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7. Hand and Wrist MCQs

Practice Set 56 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 1101

Topic: Nerve & Tendon

A 68-year-old male undergoes an open A1 pulley release for a trigger middle finger. Two weeks post-operatively, he reports that while the pain has improved, he still experiences a 'catching' sensation when actively flexing and extending his finger, similar to his pre-operative symptoms, though perhaps less severe. On examination, a subtle click is still palpable at the base of the finger. Based on the case, what is the most likely cause of his persistent symptoms?

. Development of Complex Regional Pain Syndrome (CRPS).
. Digital nerve injury causing dysesthesia.
. Inadvertent division of the A2 pulley leading to bowstringing.
. Incomplete release of the A1 pulley fibers.
. Post-operative infection requiring antibiotics.

Correct Answer & Explanation

. Incomplete release of the A1 pulley fibers.

Explanation

Correct Answer: DThe case identifies "Incomplete Release/Recurrence" as a common complication (1-5% incidence) and states: "The most common reason for persistent symptoms post-surgery [is] Insufficient division of the A1 pulley fibers..." The patient's description of persistent 'catching' and a palpable click strongly suggests an incomplete release.Option A is incorrectbecause CRPS presents with a constellation of symptoms including disproportionate pain, swelling, skin changes, and temperature dysregulation, which are not described here. Persistent triggering is not a primary symptom of CRPS.Option B is incorrectbecause digital nerve injury typically causes sensory deficits, numbness, or painful neuroma/dysesthesia, not a mechanical 'catching' or 'triggering' sensation.Option C is incorrectbecause inadvertent division of the A2 pulley leads to bowstringing, which is a visible displacement of the tendon away from the bone, and is extremely rare with isolated A1 release. It does not typically manifest as persistent 'catching' in the same way as an incomplete A1 release.Option E is incorrectbecause infection would present with signs such as redness, warmth, purulent discharge, and increased pain, none of which are mentioned in the vignette.

Question 1102

Topic: Nerve & Tendon

During an open A1 pulley release, after identifying and retracting the neurovascular bundles, the surgeon exposes the glistening white flexor tendon sheath. To ensure safe and complete release of the A1 pulley, which critical step should be performed immediately before incising the pulley?

. Apply a digital tourniquet to ensure a bloodless field.
. Perform a test flexion and extension of the digit to confirm the triggering site.
. Insert the tip of a curved mosquito hemostat or probe under the A1 pulley and over the flexor tendons.
. Inject local anesthetic directly into the flexor tendon to reduce post-operative pain.
. Incise the A2 pulley to prevent future bowstringing.

Correct Answer & Explanation

. Insert the tip of a curved mosquito hemostat or probe under the A1 pulley and over the flexor tendons.

Explanation

Correct Answer: CThe case describes the A1 pulley release technique: "Crucial Step: Insert the tip of a curved mosquito hemostat or a probeunderthe A1 pulley andoverthe flexor tendons. This elevates the pulley off the tendons and protects the underlying tendons from inadvertent laceration." This is a fundamental safety step to prevent iatrogenic tendon injury.Option A is incorrectbecause a tourniquet (usually an upper arm tourniquet) would have been applied and inflated much earlier in the procedure to create a bloodless field for the entire dissection, not immediately before incising the pulley.Option B is incorrectbecause the triggering site would have been confirmed during the pre-operative physical examination and potentially intra-operatively before the incision, but not immediately before incising the pulley after full exposure.Option D is incorrectbecause injecting local anesthetic into the tendon itself is not a standard practice and could cause tendon damage or irritation. Local anesthetic is typically infiltrated into the surrounding tissues for regional anesthesia.Option E is incorrectbecause the A2 pulley is a critical pulley that must be preserved to prevent bowstringing. Incising it would be a significant complication, not a necessary step.

Question 1103

Topic: 7. Hand and Wrist

A 55-year-old patient undergoes an uncomplicated open A1 pulley release for a trigger ring finger. The surgeon provides post-operative instructions. Which of the following instructions is most critical for the immediate post-operative phase (Day 0-7) to prevent stiffness and promote early recovery, as emphasized in the rehabilitation protocol?

. Keep the hand immobilized in a splint for the first week to protect the incision.
. Begin gentle, active flexion and extension of the affected digit immediately.
. Avoid all hand movements for 3 weeks to allow for complete wound healing.
. Start progressive grip strengthening exercises with a squeeze ball on post-operative day 2.
. Apply heat packs to the surgical site to reduce swelling and pain.

