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7. Hand and Wrist MCQs

Practice Set 236 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 4701

Topic: Nerve & Tendon

A patient with lateral epicondylitis symptoms also describes numbness and tingling in the thumb and index finger. Which additional diagnostic consideration becomes critical?

. Ulnar nerve entrapment
. Median nerve entrapment (e.g., carpal tunnel syndrome or pronator syndrome)
. Cervical radiculopathy
. Thoracic outlet syndrome
. All of the above

Correct Answer & Explanation

. All of the above

Explanation

Numbness and tingling in the thumb and index finger suggest involvement of the median nerve (e.g., carpal tunnel, pronator syndrome) or cervical radiculopathy at C6 or C7. While ulnar nerve entrapment affects the little and ring fingers, and thoracic outlet syndrome can affect various nerves, the specific distribution (thumb and index finger) makes median nerve and cervical radiculopathy particularly critical to consider alongside lateral epicondylitis. Therefore, to ensure a comprehensive differential, 'All of the above' encompasses the potential for multiple etiologies or concomitant conditions.

Question 4702

Topic: 7. Hand and Wrist

What is the primary differentiating feature between lateral epicondylitis and posterior interosseous nerve (PIN) entrapment on clinical examination?

. Location of maximal tenderness.
. Presence of pain with resisted wrist extension.
. Sensory deficits in the superficial radial nerve distribution.
. Presence of motor weakness in specific forearm/hand muscles.
. Pain with passive wrist flexion.

Correct Answer & Explanation

. Presence of motor weakness in specific forearm/hand muscles.

Explanation

The primary differentiating feature is the presence of motor weakness in specific forearm/hand muscles without sensory loss in PIN entrapment (a purely motor nerve). Lateral epicondylitis is a tendinopathy, causing pain but typically no true motor weakness (though grip strength may be pain-inhibited). While tenderness and resisted movements can overlap, true, objective muscle weakness strongly points to PIN entrapment. Sensory deficits are not typical for PIN entrapment as it's a motor nerve, and radial tunnel syndrome typically involves pain but not usually overt motor weakness to the degree seen in PIN syndrome which affects more distal motor branches.

Question 4703

Topic: 7. Hand and Wrist

A patient reports relief of lateral elbow pain with a trial of a counterforce brace. This response supports the hypothesis that the brace works by:

. Compressing the radial nerve to reduce pain signals.
. Preventing all wrist movement during activity.
. Reducing the tensile load and strain at the extensor origin.
. Increasing blood flow to the affected tendon.
. Providing direct heat therapy to the lateral epicondyle.

Correct Answer & Explanation

. Reducing the tensile load and strain at the extensor origin.

Explanation

A counterforce brace is believed to work by applying compression distal to the epicondyle, thereby creating a new, more distal origin for the wrist extensor muscles. This effectively lengthens the muscle-tendon unit, altering the angle of pull and reducing the tensile load and strain experienced at the common extensor origin during gripping and wrist extension, which helps to alleviate pain. It does not compress the radial nerve, prevent all wrist movement, increase blood flow, or provide heat therapy.

Question 4704

Topic: Nerve & Tendon

When performing an elbow examination for lateral epicondylitis, which nerve should be assessed for potential concurrent entrapment or irritation that might contribute to lateral elbow pain?

. Ulnar nerve
. Median nerve
. Musculocutaneous nerve
. Posterior interosseous nerve (PIN)
. Anterior interosseous nerve (AIN)

Correct Answer & Explanation

. Posterior interosseous nerve (PIN)

Explanation

The Posterior Interosseous Nerve (PIN), a motor branch of the radial nerve, passes through the supinator muscle in the radial tunnel, an area anatomically close to the common extensor origin. Entrapment of the PIN (or the radial nerve proper in the radial tunnel) is a key differential diagnosis for lateral epicondylitis and can sometimes coexist or mimic it, causing lateral elbow pain and forearm symptoms. Therefore, assessing for PIN involvement (e.g., specific motor weakness) is crucial. The ulnar, median, musculocutaneous, and anterior interosseous nerves are located more medially or anteriorly and are less directly implicated in lateral epicondyle pain etiology, though all upper extremity nerves should be considered in a comprehensive exam if symptoms warrant.

