MSK 4 elbow wrist hand exam

Question 1

A patient complains of decreased ability to flex the PIP and DIP of the right index finger. You place the MCP of the index finger in extension, and you attempt to flex the PIP passively. You note the PIP does not flex. You then place the MCP in 45 degrees of flexion and try to flex the PIP. You note that in MCP flexion the PIP joint is now able to flex. Why does the PIP not flex in MCP extension, but does in MCP flexion?

Answers:
A. Tight lumbricals
B. Hypermobile PIP joint capsule
C. Intersection syndrome
D. Median nerve injury

Answer 1

A. Tight lumbricals

Correct Answer: A. Tight lumbricals

Explanation: The lumbricals attach to the extensor expansion of the fingers and flex the MCP while extending the PIP and DIP joints. When the MCP joint is in extension, tight lumbricals can prevent the PIP from flexing due to increased tension. However, when the MCP is flexed, this tension is relieved, allowing the PIP joint to flex.

Incorrect Options:

B. Hypermobile PIP joint capsule: This would typically allow more movement, not restrict it as described.
C. Intersection syndrome: This is a condition affecting the forearm, not the fingers, and wouldn’t explain the limitation in PIP flexion.
D. Median nerve injury: This would cause weakness and sensory deficits but wouldn’t explain the specific pattern of limitation described.

Question 2

Identify the finger deformity (digit 3)?

Answers:
A. Swan neck
B. Mallet
C. Claw
D. Boutonniere

Answer 2

AI put D. Boutonniere. we put A swan neck

Correct Answer: D. Boutonniere

Explanation: Boutonniere deformity is characterized by flexion of the PIP joint and hyperextension of the DIP joint, typically due to a central slip injury.

Incorrect Options:

A. Swan neck: This deformity is the opposite, with hyperextension of the PIP and flexion of the DIP.
B. Mallet: Involves the DIP joint only, not the PIP.
C. Claw: Typically involves hyperextension of the MCP joint and flexion of both the PIP and DIP joints, which is not the case here.

Question 3

Upon observation of a patient during an initial examination, you note the following deformity of the left elbow. What is your impression?

Answers:
A. Gunstock Deformity
B. Dinner Fork Deformity
C. Excessive Cubital Valgus Deformity
D. Cubital Hyperextension Deformity

Answer 3

A. Gunstock Deformity should be this answer

Correct Answer: A. Gunstock Deformity

Explanation: Gunstock deformity is a varus deformity of the elbow, often resulting from a fracture.

Incorrect Options:

B. Dinner Fork Deformity: Associated with a Colles fracture and affects the wrist, not the elbow.
C. Excessive Cubital Valgus Deformity: This is an outward deviation, not varus.
D. Cubital Hyperextension Deformity: Refers to excessive extension, not the varus position described.

Question 4

Which hand deformity is often associated with a severe ulnar nerve injury?

Answers:
A. Claw Hand
B. Ape Hand
C. Ulnar Drift Hand
D. Intrinsic Plus Hand

Answer 4

A. Claw Hand

Correct Answer: A. Claw Hand

Explanation: Claw hand deformity is characteristic of severe ulnar nerve damage, where the MCP joints are hyperextended, and the PIP and DIP joints are flexed.

Incorrect Options:

B. Ape Hand: Associated with median nerve injury, not ulnar nerve.
C. Ulnar Drift Hand: This is a condition related to rheumatoid arthritis, not specifically ulnar nerve injury.
D. Intrinsic Plus Hand: This is not typically associated with ulnar nerve injury but rather seen in conditions with tight intrinsic muscles.

Question 5

Which of the below best describes an “intrinsic plus” hand position?

Answers:
A. MCP flexion, DIP and PIP extension
B. MCP flexion, DIP and PIP flexion
C. MCP extension, DIP and PIP extension
D. MCP extension, DIP and PIP flexion

Answer 5

A. MCP flexion, DIP and PIP extension

Correct Answer: A. MCP flexion, DIP and PIP extension

Explanation: This is the classic intrinsic plus hand position, often seen in conditions with intrinsic muscle tightness.

Incorrect Options:

B. MCP flexion, DIP and PIP flexion: This describes a claw hand, not intrinsic plus.
C. MCP extension, DIP and PIP extension: This position doesn’t match the intrinsic plus hand.
D. MCP extension, DIP and PIP flexion: This is not characteristic of intrinsic plus hand

Question 6

A patient presents with the following findings involving the right upper limb:

Observation: increased cubital valgus of the right elbow, atrophy of the hand intrinsics.
PROM: Normal
MMT: Abductor digiti quinti = 4/5, First dorsal interossei = 4/5, Abductor pollicis brevis = 5/5, Flexor Digitorum Profundus (Digits 4 & 5) = 4/5
Reflex: normal
Sensation: decreased over palmar and dorsal aspect of the fifth digit, ulnar hand, and wrist
What is the most likely condition this patient is suffering from?

Answers:
A. Ulnar nerve injury in the palm
B. Ulnar nerve injury at the wrist
C. Ulnar nerve injury at the elbow
D. C6 radiculopathy

Answer 6

C. Ulnar nerve injury at the elbow

Explanation: The combination of cubital valgus, hand intrinsic atrophy, and sensory loss over the ulnar distribution points to an ulnar nerve injury at the elbow.

Incorrect Options:

A. Ulnar nerve injury in the palm: This would cause different sensory and motor deficits.
B. Ulnar nerve injury at the wrist: Sensory deficits would be more distal and isolated to the hand.
D. C6 radiculopathy: This would typically involve different sensory and motor distributions, not specifically ulnar.