Correct Answer & Explanation

. Begin gentle, active flexion and extension of the affected digit immediately.

Explanation

Correct Answer: BThe case's "Immediate Post-Operative Phase (Day 0-7)" section explicitly states: "Early Active Range of Motion (AROM): Crucial for preventing stiffness and adhesion formation. Begin gentle, active flexion and extension of the affected digit, starting immediately post-surgery or within the first 24 hours..." This is a cornerstone of trigger finger post-operative care.Option A is incorrectbecause immobilization is generally avoided to prevent stiffness. Early motion is preferred.Option C is incorrectbecause avoiding all hand movements for 3 weeks would lead to significant stiffness and adhesion formation, directly contradicting the rehabilitation goals.Option D is incorrectbecause progressive grip strengthening is typically introduced in the intermediate rehabilitation phase (Week 3-6), not immediately post-operatively, to avoid excessive stress on the healing tissues.Option E is incorrectbecause ice application is recommended in the immediate post-operative phase to reduce swelling and discomfort, not heat, which could increase swelling.

Question 1104

Topic: Nerve & Tendon

A surgeon is performing an A1 pulley release. During the procedure, there is concern about inadvertently damaging adjacent pulleys. The case highlights the importance of preserving specific pulleys to prevent bowstringing and maintain the mechanical advantage of the flexor tendons. Which of the following pulleys is considered critical to preserve during an A1 pulley release to avoid bowstringing?

. A3 Pulley
. C1 Pulley
. A5 Pulley
. A2 Pulley
. C3 Pulley

Correct Answer & Explanation

. A2 Pulley

Explanation

Correct Answer: DThe case explicitly states under Annular Pulleys: "A2 Pulley: Originates from the proximal half of the proximal phalanx. It is a critical pulley for flexor tendon mechanics and must be preserved during A1 pulley release to avoid bowstringing." This directly answers the question.Option A is incorrectbecause the A3 pulley overlies the PIP joint volar plate and is less critical for preventing bowstringing compared to A2. While important, its division alone after A1 release is less likely to cause significant bowstringing.Option B is incorrectbecause C1 is a cruciate pulley, which are thinner and more flexible, and their primary role is not to prevent bowstringing in the same critical manner as the A2 pulley.Option C is incorrectbecause the A5 pulley overlies the DIP joint volar plate and is not the primary pulley for preventing bowstringing at the MCP/proximal phalanx level.Option E is incorrectbecause C3 is a cruciate pulley, similar to C1, and not the critical pulley for preventing bowstringing in the context of A1 release.

Question 1105

Topic: 7. Hand and Wrist

A 62-year-old patient with a trigger middle finger is discussing treatment options with her orthopedic surgeon. She asks about the efficacy and risks of corticosteroid injections versus open surgical release. Based on the summary of key literature and guidelines provided in the case, which statement accurately reflects the current understanding of these treatments?

. Corticosteroid injections are curative in nearly all cases and carry a lower recurrence rate than surgery.
. Percutaneous release is generally preferred over open release for all digits due to faster recovery and lower risk of nerve injury.
. Open A1 pulley release has high success rates (90-98%) and is considered the gold standard, especially after failed injections.
. Repeated corticosteroid injections (more than 3-4) are encouraged to avoid surgery, even if temporary relief is achieved.
. Patient-Reported Outcome Measures (PROMs) show no significant difference between surgical and non-surgical treatments.

Correct Answer & Explanation

. Open A1 pulley release has high success rates (90-98%) and is considered the gold standard, especially after failed injections.