Question 4705

Topic: Nerve & Tendon

A surgeon performs a primary distal biceps tendon repair utilizing a single-incision anterior approach. Postoperatively, the patient reports numbness and tingling along the radial aspect of the forearm. Which nerve is most likely injured?

. Posterior interosseous nerve (PIN)
. Lateral antebrachial cutaneous nerve (LABC)
. Superficial radial nerve
. Median nerve
. Ulnar nerve

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve (LABC)

Explanation

The lateral antebrachial cutaneous nerve (LABC) is the most commonly injured nerve during a single-incision anterior approach to the distal biceps. It courses just lateral to the biceps tendon in the subcutaneous tissue. The PIN is more at risk during a two-incision approach or if retractors are placed too deeply on the radial neck.

Question 4706

Topic: Nerve & Tendon

During surgical decompression of the ulnar nerve for cubital tunnel syndrome, a tight fascial band spanning between the olecranon and the medial epicondyle is identified overlying the two heads of the flexor carpi ulnaris (FCU). What is the anatomical name of this structure?

. Arcade of Struthers
. Osborne's ligament
. Ligament of Struthers
. Lacertus fibrosus
. Arcade of Frohse

Correct Answer & Explanation

. Osborne's ligament

Explanation

Osborne's ligament (or the cubital tunnel retinaculum) forms the roof of the cubital tunnel, bridging the olecranon and medial epicondyle over the two heads of the FCU. The Arcade of Struthers is a fascial band approximately 8 cm proximal to the medial epicondyle. The Ligament of Struthers is associated with the median nerve and a supracondylar process.

Question 4707

Topic: Nerve & Tendon

A 42-year-old recreational weightlifter undergoes an anterior single-incision approach for a distal biceps tendon repair. Which of the following is the most common neurologic complication specifically associated with this surgical approach?

. Posterior interosseous nerve palsy
. Lateral antebrachial cutaneous nerve neuropraxia
. Median nerve injury
. Ulnar nerve entrapment
. Superficial radial nerve palsy

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve neuropraxia

Explanation

The lateral antebrachial cutaneous nerve (LABCN) is the most frequently injured nerve during a single-incision anterior approach to the distal biceps, due to its proximity to the cephalic vein and the superficial dissection plane. Posterior interosseous nerve (PIN) injury is also a severe risk if retractors are placed too deeply or blindly on the radial neck, but LABCN neuropraxia is significantly more common.

Question 4708

Topic: Nerve & Tendon

A 40-year-old carpenter presents with numbness in his small finger and the ulnar half of the ring finger. During an in situ decompression for cubital tunnel syndrome, the surgeon releases a thick fascial band spanning between the olecranon and the medial epicondyle (connecting the two heads of the flexor carpi ulnaris). What is the eponym for this specific structure?

. Ligament of Struthers
. Arcade of Struthers
. Osborne's ligament
. Lacertus fibrosus
. Arcade of Frohse

Correct Answer & Explanation

. Osborne's ligament

Explanation

Osborne's ligament (or the arcuate ligament) forms the roof of the cubital tunnel. It is a fibrous band connecting the humeral and ulnar heads of the flexor carpi ulnaris (FCU), spanning from the medial epicondyle to the olecranon. Release of this structure is the key step in surgical decompression of the ulnar nerve at the elbow. The Arcade of Struthers is a different potential compression site located 8-10 cm proximal to the medial epicondyle.