Question 7

Which of the below is true when performing a joint mobilization to increase wrist extension at the radiocarpal joint?

Answers:
A. The radius is mobilized in a ventral direction
B. The ulna is mobilized in a dorsal direction
C. The proximal row of carpal bones are mobilized in a dorsal direction
D. The proximal row of carpal bones are mobilized in a ventral direction

Answer 7

D. The proximal row of carpal bones are mobilized in a ventral direction

Correct Answer: D. The proximal row of carpal bones are mobilized in a ventral direction

Explanation: To increase wrist extension, you mobilize the proximal row of carpal bones in a ventral (palmar) direction relative to the radius.

Incorrect Options:

A. The radius is mobilized in a ventral direction: The radius is typically stabilized during wrist joint mobilizations.
B. The ulna is mobilized in a dorsal direction: The ulna is not directly involved in wrist extension mobilizations.
C. The proximal row of carpal bones are mobilized in a dorsal direction: This would increase wrist flexion, not extension.

Question 8

A wrist splint that has a dorsal block while maintaining the wrist in 20-30 degrees of flexion and MCPs in 70-80 degrees of flexion, along with palmar pulleys, would be best for treating:

Answers:
A. DeQuervain’s
B. Flexor tendon repair
C. Extensor tendon repair
D. Trigger finger repair

Answer 8

B. Flexor tendon repair.

Correct Answer: B. Flexor tendon repair

Explanation: The described splinting position is ideal for protecting repaired flexor tendons by limiting extension and allowing healing.

Incorrect Options:

A. DeQuervain’s: This condition involves the extensor tendons of the thumb, requiring a different splint.
C. Extensor tendon repair: This would require a different positioning that prevents excessive flexion.
D. Trigger finger repair: This involves the A1 pulley, typically requiring different splinting.

Question 9

Upon observation of a patient during an initial examination, you note the following deformity of the arm. What is your impression?

Answers:
A. Distal Biceps Rupture
B. Proximal Biceps Rupture
C. Distal Brachialis Rupture
D. Proximal Brachialis Rupture

Answer 9

we put A. Distal Biceps Rupture AI had B Proximal Biceps Rupture

Correct Answer: A. Distal Biceps Rupture

Explanation: Distal biceps rupture presents with a bulge in the upper arm and loss of flexion strength.

Incorrect Options:

B. Proximal Biceps Rupture: This would present differently, typically with a “Popeye” deformity higher up.
C. Distal Brachialis Rupture: Rare, and doesn’t typically present with the described deformity.
D. Proximal Brachialis Rupture: This would not cause a visible deformity as the biceps do.

Question 10

A 38-year-old female who works on the assembly line at Ford Motor Company reports the following complaints: painful/weak grip and pinpoint pain over the lateral epicondyle that radiates down the dorsal forearm. What condition listed below is most likely given the patient’s complaints?

Answers:
A. C6-7 Radiculopathy
B. Lateral Epicondylitis
C. Radial Nerve entrapment
D. Dorsal compartment syndrome

Answer 10

B. Lateral Epicondylitis

Correct Answer: B. Lateral Epicondylitis

Explanation: The description of pain at the lateral epicondyle and weakness in grip strongly indicates lateral epicondylitis.

Incorrect Options:

A. C6-7 Radiculopathy: Would involve different pain distribution and possibly neurological signs.
C. Radial Nerve entrapment: This could cause pain, but not specifically at the lateral epicondyle.
D. Dorsal compartment syndrome: This affects the extensor tendons of the wrist and thumb, not the epicondyle.

Question 11

You are aggressively rehabilitating a patient that is ten weeks post-elbow fracture (the fracture is healed). You perform grade 3 (Kaltenborn) mobilizations to increase elbow extension and supination and vigorous elbow exercises. You note that the patient’s ROM is not improving; it is worsening. What could be going on with this patient?

Answers:
A. Myositis Ossificans
B. Pulled Elbow
C. Proximal biceps rupture
D. Terrible Triad Fracture

Answer 11

A. Myositis Ossificans

Correct Answer: A. Myositis Ossificans

Explanation: Myositis ossificans is a condition where bone tissue forms inside muscle or other soft tissues after an injury. It can occur after aggressive rehabilitation, especially following fractures, leading to a worsening range of motion due to the formation of bone in the muscle.

Incorrect Options:

B. Pulled Elbow: Typically seen in children and involves subluxation of the radial head. It wouldn’t cause worsening ROM after a fracture.
C. Proximal biceps rupture: This would cause weakness but not necessarily a worsening range of motion as described.
D. Terrible Triad Fracture: This is a specific injury involving the elbow, but if it’s healed, the symptoms would not typically include progressive ROM loss unless complications like myositis ossificans occur.

Question 12

A patient reports to physical therapy with complaints of right forearm pain, intermittent numbness and tingling in digits 1-3, especially at the thenar eminence, and has cramping in her hand and forearm. There are no nocturnal symptoms. Symptoms worsen when she uses her hand. The patient denies neck pain. The most likely diagnosis would be?

Answers:
A. C6 cervical radiculopathy
B. Compartment syndrome
C. Pronator teres syndrome
D. Carpal tunnel syndrome

Answer 12

C. Pronator teres syndrome

Correct Answer: C. Pronator teres syndrome

Explanation: Pronator teres syndrome involves compression of the median nerve by the pronator teres muscle, leading to symptoms similar to carpal tunnel syndrome but without nocturnal symptoms and with involvement of the forearm.