Explanation

Correct Answer: CThe case states under "Efficacy of Surgical Release": "Multiple studies consistently report success rates (defined as complete resolution of triggering and pain) ranging from 90% to 98% for open A1 pulley release. This makes it one of the most reliable hand surgery procedures." And under "Comparative Studies (Open vs. Percutaneous)": "Open Release: Remains the gold standard, offering direct visualization of structures, ensuring complete release, and minimizing nerve injury risk." It also notes that surgery is indicated after failure of 1-2 injections.Option A is incorrectbecause the case states that corticosteroid injections are effective in about 50-70% of cases and have higher recurrence rates, especially in diabetic patients, not 'nearly all cases' with lower recurrence.Option B is incorrectbecause while percutaneous release has comparable efficacy in selected cases, the case notes "concerns remain regarding the increased risk of digital nerve injury, particularly for the thumb and small finger... The American Academy of Orthopaedic Surgeons (AAOS) and American Society for Surgery of the Hand (ASSH) guidelines generally support open release as the primary surgical method." It is not preferred for 'all digits' due to lower nerve injury risk.Option D is incorrectbecause the case advises that "repeated injections (more than 2-3) are generally not recommended due to potential tendon weakening or skin atrophy."Option E is incorrectbecause the case states under "Outcomes and Patient-Reported Measures": "Studies evaluating PROMs... consistently demonstrate significant improvement in pain, function, and quality of life following A1 pulley release," implying a significant difference and benefit from surgical treatment when indicated.

Question 1106

Topic: 7. Hand and Wrist

A 29-year-old G1 P0 woman, 7 months pregnant, presents with bilateral thumb numbness, worse at night, waking her from sleep. She has edematous hands and a positive Durkan test, but no weakness or thenar atrophy. She is diagnosed with carpal tunnel syndrome of pregnancy. Considering the diagnostic workup, which of the following statements regarding the Durkan test is most accurate?

. It involves sustained wrist flexion for 60 seconds and has a sensitivity of approximately 50%.
. It is performed by tapping over the median nerve at the wrist and is primarily used to assess nerve regeneration.
. It entails direct compression over the median nerve at the carpal tunnel for about 30 seconds, with an approximate sensitivity of 90%.
. It requires the patient to make a fist and then extend their fingers, assessing for median nerve motor weakness.
. It is a provocative test for de Quervain's tenosynovitis, involving ulnar deviation of the wrist with the thumb flexed into the palm.

Correct Answer & Explanation

. It entails direct compression over the median nerve at the carpal tunnel for about 30 seconds, with an approximate sensitivity of 90%.

Explanation

Correct Answer: CThe Durkan test, also known as the carpal compression test, involves direct compression over the median nerve at the carpal tunnel for approximately 30 seconds. A positive test is indicated by the onset of paresthesias or pain in the median nerve distribution. This test is highly sensitive and specific, with reported values around 90% for both. It is considered one of the most reliable clinical tests for carpal tunnel syndrome.Option Adescribes the Phalen test (wrist flexion), not the Durkan test, and while the duration is similar, its sensitivity is generally lower than Durkan's.Option Bdescribes the Tinel sign, which involves tapping over the median nerve. While used for CTS, its sensitivity is lower than the Durkan test, and it's not primarily for nerve regeneration assessment in this context.Option Ddescribes a motor assessment, not a specific provocative test for median nerve compression.Option Edescribes Finkelstein's test, which is used to diagnose de Quervain's tenosynovitis, a completely different wrist pathology.

Question 1107

Topic: 7. Hand and Wrist

Following the diagnosis of carpal tunnel syndrome of pregnancy, the patient asks about the likelihood of other pregnant women experiencing similar symptoms. Based on current orthopedic literature, what is the approximate incidence of pregnancy-induced carpal tunnel syndrome?

. Less than 5%
. Approximately 10%
. Around 25%
. Greater than 50%
. Nearly 75%

Correct Answer & Explanation

. Around 25%

Explanation

Correct Answer: CCarpal tunnel syndrome is a common condition during pregnancy, with an approximate incidence of 25% among pregnant women. This high incidence is primarily attributed to the generalized edema experienced during the later stages of pregnancy, which leads to increased pressure within the carpal tunnel and compression of the median nerve. Symptoms typically resolve spontaneously after delivery.Options A, B, D, and Eare incorrect as they do not reflect the established incidence rate of carpal tunnel syndrome in pregnant women, which is widely reported to be around 25%.

Question 1108

Topic: 7. Hand and Wrist

The patient's symptoms are primarily nocturnal, waking her from sleep. She is concerned about the long-term implications and potential need for surgery. Which of the following is the most appropriate initial management strategy for this patient?

. Immediate referral for bilateral carpal tunnel release surgery due to the severity of nocturnal symptoms.
. Prescription of oral corticosteroids to reduce inflammation and nerve compression.
. Initiation of nocturnal wrist splinting in a neutral position and patient education on activity modification.
. A series of corticosteroid injections into the carpal tunnel bilaterally.
. Recommendation for strict bed rest to reduce overall body edema.