Question 4709

Topic: Nerve & Tendon

A 28-year-old competitive weightlifter presents with medial elbow pain and parasthesias in the ring and small fingers. He describes feeling two distinct 'snaps' at the posteromedial elbow when moving from flexion to extension under load. The first snap corresponds to the ulnar nerve dislocating over the medial epicondyle. What anatomical structure is responsible for the second snap?

. Subluxation of the anterior band of the MUCL
. Subluxation of the medial head of the triceps
. Dislocation of the anconeus epitrochlearis
. Snapping of the common flexor tendon
. Subluxation of the lateral head of the triceps

Correct Answer & Explanation

. Subluxation of the medial head of the triceps

Explanation

Snapping triceps syndrome involves the sequential dislocation of the ulnar nerve and the medial head of the triceps over the medial epicondyle during elbow flexion, creating two distinct palpable and audible snaps. Hypertrophy of the medial head of the triceps in weightlifters is a common predisposing factor. Management often requires surgical transposition of the ulnar nerve and excision of the subluxating portion of the medial triceps head.

Question 4710

Topic: Wrist & Carpus

During the surgical management of a severely comminuted radial head fracture, the radial head is deemed unsalvageable and is excised without replacement. Three months postoperatively, the patient returns with progressive ulnar-sided wrist pain, grip weakness, and proximal migration of the radius seen on radiographs. Injury to which anatomic structure was most likely missed initially?

. Triangular fibrocartilage complex (TFCC)
. Annular ligament
. Interosseous membrane
. Quadrate ligament
. Lateral ulnar collateral ligament

Correct Answer & Explanation

. Interosseous membrane

Explanation

The clinical presentation describes an Essex-Lopresti lesion, which involves a highly comminuted radial head fracture accompanied by a longitudinal disruption of the interosseous membrane (IOM) and the distal radioulnar joint (DRUJ). The radial head and the central band of the IOM are the primary stabilizers against proximal migration of the radius. If the radial head is excised in the presence of an IOM rupture, the radius migrates proximally, leading to severe positive ulnar variance, DRUJ incongruity, and ulnar impaction syndrome. Radial head replacement is strictly indicated to prevent this.

Question 4711

Topic: Nerve & Tendon

A 28-year-old weightlifter presents with medial elbow pain and a snapping sensation when moving from flexion to extension. Examination shows ulnar neuropathy symptoms and a palpable 'double snap' over the medial epicondyle during flexion. Ultrasound demonstrates dynamic subluxation of the ulnar nerve along with an adjacent muscular structure. What is the involved muscular structure?

. Anconeus epitrochlearis
. Medial head of the triceps
. Brachialis
. Pronator teres
. Flexor carpi ulnaris

Correct Answer & Explanation

. Medial head of the triceps

Explanation

Snapping triceps syndrome occurs when the medial head of the triceps dynamically subluxates over the medial epicondyle during elbow flexion. It often pushes the ulnar nerve out of the cubital tunnel ahead of it, causing a characteristic 'double snap' (first the nerve, then the triceps) and secondary ulnar neuropathy.

Question 4712

Topic: Nerve & Tendon

A 40-year-old male presents with cubital tunnel syndrome. During surgical decompression, the surgeon explores potential sites of ulnar nerve compression. Which of the following anatomic structures is located approximately 8 cm proximal to the medial epicondyle?

. Osborne's ligament
. Medial intermuscular septum
. Arcade of Frohse
. Lacertus fibrosus
. Arcade of Struthers

Correct Answer & Explanation

. Arcade of Struthers

Explanation

The Arcade of Struthers is a fascial band extending from the medial head of the triceps to the medial intermuscular septum, located approximately 8 cm proximal to the medial epicondyle. It is a known potential site of ulnar nerve compression, especially if the nerve is transposed anteriorly without adequate proximal release. Osborne's ligament is at the level of the epicondyle (spanning the two heads of FCU).

