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7. Hand and Wrist MCQs

Practice Set 235 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 4681

Topic: Nerve & Tendon

A patient undergoing an ulnar nerve transposition procedure should be counseled about potential for injury to which nearby structure if dissection is not meticulous?

. Radial nerve
. Brachial artery
. Medial antebrachial cutaneous nerve
. Musculocutaneous nerve
. Posterior interosseous nerve

Correct Answer & Explanation

. Medial antebrachial cutaneous nerve

Explanation

During ulnar nerve transposition (subcutaneous, intramuscular, or submuscular), the medial antebrachial cutaneous nerve (MABCN) is consistently in the surgical field and is at high risk of injury. It provides sensation to the medial forearm. Injury can lead to a painful neuroma or numbness in its distribution. The other listed nerves and artery are generally not in the immediate vicinity of the ulnar nerve transposition, assuming proper surgical technique.

Question 4682

Topic: Nerve & Tendon

Which nerve is at greatest risk during an anterior capsular release for elbow flexion contracture?

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

Correct Answer & Explanation

. Median nerve

Explanation

During an anterior capsular release, particularly if performed from a medial approach, the median nerve is at greatest risk. It lies anterior to the elbow joint and crosses the anterior capsule. The brachial artery is also in close proximity. The ulnar nerve is typically protected posteriorly. The radial nerve is lateral. PIN and AIN are distal branches.

Question 4683

Topic: Nerve & Tendon

When performing an ulnar nerve anterior transposition, what is a common complication specific to placing the nerve subcutaneously?

. Posterior interosseous nerve injury
. Compression by the arcade of Struthers
. Subluxation of the nerve over the epicondyle
. Persistent pain from superficial positioning
. Brachial artery injury

Correct Answer & Explanation

. Persistent pain from superficial positioning

Explanation

When the ulnar nerve is transposed subcutaneously, a common specific complication is persistent pain from its superficial positioning, making it susceptible to direct trauma or pressure. The nerve can also sometimes subluxate back over the epicondyle, although this is less common with proper soft tissue release and fixation. Compression by the arcade of Struthers (proximal to the cubital tunnel) is a cause of compression that needs to be released, not a specific complication of subcutaneous transposition. PIN injury is not related. Brachial artery injury is also not a specific complication of subcutaneous transposition, although always a general risk.

Question 4684

Topic: Nerve & Tendon

Which of the following describes the anatomical structure known as the 'arcade of Struthers'?

. A fibrous arch formed by the pronator teres at the median nerve entry
. A fibrous band extending from the medial head of the triceps to the medial intermuscular septum, potentially compressing the ulnar nerve
. A fascial arch in the supinator muscle that can entrap the posterior interosseous nerve
. A fibrous thickening of the annular ligament causing radial head subluxation
. A calcified insertion of the common extensor origin

Correct Answer & Explanation

. A fibrous band extending from the medial head of the triceps to the medial intermuscular septum, potentially compressing the ulnar nerve

Explanation

The arcade of Struthers is a fibrous band or ligamentous structure that extends from the medial head of the triceps to the medial intermuscular septum. It is a potential site of ulnar nerve compression, located approximately 8 cm proximal to the medial epicondyle. It is distinct from the pronator teres arch (median nerve), the arcade of Frohse (PIN), or the annular ligament.

Question 4685

Topic: 7. Hand and Wrist

A 55-year-old male undergoes open reduction and internal fixation (ORIF) of a comminuted olecranon fracture. Post-operatively, he develops a dropped wrist and sensory loss in the dorsum of the hand. Which nerve injury is most likely?

. Ulnar nerve
. Median nerve
. Radial nerve
. Musculocutaneous nerve
. Anterior interosseous nerve

Correct Answer & Explanation

. Radial nerve

Explanation

A 'dropped wrist' and sensory loss on the dorsum of the hand are classic signs of radial nerve palsy. The radial nerve courses closely to the posterior aspect of the humerus and elbow joint, making it susceptible to injury during olecranon fracture fixation, especially with plating or extensive dissection. Ulnar nerve injury would cause clawing of the hand and sensory loss in the medial digits. Median nerve injury would affect forearm pronation, thumb opposition, and sensation in the radial digits. Musculocutaneous nerve injury affects elbow flexion. Anterior interosseous nerve injury specifically affects the flexor pollicis longus and flexor digitorum profundus to the index and middle fingers, leading to loss of the 'OK' sign.

Question 4686

Topic: Nerve & Tendon

A 28-year-old construction worker presents with insidious onset of pain and paresthesias in his little finger and ulnar half of the ring finger, particularly at night and with elbow flexion. Tinel's sign is positive at the cubital tunnel. What is the most common cause of cubital tunnel syndrome?

