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7. Hand and Wrist MCQs

Practice Set 42 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 821

Topic: 7. Hand and Wrist

A female patient who developed severe carpal tunnel syndrome during her third trimester of pregnancy recently delivered her baby. She asks when her symptoms are likely to resolve. Which of the following factors is most strongly associated with delayed postpartum resolution of her symptoms?

. Advanced maternal age
. Delivery via Cesarean section
. High birth weight of the infant
. Exclusive breastfeeding
. Epidural anesthesia during labor

Correct Answer & Explanation

. Exclusive breastfeeding

Explanation

While pregnancy-induced CTS typically resolves rapidly after delivery, exclusive breastfeeding can prolong symptoms. This is due to continued fluid retention secondary to elevated prolactin and oxytocin levels.

Question 822

Topic: Nerve & Tendon

Patients with Hypothenar Hammer Syndrome are at highest risk for severe digit ischemia and necrosis if they possess which of the following anatomic variants?

. Persistent median artery
. Incomplete superficial palmar arch
. Bifid median nerve
. Anomalous superficial radial artery
. Martin-Gruber anastomosis

Correct Answer & Explanation

. Incomplete superficial palmar arch

Explanation

An incomplete superficial palmar arch means there is no collateral blood supply from the radial artery to the ulnar digits. If the ulnar artery thromboses in a patient with an incomplete arch, the ulnar-sided digits are at extreme risk for profound ischemia.

Question 823

Topic: 7. Hand and Wrist

A 36-week pregnant patient has severe, sleep-depriving symptoms of Carpal Tunnel Syndrome that have failed to improve with 4 weeks of diligent nocturnal splinting. What is the next best step in management?

. Induction of labor
. Endoscopic carpal tunnel release
. Local corticosteroid injection
. Oral gabapentin
. Immediate open carpal tunnel release

Correct Answer & Explanation

. Local corticosteroid injection

Explanation

Local corticosteroid injections are safe and highly effective during pregnancy for refractory CTS symptoms. Surgery is rarely indicated during pregnancy and is reserved for extreme cases with progressive motor deficits.

Question 824

Topic: 7. Hand and Wrist

During which phase of pregnancy does Carpal Tunnel Syndrome most commonly present, and what is the primary pathophysiological mechanism?

. First trimester; relaxin-induced ligamentous laxity
. Second trimester; median nerve demyelination
. Third trimester; extracellular fluid accumulation
. First trimester; microvascular thrombosis
. Second trimester; pre-eclampsia onset

Correct Answer & Explanation

. Third trimester; extracellular fluid accumulation

Explanation

CTS in pregnancy most commonly occurs in the third trimester. The primary etiology is a transient increase in extracellular fluid volume causing tissue edema and subsequent elevated pressure within the carpal tunnel.

Question 825

Topic: 7. Hand and Wrist

Under which of the following circumstances is surgical carpal tunnel release strictly indicated during pregnancy?

. Bilateral symptoms present for more than 4 weeks
. Positive Tinel's sign at the wrist
. Symptoms that cause nighttime awakening despite splinting
. Progressive severe thenar atrophy and motor deficit
. Concurrent de Quervain's tenosynovitis

Correct Answer & Explanation

. Progressive severe thenar atrophy and motor deficit

Explanation

Surgery for CTS during pregnancy is extremely rare because most cases resolve postpartum. However, profound or progressive motor weakness and thenar atrophy represent absolute indications for surgical decompression to prevent irreversible nerve damage.

Question 826

Topic: 7. Hand and Wrist

When performing an angiogram on a patient with chronic Hypothenar Hammer Syndrome, which of the following classic radiographic signs is most commonly observed in the ulnar artery at the level of the hamate?

. String of pearls sign
. Bird's beak tapering
. Double-barrel sign
. Tree-in-bud opacity
. Corkscrew appearance

Correct Answer & Explanation

. Corkscrew appearance

Explanation

The classic angiographic finding in HHS is a tortuous, 'corkscrew' appearance of the ulnar artery at the wrist. This reflects chronic intimal damage, mural thrombosis, and vessel wall remodeling from repetitive trauma.

Question 827

Topic: Nerve & Tendon

In Hypothenar Hammer Syndrome, ischemic changes typically affect the ring and small fingers. What is the pathophysiological mechanism responsible for ischemia specifically in these digits?

. Direct traumatic transection of the digital nerves
. Microemboli shedding from an ulnar artery aneurysm
. Venous congestion of the superficial palmar arch
. Vasospasm triggered by the median nerve
. Atherosclerotic plaque rupture in the radial artery

Correct Answer & Explanation

. Microemboli shedding from an ulnar artery aneurysm

Explanation

The repetitive trauma in HHS causes ulnar artery thrombosis or aneurysm formation. Microemboli can subsequently shed from this site and travel distally, occluding the proper digital arteries of the ring and small fingers.