Incorrect Options:

A. C6 cervical radiculopathy: This would involve neck pain and different sensory distribution.
B. Compartment syndrome: This is a surgical emergency and presents with severe pain, not intermittent symptoms.
D. Carpal tunnel syndrome: Typically involves nocturnal symptoms and does not cause forearm pain or cramping as described.

Question 13

As a DPT student, you are observing a certified hand therapist. You note a patient performing the exercise in the video. What is the purpose of this exercise?

Answers:
A. Facilitate healing of an AIN injury
B. Promote tendon excursion between the FDS and FDP tendons
C. Improve thumb opposition strength
D. Reduce lateral elbow pain

Answer 13

C. Improve thumb opposition strength

Correct Answer: C. Improve thumb opposition strength

Explanation: The exercise shown is likely focused on improving the strength and function of the muscles responsible for thumb opposition, crucial for gripping and pinching activities.

Incorrect Options:

A. Facilitate healing of an AIN injury: This would involve different exercises targeting the anterior interosseous nerve.
B. Promote tendon excursion between the FDS and FDP tendons: This would involve gliding exercises, not thumb opposition.
D. Reduce lateral elbow pain: This would involve exercises targeting the forearm muscles, not thumb-specific exercises.

Question 14

Upon observation of a patient during an initial examination, you note a small bump on the dorsal aspect of the wrist. Upon palpation, you note that the bump is soft and fluctuant. What is your initial impression?

Answers:
A. Baker’s Cyst
B. Ganglion Cyst
C. Trichilemmal Cyst
D. Myxoid Cyst

Answer 14

B. Ganglion Cyst

Correct Answer: B. Ganglion Cyst

Explanation: Ganglion cysts are common lumps found on the dorsal aspect of the wrist. They are soft, fluctuant, and filled with a jelly-like fluid.

Incorrect Options:

A. Baker’s Cyst: This is found in the popliteal region of the knee, not the wrist.
C. Trichilemmal Cyst: Found on the scalp, not the wrist.
D. Myxoid Cyst: Typically found near the finger joints, not the wrist.

Question 15

Which of the following is a differential diagnosis for carpal tunnel syndrome?

Answers:
A. C6 Radiculopathy
B. Pronator Quadratus Syndrome
C. Shoulder impingement
D. Ulnar nerve injury at the elbow

Answer 15

A. C6 Radiculopathy

Correct Answer: A. C6 Radiculopathy

Explanation: C6 radiculopathy can mimic carpal tunnel syndrome symptoms, as both can cause pain and numbness in the same area of the hand.

Incorrect Options:

B. Pronator Quadratus Syndrome: Not a recognized clinical syndrome and doesn’t typically mimic carpal tunnel syndrome.
C. Shoulder impingement: This would cause shoulder pain, not hand or wrist symptoms.
D. Ulnar nerve injury at the elbow: This affects the ulnar distribution, not the median nerve distribution affected in carpal tunnel syndrome.

Question 16

A 25-year-old male presents to your clinic with a 2-week history of pain on the lateral aspect of his wrist and thumb after falling off his skateboard at the local skate park. Initial x-rays were negative. He complains of pain at the anatomical snuff box, pain with longitudinal proximal compression of the 1st metacarpal, and tenderness at the volar radial aspect of his wrist just distal to the distal radius. You suspect:

Answers:
A. Carpal Tunnel syndrome
B. DeQuervain’s tendonitis
C. Arthritis of the thumb and wrist
D. Scaphoid fracture

Answer 16

D. Scaphoid fracture

Correct Answer: D. Scaphoid fracture

Explanation: The symptoms, particularly pain in the anatomical snuff box and with compression, are classic for a scaphoid fracture, even if initial x-rays are negative.

Incorrect Options:

A. Carpal Tunnel syndrome: Would not present with localized pain in the snuff box or pain with compression of the 1st metacarpal.
B. DeQuervain’s tendonitis: Involves the tendons of the thumb, but wouldn’t present with pain on longitudinal compression.
C. Arthritis of the thumb and wrist: This would be more chronic and less likely after an acute fall.

Question 17

How will a patient with compression of the radial nerve in the spiral groove (Saturday night palsy) present?

Answers:
A. Inability to extend the elbow, wrist, fingers, and thumb
B. Inability to extend wrist, fingers, and thumb
C. Inability to extend the fingers and thumb
D. Inability to extend the thumb

Answer 17

B. Inability to extend wrist, fingers, and thumb

Correct Answer: B. Inability to extend wrist, fingers, and thumb

Explanation: Compression of the radial nerve in the spiral groove leads to “wrist drop” and an inability to extend the wrist, fingers, and thumb due to paralysis of the extensor muscles.

Incorrect Options:

A. Inability to extend the elbow, wrist, fingers, and thumb: The triceps (responsible for elbow extension) are innervated by the radial nerve before it enters the spiral groove, so they are usually spared.
C. Inability to extend the fingers and thumb: This would be incomplete, as wrist extension is also lost.
D. Inability to extend the thumb: Too limited; the wrist and finger extensors are also affected.

Question 18

A patient is being considered for discharge S/P distal radius fracture. What amount of radio-carpal joint ROM would be considered functionally sufficient and favor discharge?

Answers:
A. 40 degrees of flexion and 40 degrees of extension
B. 25 degrees of flexion and 25 degrees of extension
C. 70 degrees of pronation and 30 degrees of supination
D. 15 degrees of radial deviation and 15 degrees of ulnar deviation

Answer 18

B. 25 degrees of flexion and 25 degrees of extension

Correct Answer: B. 25 degrees of flexion and 25 degrees of extension

Explanation: This amount of ROM is generally considered functionally sufficient for most daily activities, justifying discharge from therapy.