. Compression by the arcade of Struthers
. Subluxation of the ulnar nerve over the medial epicondyle
. Compression beneath the aponeurosis of the flexor carpi ulnaris (FCU)
. Entrapment in Guyon's canal
. Direct trauma to the medial epicondyle

Correct Answer & Explanation

. Compression beneath the aponeurosis of the flexor carpi ulnaris (FCU)

Explanation

The most common site of compression for the ulnar nerve in cubital tunnel syndrome is beneath the aponeurosis of the flexor carpi ulnaris (also known as the cubital tunnel retinaculum or Osborne's ligament). Other potential sites of compression include the arcade of Struthers (proximal to the elbow), subluxation of the nerve, anconeus epitrochlearis, and fibrous bands. Guyon's canal is at the wrist. While direct trauma can cause it, compression by the FCU aponeurosis is the most prevalent anatomical cause of entrapment. Subluxation can contribute but is often a consequence or a coexisting factor with compression.

Question 4687

Topic: 7. Hand and Wrist

What is the typical presentation of a patient with posterior interosseous nerve (PIN) syndrome?

. Weakness in wrist flexion and finger flexion
. Sensory loss in the dorsum of the hand and a 'wrist drop'
. Motor weakness affecting finger and thumb extension, often without sensory loss
. Paresthesias in the little finger and ulnar half of the ring finger
. Weakness in forearm pronation and thumb opposition

Correct Answer & Explanation

. Motor weakness affecting finger and thumb extension, often without sensory loss

Explanation

Posterior interosseous nerve (PIN) syndrome is a purely motor neuropathy characterized by weakness in the muscles it innervates, primarily the extensors of the fingers and thumb. This leads to an inability to extend the metacarpophalangeal joints of the fingers and the interphalangeal joint of the thumb, often described as 'finger drop' or 'thumb drop.' Sensory loss is typically absent because the PIN is a motor nerve. 'Wrist drop' is more indicative of a more proximal radial nerve lesion. Other options describe ulnar, median, or more global radial nerve palsies.

Question 4688

Topic: Nerve & Tendon

Which of the following describes the anatomical landmark for identifying the ulnar nerve during an elbow surgical approach?

. It runs anterior to the medial epicondyle.
. It lies superficial to the biceps tendon in the cubital fossa.
. It courses posterior to the medial epicondyle, within the cubital tunnel.
. It passes through the supinator muscle in the proximal forearm.
. It is found directly beneath the brachialis muscle.

Correct Answer & Explanation

. It courses posterior to the medial epicondyle, within the cubital tunnel.

Explanation

The ulnar nerve is consistently located posterior to the medial epicondyle as it passes through the cubital tunnel. This is a critical anatomical landmark for both identification and protection during surgical approaches to the medial elbow. Its position makes it vulnerable to compression and injury. The radial nerve passes through the supinator (arcade of Frohse), and the median nerve is anterior in the cubital fossa.

Question 4689

Topic: Nerve & Tendon

Which of the following describes the 'arcade of Frohse' and its clinical significance?

. A fibrous band forming the roof of the cubital tunnel, compressing the ulnar nerve.
. The site of compression of the median nerve in pronator syndrome.
. A fibrous arch formed by the superficial head of the supinator muscle, compressing the posterior interosseous nerve (PIN).
. The proximal attachment of the common flexor tendon to the medial epicondyle.
. A fibrous band that can compress the radial nerve at the level of the radial head.

Correct Answer & Explanation

. A fibrous arch formed by the superficial head of the supinator muscle, compressing the posterior interosseous nerve (PIN).

Explanation

The arcade of Frohse is a fibrous arch formed by the superficial head of the supinator muscle. It is a common site of compression for the posterior interosseous nerve (PIN), leading to PIN syndrome, characterized by motor weakness in the finger and thumb extensors without sensory deficits. The cubital tunnel retinaculum (Osborne's ligament) compresses the ulnar nerve. Pronator syndrome involves the median nerve, and the common flexor tendon is involved in medial epicondylitis.

Question 4690

Topic: Nerve & Tendon

What nerve is at highest risk of injury during a medial approach to the elbow?

. Radial nerve
. Median nerve
. Ulnar nerve
. Musculocutaneous nerve
. Posterior interosseous nerve

Correct Answer & Explanation

. Ulnar nerve

Explanation

The ulnar nerve is located directly posterior to the medial epicondyle and within the cubital tunnel. Any medial approach to the elbow, especially those involving dissection around the medial epicondyle or the cubital tunnel, places the ulnar nerve at the highest risk of injury. Careful identification and protection of the nerve are paramount. The median nerve is more anterior. The radial and PIN are lateral/posterior. The musculocutaneous nerve is more anterior in the arm.