Correct Answer & Explanation

. Initiation of nocturnal wrist splinting in a neutral position and patient education on activity modification.

Explanation

Correct Answer: CFor carpal tunnel syndrome during pregnancy, conservative management is almost always the first-line treatment, especially given that symptoms often resolve spontaneously after delivery. Nocturnal wrist splinting in a neutral position is highly effective in reducing pressure within the carpal tunnel during sleep, alleviating nocturnal symptoms. Patient education on activity modification (avoiding repetitive wrist flexion/extension, prolonged gripping) is also crucial. Most women respond well to these measures.Option Ais incorrect. Surgical intervention is rarely needed during pregnancy and is reserved for severe, refractory cases, especially those with objective motor weakness or thenar atrophy, which this patient does not exhibit. Furthermore, symptoms often resolve post-partum.Option Bis generally avoided in pregnancy due to potential fetal risks, especially systemic corticosteroids.Option D, while a conservative option for non-pregnant individuals, is approached with caution in pregnancy due to concerns about fetal exposure to corticosteroids, although local injections carry less systemic risk than oral steroids. It is typically considered after splinting fails, and often with careful discussion with the obstetrician.Option Eis not a standard treatment for carpal tunnel syndrome and is not generally recommended for managing edema in pregnancy unless other obstetric indications exist.

Question 1109

Topic: 7. Hand and Wrist

The patient's symptoms persist despite 4 weeks of nocturnal splinting and activity modification. She is now 8 months pregnant and reports increasing difficulty with daily tasks due to the numbness. She asks about the safety of surgical intervention. What is the most accurate statement regarding carpal tunnel release surgery during pregnancy?

. Carpal tunnel release surgery is absolutely contraindicated during pregnancy due to significant risks to the fetus and mother.
. Surgery should be delayed until at least 6 months postpartum to ensure complete resolution of pregnancy-related edema.
. If conservative measures fail and symptoms are severe, carpal tunnel release can be safely performed during pregnancy under the direction of an experienced anesthesiologist.
. Only local anesthesia without epinephrine can be used, which significantly limits the safety and efficacy of the procedure.
. Endoscopic carpal tunnel release is preferred over open release during pregnancy to minimize surgical invasiveness and recovery time.

Correct Answer & Explanation

. If conservative measures fail and symptoms are severe, carpal tunnel release can be safely performed during pregnancy under the direction of an experienced anesthesiologist.

Explanation

Correct Answer: CWhile conservative management is preferred, if symptoms are severe, debilitating, and refractory to conservative measures, carpal tunnel release surgery can be safely performed during pregnancy. The key is careful planning and execution under the direction of an experienced anesthesiologist, often in consultation with the obstetrician, to ensure maternal and fetal well-being. The second trimester is generally considered the safest period for non-emergent surgery, but it can be performed in the third trimester if necessary.Option Ais incorrect. While generally avoided if possible, it is not absolutely contraindicated and can be performed safely when indicated.Option Bis incorrect. While many symptoms resolve postpartum, delaying surgery for 6 months is unnecessary if the patient is severely symptomatic and conservative measures have failed. The goal is symptom relief, and if surgery is indicated, it can be performed earlier.Option Dis incorrect. Various anesthetic techniques can be employed, including regional blocks, and the use of epinephrine in local anesthetics is often carefully considered and used in diluted concentrations, not an absolute contraindication that limits efficacy.Option Eis not necessarily true. The choice between open and endoscopic release is typically based on surgeon preference and experience, and there is no strong evidence to suggest one is inherently safer or more beneficial than the other specifically during pregnancy.

Question 1110

Topic: 7. Hand and Wrist

The patient asks about the underlying physiological reason for her symptoms during pregnancy. Which of the following is the primary mechanism contributing to carpal tunnel syndrome in pregnant women?

. Increased repetitive strain injuries due to changes in posture and activity levels.
. Hormonal changes leading to direct demyelination of the median nerve.
. Generalized whole-body edema causing increased pressure within the carpal tunnel.
. Compression of the median nerve by an enlarged uterus.
. Increased incidence of gestational diabetes leading to diabetic neuropathy.

Correct Answer & Explanation

. Generalized whole-body edema causing increased pressure within the carpal tunnel.