Incorrect Options:

A. 40 degrees of flexion and 40 degrees of extension: While more ROM is beneficial, it’s not necessary for discharge.
C. 70 degrees of pronation and 30 degrees of supination: These measurements are for forearm rotation, not wrist flexion/extension.
D. 15 degrees of radial deviation and 15 degrees of ulnar deviation: These are measurements for wrist deviation, not flexion/extension.

Question 19

The most appropriate intervention for intrinsic muscle contracture would be:

Answers:
A. Dynamic PIP joint extension splinting
B. Active/passive MCP extension and IP flexion stretching
C. Active/passive MCP and IP stretching into flexion
D. Active/passive MCP and IP stretching into extension

Answer 19

B. Active/passive MCP extension and IP flexion stretching

Correct Answer: B. Active/passive MCP extension and IP flexion stretching

Explanation: This stretching technique helps to lengthen the contracted intrinsic muscles, which often cause MCP flexion and IP extension deformities.

Incorrect Options:

A. Dynamic PIP joint extension splinting: This addresses PIP joint issues, not intrinsic muscle contracture.
C. Active/passive MCP and IP stretching into flexion: This would worsen an intrinsic muscle contracture by encouraging more flexion.
D. Active/passive MCP and IP stretching into extension: This could exacerbate intrinsic muscle tightness by overstretching already tight muscles.

Question 20

During the myotome testing portion of an upper limb clearing examination, you note weakness of the elbow flexors and wrist extensors. What myotome/nerve root is demonstrating weakness?

Answers:
A. C5
B. C6
C. C7
D. C8

Answer 20

B. C6

Correct Answer: B. C6

Explanation: The C6 nerve root innervates muscles responsible for elbow flexion and wrist extension. Weakness in these areas indicates C6 involvement.

Incorrect Options:

A. C5: Involves shoulder abduction and elbow flexion, not wrist extension.
C. C7: Involves elbow extension, wrist flexion, and finger extension, not specifically elbow flexion and wrist extension.
D. C8: Primarily involves finger flexion, not the elbow or wrist movements described.

Question 20

You are evaluating a patient with wrist pain. You note during the examination the patient has extreme pain over the distal lateral aspect of the radius with the maneuver shown in the photo. What is your preliminary impression?

Answers:
A. Complex Regional Pain Syndrome (CRPS)
B. Dupuytren’s Contracture
C. De Quervain’s Tenosynovitis
D. Colles Fracture

Answer 20

C. De Quervain’s Tenosynovitis

Correct Answer: C. De Quervain’s Tenosynovitis

Explanation: De Quervain’s Tenosynovitis is a condition involving inflammation of the tendons at the base of the thumb, often causing pain over the distal lateral aspect of the radius. The Finkelstein test, which involves ulnar deviation of the wrist while the thumb is grasped in the palm, typically elicits this pain.

Incorrect Options:

A. Complex Regional Pain Syndrome (CRPS): This is a broader condition involving chronic pain and typically affects the entire limb, not just a specific spot like De Quervain’s.
B. Dupuytren’s Contracture: This condition involves the palmar fascia of the hand, leading to contractures, not pain over the lateral aspect of the radius.
D. Colles Fracture: A Colles fracture involves a fracture of the distal radius, often from a fall, but would present with a different pain pattern and mechanism.

Question 21

This patient reports being involved in a fight. He reports hitting the combatant with a glancing blow with his left hand. He now reports pain over the 5th metacarpal. His radiograph is included. What best describes this patient’s condition?

Answers:
A. Barton Fracture
B. Boxer’s Fracture
C. Colles Fracture
D. Smith Fracture

Answer 21

B. Boxer’s Fracture

Correct Answer: B. Boxer’s Fracture

Explanation: A Boxer’s fracture is a fracture of the 5th metacarpal neck, often caused by punching or striking with a closed fist, which aligns with the patient’s history of a fight and pain over the 5th metacarpal.

Incorrect Options:

A. Barton Fracture: This is a fracture-dislocation of the distal radius, not involving the 5th metacarpal.
C. Colles Fracture: Involves the distal radius, not the metacarpals.
D. Smith Fracture: This is a fracture of the distal radius with volar displacement, unrelated to the 5th metacarpal.

Question 21

What is the optimal position to splint the wrist for a patient suffering from carpal tunnel syndrome?

Answers:
A. 0 degrees of flexion & extension
B. 15 degrees of extension
C. 45 degrees of extension
D. 25 degrees of flexion

Answer 21

B. 15 degrees of extension

Correct Answer: B. 15 degrees of extension

Explanation: Splinting the wrist in 15 degrees of extension is considered optimal for reducing pressure within the carpal tunnel while maintaining functional hand use.

Incorrect Options:

A. 0 degrees of flexion & extension: Neutral might be acceptable, but slight extension is preferred.
C. 45 degrees of extension: This would increase tension on the median nerve and could exacerbate symptoms.
D. 25 degrees of flexion: Flexion would worsen carpal tunnel symptoms by increasing pressure within the tunnel.

Question 22

identify the finger deformity (Digit 3)?

Answers:
A. Swan neck
B. Mallet
C. Claw
D. Boutonniere

Answer 22

we put D. Boutonniere AI put A. swan neck

Correct Answer: A. Swan neck

Explanation: Swan neck deformity involves hyperextension of the PIP joint and flexion of the DIP joint, which is consistent with the description.

Incorrect Options:

B. Mallet: This deformity involves flexion of the DIP joint only.
C. Claw: This involves hyperextension at the MCP and flexion at the PIP and DIP joints.
D. Boutonniere: This involves flexion of the PIP and hyperextension of the DIP, opposite of the swan neck.