Question 4691

Topic: Nerve & Tendon

A 4-year-old child presents with a minimally displaced medial epicondyle fracture. The ulnar nerve is intact, and the elbow is stable. What is the most appropriate management?

. Open reduction and internal fixation to prevent nonunion
. Closed reduction with percutaneous pinning
. Long arm cast immobilization in flexion for 4-6 weeks
. Sling immobilization with early protected range of motion
. Surgical exploration to rule out ulnar nerve entrapment

Correct Answer & Explanation

. Sling immobilization with early protected range of motion

Explanation

Minimally displaced medial epicondyle fractures in children, especially when the ulnar nerve is intact and the elbow is stable, are typically managed non-operatively with sling immobilization and early protected range of motion. Surgical intervention is usually reserved for significant displacement (e.g., >1 cm or intra-articular entrapment), ulnar nerve entrapment, or elbow instability. Immobilization for too long can lead to stiffness.

Question 4692

Topic: Nerve & Tendon

Which of the following describes the anatomical course of the radial nerve at the elbow, making it vulnerable to certain injuries?

. It passes directly posterior to the medial epicondyle.
. It lies superficial to the bicipital aponeurosis.
. It branches into superficial radial and posterior interosseous nerves within the cubital fossa, anterior to the lateral epicondyle.
. It passes through the cubital tunnel with the ulnar nerve.
. It courses medial to the brachial artery in the antecubital fossa.

Correct Answer & Explanation

. It branches into superficial radial and posterior interosseous nerves within the cubital fossa, anterior to the lateral epicondyle.

Explanation

The radial nerve divides into its superficial radial (sensory) and posterior interosseous (motor) branches within the cubital fossa, anterior to the lateral epicondyle and often piercing the supinator muscle (arcade of Frohse). This anatomical arrangement makes it vulnerable to injury during lateral elbow approaches, supracondylar fractures, or forearm trauma. The ulnar nerve is posterior to the medial epicondyle. The median nerve is medial to the brachial artery.

Question 4693

Topic: Nerve & Tendon

A patient with a history of elbow trauma presents with a fixed flexion deformity of 40 degrees and inability to supinate beyond neutral. Radiographs show a congruent joint with no loose bodies. What is the most appropriate surgical approach for a capsular release in this patient?

. Posterior approach with triceps sparing
. Anterior approach to release the median nerve
. Combined medial and lateral approaches
. Medial approach to address the ulnar nerve
. Lateral approach only

Correct Answer & Explanation

. Combined medial and lateral approaches

Explanation

For severe, fixed flexion deformities and significant loss of forearm rotation at the elbow, a combined medial and lateral approach is often required. This allows for comprehensive release of both the anterior and posterior capsule (often through a single posterior incision with lateral and medial extensions or separate incisions), excision of heterotopic ossification, and neurolysis of the ulnar nerve if needed. Isolated lateral or medial approaches are insufficient for global contracture. An anterior approach to release the median nerve is not the primary target for contracture release.

Question 4694

Topic: Nerve & Tendon

In an anterior approach to the elbow, which major neurovascular structure is located medially and is at risk?

. Radial nerve
. Ulnar nerve
. Median nerve and brachial artery
. Musculocutaneous nerve
. Posterior interosseous nerve

Correct Answer & Explanation

. Median nerve and brachial artery

Explanation

In an anterior approach to the elbow (e.g., for distal humerus fractures or contracture release), the median nerve and brachial artery run together in the medial aspect of the antecubital fossa and are the primary neurovascular structures at risk. They should be identified and protected. The ulnar nerve is more medial and posterior. The radial nerve and its branches are more lateral.

Question 4695

Topic: Nerve & Tendon

A patient is undergoing surgical repair of a distal biceps tendon rupture using a single anterior incision. Which nerve is most at risk during the drilling of the radial tuberosity for tendon reinsertion?

. Ulnar nerve
. Median nerve
. Posterior interosseous nerve (PIN)
. Lateral cutaneous nerve of the forearm
. Anterior interosseous nerve (AIN)

Correct Answer & Explanation

. Posterior interosseous nerve (PIN)

Explanation

When performing a single anterior incision approach for distal biceps tendon repair, especially during drilling or placing anchors into the radial tuberosity, the posterior interosseous nerve (PIN) is at significant risk. The PIN wraps around the radial neck and passes through the supinator muscle, which lies directly over the radial tuberosity. Hyperpronation of the forearm during the procedure is critical to move the PIN away from the drilling path. The median and AIN are more medial, the ulnar nerve is posterior, and the lateral cutaneous nerve of the forearm is superficial and sensory.

Question 4696

Topic: Nerve & Tendon

Which of the following conditions is LEAST likely to be confused with lateral epicondylitis based on clinical presentation and physical examination?

