct Answer & Explanation

. Paresthesias involving the ulnar forearm and exacerbation with arm elevation

Explanation

Thoracic outlet syndrome commonly involves the lower trunk of the brachial plexus, presenting with symptoms in the ulnar nerve distribution (medial forearm/hand) that worsen with overhead activity (positive Roos test). Carpal tunnel syndrome affects the median nerve distribution.

Question 816

Topic: Nerve & Tendon

A patient with Hypothenar Hammer Syndrome complains of concurrent numbness and tingling in the small finger. Compression of which specific neurological structure is most likely occurring?

. Median nerve in the carpal tunnel
. Superficial sensory branch of the ulnar nerve in Guyon's canal
. Anterior interosseous nerve in the proximal forearm
. Deep motor branch of the ulnar nerve in the hypothenar muscles
. Posterior interosseous nerve at the arcade of Frohse

Correct Answer & Explanation

. Superficial sensory branch of the ulnar nerve in Guyon's canal

Explanation

An enlarging ulnar artery aneurysm in the hypothenar region can compress the adjacent ulnar nerve in Guyon's canal. Numbness in the small finger indicates involvement of the superficial sensory branch of the ulnar nerve.

Question 817

Topic: 7. Hand and Wrist

Which of the following systemic hormones is most highly implicated in the physiological tissue changes leading to Carpal Tunnel Syndrome during the third trimester of pregnancy?

. Testosterone
. Parathyroid hormone
. Relaxin
. Thyroxine (T4)
. Glucagon

Correct Answer & Explanation

. Relaxin

Explanation

Relaxin and estrogen contribute significantly to ligamentous laxity and fluid retention (edema) during pregnancy. This leads to increased volume within the rigid carpal tunnel, directly elevating pressure on the median nerve.

Question 818

Topic: 7. Hand and Wrist

A pregnant patient with severe CTS asks why her symptoms are worse at night. What is the primary anatomical/physiological reason for nocturnal exacerbation of Carpal Tunnel Syndrome?

. Decrease in systemic relaxin levels during sleep
. Sleep-induced sympathetic overactivity causing median artery spasm
. Prolonged wrist flexion during sleep combined with supine fluid redistribution
. Nighttime increases in maternal serum cortisol levels
. Atrophy of the lumbricals due to lack of movement

Correct Answer & Explanation

. Prolonged wrist flexion during sleep combined with supine fluid redistribution

Explanation

Nocturnal exacerbation of CTS is primarily due to the natural tendency to sleep with wrists in a flexed position, which maximizes carpal tunnel pressure. Additionally, recumbency redistributes tissue fluid, exacerbating local edema.

Question 819

Topic: 7. Hand and Wrist

In Hypothenar Hammer Syndrome (HHS), repetitive trauma leads to vascular injury of the ulnar artery. Against which specific carpal bony structure is the ulnar artery typically compressed and injured in this condition?

. Pisiform
. Trapezium
. Hook of the hamate
. Capitate
. Lister's tubercle

Correct Answer & Explanation

. Hook of the hamate

Explanation

The ulnar artery exits Guyon's canal and travels superficial to the hook of the hamate. Repetitive blunt trauma to the hypothenar eminence crushes the ulnar artery against the unyielding hook of the hamate, leading to thrombosis or aneurysm.

Question 820

Topic: 7. Hand and Wrist

A 32-week pregnant patient presents with bilateral numbness and tingling in her thumb, index, and middle fingers that wakes her up at night. What is the most appropriate initial management?

. Nocturnal splinting in a neutral wrist position
. Corticosteroid injection into the carpal tunnel
. Oral non-steroidal anti-inflammatory drugs (NSAIDs)
. Open carpal tunnel release
. Diuretic therapy to reduce fluid retention

Correct Answer & Explanation

. Nocturnal splinting in a neutral wrist position

Explanation

Carpal tunnel syndrome in pregnancy is primarily managed conservatively due to its high rate of postpartum resolution. Nocturnal splinting in a neutral wrist position is the first-line treatment to maximize carpal tunnel volume and relieve symptoms.

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