Question 23

Based on the Carpal Tunnel CPG Guidelines of the APTA, which of the following is considered the “BEST” appropriate non-surgical intervention for carpal tunnel syndrome?

Answers:
A. Patient education
B. Tendon gliding
C. Neutral wrist splint
D. Low Level Laser over the carpal tunnel

Answer 23

C. Neutral wrist splint

Correct Answer: C. Neutral wrist splint

Explanation: A neutral wrist splint is widely recommended as an effective non-surgical intervention for reducing symptoms of carpal tunnel syndrome by minimizing pressure on the median nerve.

Incorrect Options:

A. Patient education: While important, it alone is not the most effective intervention.
B. Tendon gliding: Helpful but less effective on its own compared to a neutral splint.
D. Low-Level Laser over the carpal tunnel: While it may offer some relief, it is not considered the best option according to CPG guidelines.

Question 24

Following a flexor tendon repair of the hand, a therapist performs manual muscle testing at week three. The therapist has just:

Answers:
A. Potentially disrupted the repaired tendon
B. Performed a safe evaluative procedure
C. Stretched the median nerve
D. Performed the “Bunnell-Littler” test

Answer 24

A. Potentially disrupted the repaired tendon

Correct Answer: A. Potentially disrupted the repaired tendon

Explanation: Performing manual muscle testing at three weeks post-flexor tendon repair is too early and can potentially disrupt the healing tendon, leading to a failure of the repair.

Incorrect Options:

B. Performed a safe evaluative procedure: It is not safe to perform MMT this early post-repair.
C. Stretched the median nerve: The primary concern here is tendon disruption, not nerve stretching.
D. Performed the “Bunnell-Littler” test: This test is for intrinsic tightness, not relevant to the scenario.

Question 25

A 12-year-old male presents to your clinic with medial elbow pain after pitching in a baseball tournament over the weekend. He has tenderness at the medial joint line and lateral elbow, inability to extend his elbow fully, and a positive valgus stress test. Which of the conditions is MOST likely?

Answers:
A. Ulnar collateral ligament injury requiring a Tommy John surgery
B. Little League Elbow
C. Olecranon fracture
D. Ulnar Neuropathy

Answer 25

B. Little League Elbow

Correct Answer: B. Little League Elbow

Explanation: Little League Elbow is a common condition in young athletes who pitch frequently, characterized by medial elbow pain due to repetitive stress on the growth plate.

Incorrect Options:

A. Ulnar collateral ligament injury requiring a Tommy John surgery: This is more common in older athletes and involves a specific ligament injury.
C. Olecranon fracture: This would involve pain at the posterior elbow, not medial.
D. Ulnar Neuropathy: This would present with neurological symptoms, not just medial elbow pain.

Question 26

Which of the below conditions would be associated with proximal forearm pain and weakness of DIP flexion of the index finger and thumb?

Answers:
A. Anterior interosseous nerve entrapment
B. Posterior interosseous nerve entrapment
C. Dorsal ulnar nerve entrapment
D. Lateral antebrachial nerve entrapment

Answer 26

A. Anterior interosseous nerve entrapment

Correct Answer: A. Anterior interosseous nerve entrapment

Explanation: Anterior interosseous nerve entrapment affects the motor function of the muscles responsible for DIP flexion of the index finger and thumb, leading to weakness.

Incorrect Options:

B. Posterior interosseous nerve entrapment: Affects different muscles and doesn’t typically cause DIP flexion weakness.
C. Dorsal ulnar nerve entrapment: Involves sensory changes in the ulnar distribution, not DIP flexion weakness.
D. Lateral antebrachial nerve entrapment: Primarily a sensory nerve, not affecting DIP flexion.

Question 27

Intra-neural pressure increases in the Cubital Tunnel when:

Answers:
A. The elbow is flexed greater than 90°
B. Contraction of the Pronator Teres occurs
C. The wrist is in a flexed position while sleeping
D. A patient is pregnant

Answer 27

A. The elbow is flexed greater than 90°

Correct Answer: A. The elbow is flexed greater than 90°

Explanation: Flexion beyond 90 degrees increases pressure in the cubital tunnel, which can exacerbate ulnar nerve symptoms.

Incorrect Options:

B. Contraction of the Pronator Teres occurs: This affects the median nerve, not the ulnar nerve in the cubital tunnel.
C. The wrist is in a flexed position while sleeping: This could affect the carpal tunnel, not the cubital tunnel.
D. A patient is pregnant: Pregnancy can exacerbate carpal tunnel syndrome due to fluid retention but doesn’t specifically affect the cubital tunnel.

Question 28

What is the proper management for mallet finger?

Answers:
A. A wait and see approach
B. Immediate surgery with pinning
C. Splint for 2 weeks then begin ROM
D. Splint for 6-8 weeks

Answer 28

D. Splint for 6-8 weeks

Correct Answer: D. Splint for 6-8 weeks

Explanation: Mallet finger, which involves an injury to the extensor tendon at the DIP joint, should be treated with continuous splinting for 6-8 weeks to allow proper healing.

Incorrect Options:

A. A wait and see approach: This would delay treatment and worsen the condition.
B. Immediate surgery with pinning: Surgery is usually not the first line of treatment unless conservative management fails.
C. Splint for 2 weeks then begin ROM: This is too short for tendon healing, risking re-injury.

Question 29

During a hand examination, a patient is unable to make the “OK” sign. What nerve is most likely injured or involved?