. Radial tunnel syndrome
. Cervical radiculopathy (C6/C7)
. Posterior interosseous nerve (PIN) entrapment
. Ulnar neuropathy at the elbow (cubital tunnel syndrome)
. Radiohumeral osteoarthritis

Correct Answer & Explanation

. Ulnar neuropathy at the elbow (cubital tunnel syndrome)

Explanation

Ulnar neuropathy at the elbow (cubital tunnel syndrome) primarily causes pain and paresthesias in the medial forearm and little/ring fingers, with motor weakness in ulnar-innervated intrinsic hand muscles. Its location and symptom distribution are distinct from lateral elbow pain, making it the least likely to be confused with lateral epicondylitis. Radial tunnel syndrome, PIN entrapment, cervical radiculopathy (which can refer pain to the lateral elbow/forearm), and radiohumeral osteoarthritis (with lateral elbow pain and mechanical symptoms) are all important differential diagnoses for lateral epicondylitis.

Question 4697

Topic: Nerve & Tendon

Which factor has been shown to be a positive prognostic indicator for successful non-operative treatment of lateral epicondylitis?

. Long duration of symptoms (over 6 months)
. High pain intensity at presentation
. Presence of concomitant radial tunnel syndrome
. Early initiation of physical therapy within 6 weeks of symptom onset
. Significant tears on MRI

Correct Answer & Explanation

. Early initiation of physical therapy within 6 weeks of symptom onset

Explanation

Early initiation of physical therapy, especially eccentric strengthening, tends to be associated with better outcomes in non-operative management. Long duration of symptoms generally predicts a more difficult course. High pain intensity may correlate with greater pathology and potentially longer recovery. Concomitant radial tunnel syndrome complicates treatment and may require addressing both conditions. Significant tears on MRI might indicate a more severe condition that could be less responsive to non-operative treatment, though small tears can still heal conservatively.

Question 4698

Topic: Nerve & Tendon

A patient is referred to you for chronic lateral elbow pain. You suspect radial tunnel syndrome as a differential. Which physical examination maneuver would be most helpful in differentiating radial tunnel syndrome from lateral epicondylitis?

. Pain with resisted wrist extension (Cozen's test).
. Pain with resisted middle finger extension (Maudsley's test).
. Tenderness over the lateral epicondyle.
. Pain with resisted supination of the forearm.
. Pain with passive wrist flexion with the elbow extended (Mill's test).

Correct Answer & Explanation

. Pain with resisted supination of the forearm.

Explanation

While there can be overlap, pain with resisted supination of the forearm, especially when the elbow is extended, specifically stresses the supinator muscle, under which the posterior interosseous nerve (PIN) passes, making it a key maneuver for diagnosing radial tunnel syndrome. The other tests (Cozen's, Maudsley's, Mill's, and lateral epicondyle tenderness) are classic signs of lateral epicondylitis, though some can be mildly positive in radial tunnel due to proximity or associated inflammation.

Question 4699

Topic: Nerve & Tendon

Which of the following describes the most common anatomical site of compression for the posterior interosseous nerve (PIN) in radial tunnel syndrome?

. Arcade of Struthers
. Fibrous arch of the supinator muscle (Arcade of Frohse)
. Ligament of Struthers
. Medial intermuscular septum
. Between the two heads of the pronator teres

Correct Answer & Explanation

. Fibrous arch of the supinator muscle (Arcade of Frohse)

Explanation

The most common anatomical site of compression for the posterior interosseous nerve (PIN) in radial tunnel syndrome is the fibrous arch of the supinator muscle, known as the Arcade of Frohse. The Arcade of Struthers and Ligament of Struthers are associated with high median nerve compression. The medial intermuscular septum is relevant to the ulnar nerve. Compression between the two heads of the pronator teres is a site for median nerve entrapment (pronator syndrome).

Question 4700

Topic: Nerve & Tendon

Which intrinsic muscle of the hand is innervated by the ulnar nerve and commonly tested for weakness in cases of suspected ulnar neuropathy, a condition distinct from lateral epicondylitis?

. Abductor pollicis brevis
. Flexor pollicis longus
. First dorsal interosseous
. Opponens pollicis
. Flexor digitorum profundus to the index finger

Correct Answer & Explanation

. First dorsal interosseous

Explanation

The first dorsal interosseous muscle is a key intrinsic hand muscle innervated by the ulnar nerve. Weakness here, along with other ulnar-innervated intrinsic muscles, is a hallmark of ulnar neuropathy (e.g., cubital tunnel syndrome). The abductor pollicis brevis, opponens pollicis, and flexor pollicis longus are primarily innervated by the median nerve. Flexor digitorum profundus is median and ulnar nerve-innervated, but the specific finger innervation varies.

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