Question 828

Topic: 7. Hand and Wrist

A pregnant patient with severe edema presents with sudden, rapidly progressive symptoms of bilateral carpal tunnel syndrome, accompanied by significant weight gain and a persistent headache. What is the most critical next step in her systemic evaluation?

. Cervical spine MRI
. Evaluation of blood pressure and urine protein
. Checking serum thyroid-stimulating hormone (TSH)
. Fasting blood glucose level
. Venous Doppler of the upper extremities

Correct Answer & Explanation

. Evaluation of blood pressure and urine protein

Explanation

While CTS is common in pregnancy, sudden severe generalized edema, rapid weight gain, and headache should raise high suspicion for preeclampsia. Checking blood pressure and assessing for proteinuria is the most critical immediate systemic evaluation.

Question 829

Topic: 7. Hand and Wrist

A 28-year-old female presents at 34 weeks gestation with severe paresthesias in the median nerve distribution of both hands. She notes that her symptoms are much worse upon waking up. Why does sleeping position contribute to the exacerbation of CTS symptoms?

. Increased parasympathetic tone during sleep lowers pain thresholds
. Decreased core body temperature exacerbates nerve conduction block
. Sustained wrist flexion during sleep maximally increases carpal tunnel pressure
. Prolonged wrist extension stretches the palmaris longus
. Fluid shifts to the lower extremities during recumbency

Correct Answer & Explanation

. Sustained wrist flexion during sleep maximally increases carpal tunnel pressure

Explanation

Many patients naturally sleep with their wrists in a flexed position. Wrist flexion significantly decreases the volume of the carpal tunnel and increases intracarpal pressure, which exacerbates median nerve compression.

Question 830

Topic: Nerve & Tendon

A patient with suspected Hypothenar Hammer Syndrome presents with a pulsatile mass in the proximal hypothenar region. What physical examination test is most diagnostic for localizing the vascular deficit before advanced imaging?

. Phalen's test
. Tinel's sign over Guyon's canal
. Allen's test
. Finkelstein's test
. Froment's sign

Correct Answer & Explanation

. Allen's test

Explanation

The modified Allen's test evaluates the patency of the radial and ulnar arteries and the superficial palmar arch. A positive (abnormal) test upon release of the ulnar artery strongly indicates ulnar artery occlusion or poor arch continuity.

Question 831

Topic: 7. Hand and Wrist

A 35-year-old patient presents with symptoms of CTS in her 8th month of pregnancy. Which of the following epidemiological statements regarding pregnancy-related Carpal Tunnel Syndrome is most accurate?

. It occurs in less than 5% of all pregnancies.
. It is almost always unilateral.
. Symptoms typically present earlier in subsequent pregnancies compared to the first.
. It has a higher incidence in primigravida patients.
. Symptoms correlate inversely with maternal BMI.

Correct Answer & Explanation

. Symptoms typically present earlier in subsequent pregnancies compared to the first.

Explanation

Pregnancy-related CTS is common (up to 30-60% in some cohorts) and is typically bilateral. In multiparous women, symptoms tend to present earlier in subsequent pregnancies than they did in the first.

Question 832

Topic: 7. Hand and Wrist

A carpenter is diagnosed with Hypothenar Hammer Syndrome. He undergoes surgical resection of a thrombosed ulnar artery aneurysm and reconstruction with a vein graft. Post-operatively, which lifestyle modification is most strictly mandated to ensure graft survival and prevent recurrence?

. Permanent transition to sedentary office work
. Absolute cessation of smoking
. Daily use of a static wrist splint
. Avoidance of dietary purines
. Bilateral carpal tunnel releases

Correct Answer & Explanation

. Absolute cessation of smoking

Explanation

Smoking is a profound risk factor for microvascular thrombosis and graft failure. Absolute smoking cessation is mandatory for patients undergoing vascular reconstruction in HHS to maintain graft patency and prevent further ischemic events.

Question 833

Topic: Nerve & Tendon

A 42-year-old mechanic presents with right ring finger ischemia and is suspected of having Hypothenar Hammer Syndrome. Against which of the following anatomic structures is the ulnar artery typically compressed, leading to this condition?

. Pisiform
. Trapezium
. Hook of the hamate
. Triquetrum
. Scaphoid tubercle

Correct Answer & Explanation

. Hook of the hamate

Explanation

Hypothenar hammer syndrome involves repetitive trauma to the ulnar artery as it passes through Guyon's canal. The artery becomes crushed between the external impact and the prominent bony unyielding hook of the hamate.

Question 834

Topic: 7. Hand and Wrist

A 28-year-old G1P0 woman at 34 weeks gestation presents with bilateral severe numbness in her thumb, index, and middle fingers. She has been using nocturnal neutral wrist splints for 4 weeks without relief, and her sleep is severely interrupted. What is the most appropriate next step in management?