Answers:
A. Anterior interosseous
B. Radial
C. Ulnar
D. Lateral Cutaneous Nerve of the Forearm

Answer 29

A. Anterior interosseous

Correct Answer: A. Anterior interosseous

Explanation: The anterior interosseous nerve is a branch of the median nerve that innervates the flexor pollicis longus and the flexor digitorum profundus of the index finger. Damage to this nerve impairs the ability to make an “OK” sign, where the thumb and index finger should form a circle.

Incorrect Options:

B. Radial: Affects wrist and finger extension, not the ability to make an “OK” sign.
C. Ulnar: Affects intrinsic hand muscles, not the anterior interosseous nerve distribution.
D. Lateral Cutaneous Nerve of the Forearm: This is a sensory nerve and does not affect motor function related to the “OK” sign.

Question 30

A mother reports lifting her 3-year-old daughter up by her left hand when attempting to navigate a large step. The mother reported that her daughter suddenly started crying and would not use her elbow. Which of the below is MOST likely?

Answers:
A. Radial Nerve injury within the supinator
B. Distal Biceps Tendon Rupture
C. Nursemaid’s (Pulled) Elbow
D. Monteggia Fracture

Answer 30

C. Nursemaid’s (Pulled) Elbow

Correct Answer: C. Nursemaid’s (Pulled) Elbow

Explanation: Nursemaid’s elbow, or pulled elbow, occurs when the radial head subluxates from the annular ligament, commonly after a sudden pull on an extended arm in young children.

Incorrect Options:

A. Radial Nerve injury within the supinator: Unlikely from this mechanism of injury.
B. Distal Biceps Tendon Rupture: Rare in children, especially with this mechanism.
D. Monteggia Fracture: Involves a fracture of the ulna and dislocation of the radial head, which is not suggested by the history provided.

Question 31

During a hand examination you ask a patient to make a full fist. Using the photo provided, you note that when the patient moves from hand position A to B they cannot actively flex D1-3. What is your impression?

Answers:
A. Median nerve injury at the elbow
B. Median nerve injury, specifically the anterior interosseous nerve
C. Median nerve injury at the wrist
D. Ulnar nerve injury at the wrist

Answer 31

C. Median nerve injury at the wrist

Correct Answer: C. Median nerve injury at the wrist

Explanation: A median nerve injury at the wrist (e.g., carpal tunnel syndrome) can impair the flexion of digits 1-3 due to the loss of innervation to the flexor digitorum superficialis and flexor digitorum profundus muscles.

Incorrect Options:

A. Median nerve injury at the elbow: This would typically affect more proximal functions and possibly the entire hand.
B. Median nerve injury, specifically the anterior interosseous nerve: Would prevent the “OK” sign, but full fist closure might still be possible.
D. Ulnar nerve injury at the wrist: Would primarily affect digits 4-5, not 1-3.

Question 32

A patient is referred to you who complains of burning, numbness, and tingling in their fingers. They report that their condition is exacerbated when their hands are exposed to cold temperatures. They also report blanching of the fingers. Which of the below best describes this condition?

Answers:
A. Carpal Tunnel Syndrome
B. Ulnar Nerve Injury at the Elbow
C. Raynaud’s Syndrome
D. Complex Regional Pain Syndrome (CRPS)

Answer 32

C. Raynaud’s Syndrome

Correct Answer: C. Raynaud’s Syndrome

Explanation: Raynaud’s syndrome is characterized by episodes of vasospasm in the extremities, typically the fingers, leading to color changes, numbness, and tingling in response to cold or stress.

Incorrect Options:

A. Carpal Tunnel Syndrome: Causes numbness and tingling, but not blanching or cold sensitivity.
B. Ulnar Nerve Injury at the Elbow: Would cause numbness and tingling, but not the specific symptoms described.
D. Complex Regional Pain Syndrome (CRPS): Could cause burning pain and skin changes, but usually follows an injury and doesn’t specifically involve cold-induced blanching.

Question 33

A patient presents with Chronic Regional Pain Syndrome. Which of the following interventions would result in the best functional outcome?

Answers:
A. Diathermy
B. Eccentric Exercises
C. Graded Motor Imagery
D. Cold Laser

Answer 33

C. Graded Motor Imagery

Correct Answer: C. Graded Motor Imagery

Explanation: Graded motor imagery is a therapeutic approach shown to be effective in managing CRPS by retraining the brain’s perception of the affected limb.

Incorrect Options:

A. Diathermy: May provide temporary pain relief but is not the most effective for CRPS.
B. Eccentric Exercises: Typically used for tendon injuries, not CRPS.
D. Cold Laser: Might offer some relief but is not the most effective treatment for CRPS.

Question 34

In what population do Colles’ fractures (distal radius fractures with dorsal angulation) occur most frequently?

Answers:
A. Young active males
B. Young active females
C. Elderly males
D. Elderly females

Answer 34

D. Elderly females

Correct Answer: D. Elderly females

Explanation: Colles’ fractures, which involve a fracture of the distal radius with dorsal angulation, are most common in elderly females due to osteoporosis.

Incorrect Options:

A. Young active males: More prone to fractures from high-impact activities, but not Colles’ fractures specifically.
B. Young active females: Also less likely to have Colles’ fractures compared to elderly females.
C. Elderly males: Less common than in elderly females due to lower incidence of osteoporosis.

Question 35

What is a realistic functional range of motion goal for forearm pronation and supination in a patient that is status post elbow fracture?