Question 4713

Topic: Nerve & Tendon

During elbow arthroscopy, the proximal anteromedial portal is established 2 cm proximal to the medial epicondyle, just anterior to the medial intermuscular septum. Which of the following nerves is at the greatest risk of injury during the establishment of this portal?

. Ulnar nerve
. Median nerve
. Medial antebrachial cutaneous nerve (MACN)
. Musculocutaneous nerve
. Radial nerve

Correct Answer & Explanation

. Medial antebrachial cutaneous nerve (MACN)

Explanation

The proximal anteromedial portal places the medial antebrachial cutaneous nerve (MACN) at greatest risk as it courses through the subcutaneous tissue. The ulnar nerve is posterior to the medial intermuscular septum and is protected provided the portal remains anterior to the septum.

Question 4714

Topic: Nerve & Tendon

A 26-year-old weightlifter presents with medial elbow pain and a snapping sensation when flexing and extending the elbow beyond 90 degrees. Examination demonstrates a reproducible palpable 'snap' over the medial epicondyle, accompanied by paresthesias radiating into the ring and small fingers. Which two structures are most likely translocating over the medial epicondyle?

. Median nerve and flexor carpi radialis
. Ulnar nerve and medial head of the triceps
. Ulnar nerve and anconeus epitrochlearis
. Medial antebrachial cutaneous nerve and pronator teres
. Ulnar nerve and long head of the triceps

Correct Answer & Explanation

. Ulnar nerve and medial head of the triceps

Explanation

Snapping triceps syndrome occurs when the ulnar nerve and the medial edge of the medial head of the triceps recurrently dislocate anteriorly over the medial epicondyle during dynamic elbow flexion, causing a palpable double snap and symptoms of ulnar neuritis.

Question 4715

Topic: Nerve & Tendon

A 24-year-old weightlifter presents with medial elbow pain, intermittent tingling in the ring and small fingers, and a distinct 'popping' sensation over the medial elbow when actively extending the elbow from a flexed position. Ultrasound dynamically visualizes a structure snapping over the medial epicondyle, dislocating the ulnar nerve. Which anatomic structure is the primary cause of this phenomenon?

. Osborne's ligament
. Arcade of Struthers
. Medial head of the triceps
. Flexor carpi ulnaris fascial band
. Anconeus epitrochlearis

Correct Answer & Explanation

. Medial head of the triceps

Explanation

Snapping triceps syndrome occurs when the medial margin of the medial head of the triceps dislocates over the medial epicondyle during elbow flexion and snaps back during extension. This dynamic impingement frequently causes secondary friction and subluxation of the ulnar nerve, leading to cubital tunnel symptoms.

Question 4716

Topic: Wrist & Carpus

A 40-year-old female sustains a high-energy fall, resulting in an acute, highly comminuted, irreparable radial head fracture and severe wrist pain. Examination reveals a positive ulnar variance and distal radioulnar joint (DRUJ) instability. What is the most appropriate initial surgical management?

. Radial head excision alone and casting in supination
. Radial head replacement with acute ulnar shortening osteotomy
. Radial head replacement and pinning or stabilization of the DRUJ
. Reconstruction of the interosseous membrane with a synthetic graft alone
. Closed reduction of the DRUJ with pronation casting

Correct Answer & Explanation

. Radial head replacement and pinning or stabilization of the DRUJ

Explanation

This is an acute Essex-Lopresti injury (longitudinal radioulnar dissociation). The essential management involves restoring the radiocapitellar contact to prevent proximal migration of the radius. This is achieved via radial head replacement (as the head is irreparable). The DRUJ must also be stabilized, often with temporary pinning in supination or TFCC repair. Excision of the radial head is contraindicated as it leads to progressive, debilitating proximal radial migration.

Question 4717

Topic: Nerve & Tendon

During an elbow arthroscopy for the removal of loose bodies, the surgeon establishes the standard anteromedial portal. Which of the following neurological structures is at greatest risk of iatrogenic injury during the creation of this specific portal?