. Immediate carpal tunnel release
. Prescription of oral gabapentin
. Corticosteroid injection into the carpal tunnel
. Induction of labor
. Prescribe oral non-steroidal anti-inflammatory drugs (NSAIDs)

Correct Answer & Explanation

. Corticosteroid injection into the carpal tunnel

Explanation

In pregnant patients with carpal tunnel syndrome who fail conservative splinting, a local corticosteroid injection is highly effective and safe. Surgical release is rarely indicated during pregnancy unless there is severe, progressive motor loss.

Question 835

Topic: 7. Hand and Wrist

A 31-year-old woman developed pregnancy-induced carpal tunnel syndrome in her third trimester. She recently delivered a healthy baby and asks when her hand symptoms will resolve. What is the most accurate prognostic information to provide?

. Symptoms typically resolve within a few weeks to months postpartum, though they occasionally persist longer.
. Symptoms will likely worsen postpartum due to massive fluid shifts and require immediate surgery.
. Permanent nerve damage is inevitable if symptoms do not clear within 48 hours of delivery.
. Breastfeeding guarantees the immediate resolution of her symptoms.
. Symptoms usually do not resolve, and she will require carpal tunnel release within the month.

Correct Answer & Explanation

. Symptoms typically resolve within a few weeks to months postpartum, though they occasionally persist longer.

Explanation

Pregnancy-induced carpal tunnel syndrome typically resolves spontaneously within the first few weeks to months postpartum as fluid retention decreases. Surgical intervention is rarely needed and should be delayed until several months postpartum if symptoms persist.

Question 836

Topic: 7. Hand and Wrist

Carpal tunnel syndrome occurring during pregnancy is most frequently noted to begin during which of the following periods?

. First trimester
. Second trimester
. Third trimester
. First week postpartum
. Pre-conception

Correct Answer & Explanation

. Third trimester

Explanation

Carpal tunnel syndrome in pregnancy most commonly presents in the third trimester. This coincides with the peak of maternal fluid volume expansion and subsequent extracellular edema in the unyielding carpal canal.

Question 837

Topic: 7. Hand and Wrist

Which of the following obstetric complications is most strongly associated with an increased risk of developing carpal tunnel syndrome during pregnancy?

. Gestational diabetes mellitus
. Placenta previa
. Pre-eclampsia
. Oligohydramnios
. Breech presentation

Correct Answer & Explanation

. Pre-eclampsia

Explanation

Pre-eclampsia and gestational hypertension involve significant generalized edema and extreme fluid retention. These factors are strongly correlated with a higher incidence and severity of carpal tunnel syndrome during pregnancy.

Question 838

Topic: 7. Hand and Wrist

When prescribing a nocturnal splint for a pregnant patient with carpal tunnel syndrome, in what position should the wrist be immobilized to minimize carpal canal pressure?

. 15 degrees of flexion
. Neutral (0 degrees)
. 15 degrees of extension
. 30 degrees of extension
. 30 degrees of flexion

Correct Answer & Explanation

. Neutral (0 degrees)

Explanation

Carpal canal pressure is lowest when the wrist is maintained in a neutral (0 degrees) position. Splinting prevents the patient from sleeping with the wrists flexed or fully extended, which significantly elevates intracarpal pressure.

Question 839

Topic: 7. Hand and Wrist

Within Guyon's canal, the ulnar artery is particularly susceptible to trauma due to its anatomic relationships. Which of the following best describes its position in this region?

. Deep to the transverse carpal ligament and lateral to the median nerve
. Superficial to the palmar aponeurosis and medial to the pisiform
. Deep to the pisohamate ligament and lateral to the ulnar nerve
. Superficial to the transverse carpal ligament and lateral to the ulnar nerve
. Deep to the flexor digitorum profundus tendons

Correct Answer & Explanation

. Superficial to the transverse carpal ligament and lateral to the ulnar nerve

Explanation

In Guyon's canal, the ulnar artery lies superficial to the transverse carpal ligament and lateral to the ulnar nerve. Its superficial location against the bony unyielding hook of the hamate makes it vulnerable to external blunt trauma.

Question 840

Topic: 7. Hand and Wrist

A 29-year-old woman who developed carpal tunnel syndrome in her third trimester presents at 3 months postpartum. She is exclusively breastfeeding and notes persistent median nerve symptoms. Which of the following factors is most likely contributing to her delayed recovery?

. Elevated circulating levels of estrogen
. Elevated levels of prolactin and continued fluid retention
. Postpartum decrease in relaxin levels
. Undiagnosed postpartum thyroiditis causing hyperthyroidism
. Excessive dietary calcium supplementation

Correct Answer & Explanation

. Elevated levels of prolactin and continued fluid retention

Explanation

Breastfeeding women may experience prolonged symptoms of carpal tunnel syndrome postpartum. Elevated prolactin levels contribute to continued fluid retention, preventing the rapid resolution of carpal canal edema seen in non-breastfeeding mothers.

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