Answers:
A. 90 degrees pronation & 90 degrees supination
B. 85 degrees pronation & 75 degrees supination
C. 50 degrees pronation & 50 degrees supination
D. 30 degrees pronation & 30 degrees supination

Answer 35

C. 50 degrees pronation & 50 degrees supination

Correct Answer: C. 50 degrees pronation & 50 degrees supination

Explanation: A functional range of motion for daily activities generally requires about 50 degrees of both pronation and supination.

Incorrect Options:

A. 90 degrees pronation & 90 degrees supination: This is more than typically required for functional tasks.
B. 85 degrees pronation & 75 degrees supination: More than necessary for daily functions.
D. 30 degrees pronation & 30 degrees supination: May be insufficient for many functional activities.

Question 36

Which of the following is true regarding stenosing tenosynovitis (trigger finger)?

Answers:
A. Occurs most commonly at the A2 pulley
B. Pain medicines are an effective management strategy
C. Usually resolves in 1 week without intervention
D. A static PIP splint or metacarpal phalangeal blocking splint is advised

Answer 36

D. A static PIP splint or metacarpal phalangeal blocking splint is advised

Correct Answer: D. A static PIP splint or metacarpal phalangeal blocking splint is advised

Explanation: Splinting can help manage trigger finger by preventing the finger from locking in a bent position, allowing the tendon to heal.

Incorrect Options:

A. Occurs most commonly at the A2 pulley: Trigger finger more commonly occurs at the A1 pulley.
B. Pain medicines are an effective management strategy: Pain management alone is not usually sufficient for trigger finger.
C. Usually resolves in 1 week without intervention: Trigger finger usually requires more prolonged treatment or intervention.

Question 37

Which of the following is true regarding stenosing tenosynovitis (trigger finger)?

Answers:
A. Occurs most commonly at the A2 pulley
B. Pain medicines are an effective management strategy
C. Usually resolves in 1 week without intervention
D. A static PIP splint or metacarpal phalangeal blocking splint is advised

Answer 37

A. Occurs most commonly at the A2 pulley

Correct Answer: A. Occurs most commonly at the A2 pulley

Explanation: Stenosing tenosynovitis, or trigger finger, commonly affects the A1 pulley, not the A2 pulley. (Note: The question and correct answer provided may be mismatched; typically, the correct pulley is the A1 pulley, not A2.)

Incorrect Options:

B. Pain medicines are an effective management strategy: Pain management alone is not sufficient.
C. Usually resolves in 1 week without intervention: Trigger finger typically requires longer management.
D. A static PIP splint or metacarpal phalangeal blocking splint is advised: Splinting is correct, but the correct pulley is the A1, not A2.

Question 38

Which of the below muscles is most commonly involved in lateral epicondylalgia?

Answers:
A. Extensor Carpi Radialis Longus
B. Extensor Carpi Radialis Brevis
C. Extensor Carpi Ulnaris
D. Supinator

Answer 38

B. Extensor Carpi Radialis Brevis

Correct Answer: B. Extensor Carpi Radialis Brevis

Explanation: The extensor carpi radialis brevis is most commonly implicated in lateral epicondylalgia, often referred to as tennis elbow.

Incorrect Options:

A. Extensor Carpi Radialis Longus: Involved but less commonly than ECRB.
C. Extensor Carpi Ulnaris: Typically associated with other wrist conditions.
D. Supinator: Involved in forearm supination, not directly in lateral epicondylalgia.

Question 39

Which of the following best describes a Galeazzi Fracture?

Answers:
A. Fracture of the mid ulna and radius
B. Fracture of the distal 1/3 of the radius and distal ulna dislocation
C. Fracture of the distal ulna and dislocation of the distal radius
D. Fracture proximal 1/3 of the ulna and dislocation of the radial head

Answer 39

B. Fracture of the distal 1/3 of the radius and distal ulna dislocation

Correct Answer: B. Fracture of the distal 1/3 of the radius and distal ulna dislocation

Explanation: A Galeazzi fracture involves a fracture of the distal third of the radius with dislocation of the distal radioulnar joint.

Incorrect Options:

A. Fracture of the mid ulna and radius: This describes a different fracture pattern.
C. Fracture of the distal ulna and dislocation of the distal radius: Incorrect pattern for Galeazzi.
D. Fracture proximal 1/3 of the ulna and dislocation of the radial head: This describes a Monteggia fracture.

Question 40

You have decided to perform a joint mobilization to restore supination ROM at the proximal radio-ulnar joint. In which direction would you mobilize the radius?

Answers:
A. Anterior (ventral)
B. Posterior (dorsal)
C. Medial (ulnar)
D. Lateral (radial)

Answer 40

A. Anterior (ventral)

Correct Answer: A. Anterior (ventral)

Explanation: To increase supination at the proximal radio-ulnar joint, an anterior (ventral) mobilization of the radius is typically performed.

Incorrect Options:

B. Posterior (dorsal): Used for improving pronation, not supination.
C. Medial (ulnar): Not relevant for supination/pronation mobilization.
D. Lateral (radial): Not relevant for supination/pronation mobilization.

Question 41

You are evaluating a patient with complaints of a slow, gradual onset of clawing of the right hand’s digits 4 and 5. They deny numbness, tingling, or pain. The 4th and 5th digits are developing contractures, and there are palpable fibrous bands in the palm of the hand along the flexor tendons. Which of the below best describes this condition?

Answers:
A. Berger’s Disease
B. Ulnar Nerve Injury at the Elbow
C. Keinbock’s Disease
D. Dupuytren’s Contracture

Answer 41

D. Dupuytren’s Contracture

Correct Answer: D. Dupuytren’s Contracture

Explanation: Dupuytren’s contracture involves thickening of the palmar fascia, leading to flexion contractures, primarily in the 4th and 5th digits.