Explanation

Correct Answer: CThe primary etiology of carpal tunnel syndrome during pregnancy is related to generalized whole-body edema, which is common in the later phases of pregnancy. This edema leads to fluid retention and swelling within the confined space of the carpal tunnel, increasing pressure on the median nerve and causing its compression. This mechanism is distinct from other causes of CTS.Option Ais less likely to be the primary cause, although activity changes might exacerbate symptoms. The fundamental physiological change is edema.Option Bis incorrect. Hormonal changes (e.g., relaxin) can contribute to ligamentous laxity, but they do not directly cause demyelination of the median nerve. The mechanism is mechanical compression due to fluid retention.Option Dis anatomically incorrect. The uterus is in the abdomen/pelvis and does not directly compress the median nerve at the wrist.Option Eis a potential risk factor for peripheral neuropathy, including CTS, but it is not the primary mechanism for pregnancy-induced CTS in the general pregnant population. While gestational diabetes can increase the risk, the most common cause is edema.

Question 1111

Topic: 7. Hand and Wrist

A 35-year-old non-pregnant female presents with similar symptoms of nocturnal hand numbness and tingling in the thumb, index, and middle fingers. On examination, she has a positive Phalen test. Compared to the Durkan test, what is generally true about the Phalen test?

. The Phalen test involves direct median nerve compression and has a higher sensitivity than the Durkan test.
. The Phalen test involves sustained wrist flexion and generally has lower sensitivity and specificity compared to the Durkan test.
. The Phalen test is a motor strength assessment, while the Durkan test is purely sensory.
. The Phalen test is more specific for ulnar nerve compression, whereas the Durkan test is for median nerve.
. Both tests have identical sensitivity and specificity for carpal tunnel syndrome.

Correct Answer & Explanation

. The Phalen test involves sustained wrist flexion and generally has lower sensitivity and specificity compared to the Durkan test.

Explanation

Correct Answer: BThe Phalen test (wrist flexion test) is performed by asking the patient to flex their wrists to 90 degrees and hold this position for 30-60 seconds. This maneuver increases pressure within the carpal tunnel, provoking median nerve symptoms. While a useful clinical test, its sensitivity and specificity are generally considered to be less than those of the Durkan test (carpal compression test), which involves direct compression over the median nerve.Option Ais incorrect. The Durkan test involves direct median nerve compression and generally has higher sensitivity. The Phalen test involves wrist flexion.Option Cis incorrect. Both Phalen and Durkan tests are provocative tests for sensory symptoms of median nerve compression, although severe CTS can also manifest with motor weakness.Option Dis incorrect. Both tests are designed to provoke median nerve symptoms, not ulnar nerve symptoms.Option Eis incorrect. As discussed, the Durkan test generally has superior sensitivity and specificity compared to the Phalen test.

Question 1112

Topic: 7. Hand and Wrist

The patient's symptoms resolve completely after delivery. However, 5 years later, she presents with recurrent, similar symptoms in her right hand, now accompanied by mild thenar atrophy. She is no longer pregnant. Which of the following findings on nerve conduction studies (NCS) would be most indicative of severe carpal tunnel syndrome?

. Normal median nerve sensory and motor conduction velocities.
. Prolonged median nerve sensory latency with normal motor latency.
. Prolonged median nerve motor latency with normal sensory latency.
. Absence of median nerve sensory and motor responses (CMAP and SNAP).
. Reduced ulnar nerve conduction velocity across the elbow.

Correct Answer & Explanation

. Absence of median nerve sensory and motor responses (CMAP and SNAP).

Explanation

Correct Answer: DNerve conduction studies (NCS) and electromyography (EMG) are objective diagnostic tools for carpal tunnel syndrome. The severity of CTS correlates with the degree of abnormality on NCS. The absence of median nerve sensory nerve action potentials (SNAP) and compound muscle action potentials (CMAP) indicates severe nerve damage and is highly indicative of severe carpal tunnel syndrome, especially when correlated with clinical signs like thenar atrophy.Option Awould indicate no carpal tunnel syndrome.Option B(prolonged sensory latency with normal motor latency) is characteristic of mild to moderate CTS, as sensory fibers are often affected earlier due to their superficial location and smaller diameter.Option C(prolonged motor latency with normal sensory latency) is less common as an isolated finding in CTS, as sensory changes usually precede or accompany motor changes. If present, it would still indicate nerve compromise, but not necessarily the most severe form.Option Edescribes ulnar nerve pathology (cubital tunnel syndrome), not carpal tunnel syndrome.