. Radial nerve
. Ulnar nerve
. Median nerve
. Medial antebrachial cutaneous nerve (MABC)
. Posterior interosseous nerve

Correct Answer & Explanation

. Medial antebrachial cutaneous nerve (MABC)

Explanation

The medial antebrachial cutaneous nerve (MABC) is the structure at greatest risk during the establishment of the anteromedial portal. It runs very close to the standard anteromedial portal site (typically 2 cm distal and 2 cm anterior to the medial epicondyle). The median nerve is also at risk if the portal is placed too far anteriorly. The radial nerve is primarily at risk during the creation of the anterolateral portal.

Question 4718

Topic: Nerve & Tendon

A 35-year-old male presents with recurrent episodes of a 'popping' sensation over the medial aspect of his elbow during active flexion and extension. He also reports intermittent numbness in his ring and small fingers. Physical examination reveals two distinct palpable 'snaps' over the medial epicondyle as the elbow is flexed from 0 to 120 degrees. What is the most likely diagnosis?

. Isolated ulnar nerve subluxation
. Medial epicondylitis
. Snapping triceps syndrome
. Cubital tunnel syndrome from an anconeus epitrochlearis
. Ulnar collateral ligament insufficiency

Correct Answer & Explanation

. Snapping triceps syndrome

Explanation

Snapping triceps syndrome occurs when both the ulnar nerve and the medial head of the triceps subluxate over the medial epicondyle during elbow flexion. The presence of two distinct snapsโ€”one from the ulnar nerve and the second from the medial head of the tricepsโ€”is pathognomonic for snapping triceps syndrome. Isolated ulnar nerve subluxation would typically produce only a single snap.

Question 4719

Topic: Wrist & Carpus
A 45-year-old man presents with chronic wrist pain years after an untreated scaphoid fracture. Radiographs reveal advanced arthritis at the radioscaphoid and capitolunate joints, while the radiolunate joint is well-preserved. Which of the following is the most appropriate surgical treatment?
. Proximal row carpectomy
. Scaphoid excision and four-corner arthrodesis
. Total wrist arthrodesis
. Radial styloidectomy
. Scaphoid excision and radiocarpal arthrodesis

Correct Answer & Explanation

. Scaphoid excision and four-corner arthrodesis

Explanation

This clinical scenario describes Scaphoid Nonunion Advanced Collapse (SNAC) Stage III, characterized by arthritis of the radioscaphoid and capitolunate joints with preservation of the radiolunate joint. Proximal row carpectomy is contraindicated because the capitate head is arthritic and would articulate poorly with the lunate fossa. Scaphoid excision and four-corner arthrodesis (capitate, lunate, triquetrum, and hamate) is the gold standard reconstructive option for SNAC III.

Question 4720

Topic: Nerve & Tendon

A 32-year-old avid cyclist presents with numbness in the volar aspect of his right ring and small fingers, accompanied by weakness of finger abduction. Sensation over the dorsoulnar aspect of his hand is entirely normal. Compression of the ulnar nerve is most likely occurring at which of the following anatomical locations?

. Cubital tunnel
. Zone 1 of Guyon's canal
. Zone 2 of Guyon's canal
. Zone 3 of Guyon's canal
. Arcade of Struthers

Correct Answer & Explanation

. Zone 1 of Guyon's canal

Explanation

The dorsal ulnar sensory branch branches off the ulnar nerve approximately 5-8 cm proximal to the wrist. Because dorsoulnar sensation is spared, the lesion must be at or distal to the wrist (Guyon's canal). The ulnar nerve in Guyon's canal is divided into three zones: Zone 1 is proximal to the bifurcation (contains both motor and sensory fibers), Zone 2 is the deep motor branch, and Zone 3 is the superficial sensory branch. Since both motor (weak finger abduction) and volar sensory (numbness in ring/small fingers) deficits are present, the compression is in Zone 1 of Guyon's canal.

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