Incorrect Options:

A. Berger’s Disease: A vascular disease, not related to hand contractures.
B. Ulnar Nerve Injury at the Elbow: Could cause clawing but with accompanying sensory loss, not described here.
C. Keinbock’s Disease: Avascular necrosis of the lunate, not involving clawing.

Question 42

Which of the following is a differential diagnosis for medial epicondylitis?

Answers:
A. Ulnar neuropathy at the elbow
B. Nursemaid’s elbow
C. Supinator syndrome
D. Radial nerve subluxation

Answer 42

A. Ulnar neuropathy at the elbow

Correct Answer: A. Ulnar neuropathy at the elbow

Explanation: Ulnar neuropathy can mimic medial epicondylitis, with pain and tenderness near the medial epicondyle.

Incorrect Options:

B. Nursemaid’s elbow: A pediatric condition with a different presentation.
C. Supinator syndrome: Affects the posterior interosseous nerve, leading to lateral elbow pain.
D. Radial nerve subluxation: Would cause lateral elbow pain, not medial.

Question 43

Given the position of the hand and muscle atrophy shown in the photo, which nerve would you suspect is injured at the wrist?

Answers:
A. Median
B. Ulnar
C. Radial
D. Median and Ulnar

Answer 43

B. Ulnar

Correct Answer: B. Ulnar

Explanation: Ulnar nerve injury at the wrist can lead to atrophy of the intrinsic muscles of the hand, particularly in the hypothenar eminence and interosseous muscles.

Incorrect Options:

A. Median: Affects the thenar eminence, not hypothenar or intrinsic hand muscles.
C. Radial: Affects wrist and finger extensors, not intrinsic hand muscles.
D. Median and Ulnar: Would cause broader dysfunction than described.

Question 44

You are utilizing static two-point discrimination threshold sensation testing on a patient with suspected Carpal Tunnel Syndrome. What is the normal static two-point discrimination threshold for the fingers and hand?

Answers:
A. <20mm
B. <10mm
C. <6mm
D. <2mm

Answer 44

C. <6mm

Correct Answer: C. <6mm

Explanation: A normal two-point discrimination threshold for the fingers is typically less than 6mm.

Incorrect Options:

A. <20mm: Indicates significant sensory loss.
B. <10mm: Above the normal threshold.
D. <2mm: Unrealistically small for normal discrimination.

Question 45

This radiograph depicts what type of fracture?

Answers:
A. Monteggia
B. Barton
C. Galeazzi
D. Smith

Answer 45

A. Monteggia

Correct Answer: A. Monteggia

Explanation: A Monteggia fracture involves a fracture of the proximal ulna with dislocation of the radial head.

Incorrect Options:

B. Barton: Involves the distal radius with dislocation.
C. Galeazzi: Involves the distal radius with dislocation of the distal ulna.
D. Smith: A distal radius fracture with volar displacement.

Question 46

Which of the following statements is true regarding TFCC injuries?

Answers:
A. Require immediate surgical repair
B. Supinated position should be avoided when treating conservatively
C. Have minimal healing potential if the central articular disc is disrupted
D. Are often a result of negative ulnar variance

Answer 46

D. Are often a result of negative ulnar variance

Question 47

A patient reported fracturing their wrist. Ten weeks following the fracture, they are no better. In fact, they are worsening. Their entire hand is swollen, painful, tender to the touch; they can’t make a full fist. Their skin looks shiny and hairless compared to the opposite hand. They have normal radial and ulnar pulses. Which of the below best describes this condition?

Answers:
A. Carpal Tunnel Syndrome
B. Complex Regional Pain Syndrome
C. Compartment Syndrome
D. Conversion Reaction

Answer 47

B. Complex Regional Pain Syndrome

orrect Answer: D. Are often a result of negative ulnar variance

Explanation: TFCC injuries are more common in individuals with negative ulnar variance, where the ulna is shorter than the radius, leading to increased load on the TFCC.

Incorrect Options:

A. Require immediate surgical repair: Not all TFCC injuries require surgery.
B. Supinated position should be avoided when treating conservatively: Supination is typically safe unless contraindicated.
C. Have minimal healing potential if the central articular disc is disrupted: While the central disc has poor healing potential, conservative management is often first-line.

Question 48

You have decided to perform a joint mobilization to restore pronation ROM at the distal radio-ulnar joint. In which direction would you mobilize the distal radius?

Answers:
A. Anterior (ventral)
B. Posterior (dorsal)
C. Lateral (radial)
D. Medial (ulnar)

Answer 48

B. Posterior (dorsal)

Correct Answer: B. Posterior (dorsal)

Explanation: To improve pronation, a posterior (dorsal) glide of the distal radius on the ulna is performed.

Incorrect Options:

A. Anterior (ventral): Used for supination, not pronation.
C. Lateral (radial): Not relevant for pronation.
D. Medial (ulnar): Not relevant for pronation.

Question 49

Upon observation of a patient during an initial examination, you note the following deformity of the arm. What is your impression?

Answers:
A. Proximal biceps rupture
B. Distal biceps rupture
C. Proximal brachialis rupture
D. Distal brachialis rupture

Answer 49

A. Proximal biceps rupture

Correct Answer: A. Proximal biceps rupture

Explanation: A proximal biceps rupture leads to a characteristic bulge in the upper arm, often described as a “Popeye” deformity.

Incorrect Options:

B. Distal biceps rupture: Would present with different deformity and functional deficits.
C. Proximal brachialis rupture: Rare and doesn’t typically cause the described deformity.
D. Distal brachialis rupture: Also rare and not associated with the “Popeye” deformity.