Question 1113

Topic: 7. Hand and Wrist

A 40-year-old male presents with chronic bilateral hand numbness and tingling, worse at night. He has a history of poorly controlled diabetes mellitus and hypothyroidism. On examination, he has a positive Tinel sign at the wrist and mild thenar atrophy. In addition to carpal tunnel syndrome, what other condition should be considered in the differential diagnosis given his comorbidities?

. De Quervain's tenosynovitis
. Trigger finger
. Cervical radiculopathy
. Thoracic outlet syndrome
. Diabetic peripheral neuropathy affecting the median nerve

Correct Answer & Explanation

. Diabetic peripheral neuropathy affecting the median nerve

Explanation

Correct Answer: EThe patient's history of poorly controlled diabetes mellitus is a significant risk factor for diabetic peripheral neuropathy. While he presents with classic symptoms of carpal tunnel syndrome, diabetes can cause a generalized neuropathy that can exacerbate or mimic CTS, or even cause a 'double crush' phenomenon where a nerve is compressed at two or more locations. Hypothyroidism is also a known risk factor for CTS. Therefore, diabetic peripheral neuropathy affecting the median nerve (or other nerves) should be considered in the differential or as a contributing factor.Option A(De Quervain's tenosynovitis) causes pain and tenderness at the radial styloid, not diffuse numbness and tingling in the median nerve distribution.Option B(Trigger finger) involves catching or locking of a digit due to inflammation of the flexor tendon sheath, not nerve compression symptoms.Option C(Cervical radiculopathy) can cause hand numbness, but typically involves the neck and shoulder pain, and specific dermatomal patterns that may differ from classic CTS. While it's a differential for hand numbness, the specific comorbidities point more strongly to systemic neuropathy.Option D(Thoracic outlet syndrome) can cause upper extremity numbness, but typically involves the entire hand or specific nerve distributions (often ulnar), and is associated with positional symptoms in the shoulder/neck region, less commonly purely nocturnal median nerve symptoms.

Question 1114

Topic: 7. Hand and Wrist

A 55-year-old female presents with bilateral hand numbness and tingling, worse at night. She reports that shaking her hands vigorously provides temporary relief. This maneuver is known as the 'flick sign'. Which of the following statements about the flick sign is true?

. It is a highly specific test for ulnar nerve compression at the elbow.
. It is a pathognomonic sign for cervical radiculopathy.
. It is a common and highly suggestive symptom of carpal tunnel syndrome.
. It indicates severe median nerve motor weakness requiring immediate surgical intervention.
. It is primarily used to diagnose de Quervain's tenosynovitis.

Correct Answer & Explanation

. It is a common and highly suggestive symptom of carpal tunnel syndrome.

Explanation

Correct Answer: CThe 'flick sign' (or 'shake sign') is a common and highly suggestive symptom reported by patients with carpal tunnel syndrome. Patients often describe shaking or 'flicking' their hands to relieve the numbness and paresthesias, particularly when waking up at night. This maneuver is thought to temporarily reduce pressure within the carpal tunnel or improve blood flow to the median nerve. It has been shown to have high sensitivity for CTS.Option Ais incorrect. The flick sign is associated with median nerve compression, not ulnar nerve compression.Option Bis incorrect. While cervical radiculopathy can cause hand numbness, the flick sign is not pathognomonic for it; it is much more characteristic of CTS.Option Dis incorrect. The flick sign is a sensory symptom and does not directly indicate motor weakness, nor does it automatically necessitate immediate surgery.Option Eis incorrect. The flick sign is not used to diagnose de Quervain's tenosynovitis.

Question 1115

Topic: 7. Hand and Wrist

A 32-year-old pregnant patient, similar to the case, is diagnosed with carpal tunnel syndrome. She asks about the prognosis of her condition after delivery. What is the most likely outcome for pregnancy-induced carpal tunnel syndrome?

. Symptoms will invariably worsen after delivery, requiring surgical intervention in most cases.
. The condition will likely persist indefinitely, requiring lifelong conservative management.
. Symptoms typically resolve spontaneously within weeks to months after delivery.
. There is a high risk of permanent median nerve damage if not surgically treated during pregnancy.
. The symptoms will transform into a different type of neuropathy, such as ulnar nerve compression.

Correct Answer & Explanation

. Symptoms typically resolve spontaneously within weeks to months after delivery.

Explanation

Correct Answer: CA hallmark of pregnancy-induced carpal tunnel syndrome is its excellent prognosis. The vast majority of women experience spontaneous resolution of symptoms within weeks to months after delivery. This is primarily due to the resolution of generalized edema and fluid retention that contributed to the carpal tunnel compression during pregnancy.Option Ais incorrect. Symptoms almost always improve or resolve after delivery, and surgical intervention is rarely needed.Option Bis incorrect. The condition is typically transient and resolves postpartum, not persisting indefinitely.Option Dis incorrect. While severe, untreated CTS can lead to permanent nerve damage, this is rare in pregnancy-induced CTS due to its transient nature and the effectiveness of conservative management. The risk of permanent damage is low, and surgery during pregnancy is reserved for very specific, severe, and refractory cases.Option Eis incorrect. The symptoms are specific to median nerve compression and do not typically transform into other neuropathies.

Question 1116

Topic: 7. Hand and Wrist

A 45-year-old male undergoes a split-thickness skin graft for a dorsal hand defect. During the first 48 hours postoperatively, the graft is primarily dependent on which of the following mechanisms for survival?

. Plasmatic imbibition
. Inosculation
. Neovascularization
. Capillary ingrowth
. Collateral sprouting

Correct Answer & Explanation

. Plasmatic imbibition

Explanation

During the first 24 to 48 hours, skin grafts survive via plasmatic imbibition, where the graft absorbs nutrients directly from the wound bed exudate. Inosculation occurs at 48-72 hours, followed by true neovascularization.

Question 1117

Topic: Nerve & Tendon

During an open trigger finger release of the middle finger, the surgeon incises the A1 pulley. Which adjacent annular pulley is most critical to preserve to prevent bowstringing of the flexor tendons?

. A2 pulley
. A3 pulley
. A4 pulley
. A5 pulley
. C1 pulley

Correct Answer & Explanation

. A2 pulley

Explanation

The A2 and A4 pulleys are the major biomechanical pulleys critical for preventing flexor tendon bowstringing. The A2 pulley is located just distal to the A1 pulley and must be carefully protected during a standard A1 pulley release.

Question 1118

Topic: 7. Hand and Wrist

During an open carpal tunnel release, the surgeon encounters the recurrent motor branch of the median nerve piercing directly through the transverse carpal ligament. According to the Poisel classification, which anatomic variant does this represent?

. Extraligamentous
. Subligamentous
. Transligamentous
. Pre-ligamentous
. Intraligamentous

Correct Answer & Explanation

. Transligamentous

Explanation

The transligamentous variant occurs when the recurrent motor branch pierces the transverse carpal ligament, placing it at a very high risk of iatrogenic injury during release. The extraligamentous course (distal to the ligament) is the most common variant overall.

Question 1119

Topic: Nerve & Tendon

A 2-year-old child presents with a fixed flexion deformity of the right thumb interphalangeal joint. The parents state the thumb has been "stuck" for a month. A palpable Nott's node is present at the volar metacarpophalangeal joint. What is the most appropriate initial management?

. Immediate surgical release of the A1 pulley
. Corticosteroid injection
. Rigid splinting for 6 weeks
. Observation and parental reassurance
. Surgical release of the A2 pulley

Correct Answer & Explanation

. Observation and parental reassurance

Explanation

Pediatric trigger thumb typically presents as a fixed flexion deformity rather than dynamic triggering. Observation is initially recommended, as up to 30% of cases resolve spontaneously if noted before 1 year of age, and surgery is usually reserved for non-resolving cases after age 3.

Question 1120

Topic: 7. Hand and Wrist

Which of the following electrodiagnostic findings is considered the earliest and most sensitive indicator of carpal tunnel syndrome?

. Increased sensory latency
. Increased motor latency
. Decreased motor amplitude
. Fibrillation potentials in the abductor pollicis brevis
. Decreased sensory amplitude

Correct Answer & Explanation

. Increased sensory latency

Explanation

Sensory nerve fibers are typically more susceptible to compression and demonstrate changes before motor fibers in compressive neuropathies. An increase in sensory latency and a corresponding decrease in sensory conduction velocity are the earliest electrodiagnostic findings in carpal tunnel syndrome.

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