Upper/Lower Limb Practice Questions

Q: A 33-year-old woman presents to the emergency department with pain in her right wrist. She says she was walking on the sidewalk a few hours ago when she suddenly slipped and landed forcefully on her outstretched right hand with her palm facing down. The patient is afebrile, and vital signs are within normal limits. Physical examination of her right wrist shows mild edema and tenderness on the lateral side of the right hand with a decreased range of motion. Sensation is intact. The patient is able to make a fist and OK sign with her right hand. A plain radiograph of her right wrist is shown in the image. Which of the following bones is most likely fractured in this patient?

Bone labeled 'D'. ***Bone labeled 'D'*** - The clinical presentation of a fall on an **outstretched hand (FOOSH)** with pain on the **lateral aspect** of the wrist suggests a **scaphoid fracture**. - Bone 'D' is the **scaphoid bone**, which is commonly fractured in this mechanism due to its position and poor blood supply, making it prone to **avascular necrosis** if untreated. *Bone labeled 'A'* - Bone 'A' is the **ulna**, which is less commonly fractured due to FOOSH injuries unless there is a direct impact or significant rotational force. - While it articulates with the wrist, a fracture of the ulna would typically present with pain more medially and potentially forearm instability. *Bone labeled 'C'* - Bone 'C' is the first **metacarpal**, part of the thumb, which is distal to the wrist joint. - A fracture here would cause pain more specifically localised to the thumb base rather than the general wrist area as described. *Bone labeled 'E'* - Bone 'E' is the **hamate bone**, located in the distal carpal row. - Fractures of the hamate are less common than scaphoid fractures via FOOSH and are often associated with direct impact (e.g., from a golf club) or forceful gripping. *Bone labeled 'B'* - Bone 'B' represents the **radius**, specifically its distal portion. While a **Colles fracture** of the distal radius is common with FOOSH, the tenderness being on the "lateral side of the right hand" specifically points away from a general distal radius fracture and more towards the carpal bones, particularly the scaphoid. - A Colles fracture often results in a **"dinner fork" deformity**, which is not mentioned in the presentation, and tenderness would be more widespread over the distal forearm.

Q: A 41-year-old woman comes to the doctor because of gradually progressive weakness in her right hand over the past few weeks. She goes to the gym to lift weights 5 times a week. With the dorsum of the right hand on a flat surface, the patient is unable to move her thumb to touch a pen held 2 cm above the interphalangeal joint of the thumb. An MRI of the right arm shows compression of a nerve that passes through the pronator teres muscle. Based on the examination findings, loss of innervation of which of the following muscles is most likely in this patient?

Abductor pollicis brevis. ***Abductor pollicis brevis*** - The patient's inability to move her thumb to touch a pen 2 cm above the interphalangeal joint, while the dorsum of the hand is flat, indicates a deficit in **thumb abduction**. The **abductor pollicis brevis** is the primary muscle responsible for this action and is innervated by the **median nerve**. - Compression of the **median nerve** at the **pronator teres** is consistent with an injury affecting the innervation of the abductor pollicis brevis, leading to the observed weakness. *Opponens pollicis* - The **opponens pollicis** is also innervated by the **median nerve** and is responsible for **thumb opposition** (bringing the thumb across the palm to touch other fingertips). - While opposition might be impaired in median nerve compression, the specific test described (lifting the thumb off a flat surface) directly assesses abduction, not opposition. *First dorsal interosseus* - The **first dorsal interosseus** muscle is responsible for **finger abduction**, specifically abducting the index finger away from the middle finger. It is innervated by the **ulnar nerve**. - The patient's symptoms are focused on the thumb and the median nerve distribution, making ulnar nerve involvement less likely. *Flexor pollicis longus* - The **flexor pollicis longus** muscle is responsible for **flexion of the interphalangeal joint of the thumb**. It is innervated by the **anterior interosseous nerve**, a branch of the median nerve. - While median nerve compression can affect this muscle, the described test specifically targets thumb abduction, not interphalangeal joint flexion. *Adductor pollicis* - The **adductor pollicis** muscle is responsible for **thumb adduction** (bringing the thumb towards the palm). It is innervated by the **ulnar nerve**. - The patient's symptom is one of weakness in lifting the thumb (abduction), not adduction, and points away from ulnar nerve pathology.

Q: A 26-year-old woman comes to the physician because of painful paresthesias in her foot. Examination shows decreased sensation in the first interdigital space and a hallux valgus deformity. This patient's paresthesias are most likely caused by compression of which of the following nerves?

Deep peroneal nerve. ***Deep peroneal nerve*** - The **deep peroneal nerve** provides sensation to the **first interdigital space** of the foot, and its compression would explain the described paresthesias. - A **hallux valgus deformity** can alter foot mechanics and contribute to compression of this nerve. *Saphenous nerve* - The **saphenous nerve** provides sensory innervation to the **medial aspect of the lower leg and foot**, not specifically the interdigital spaces. - Its compression is typically associated with pain or paresthesias in the medial calf or ankle. *Sural nerve* - The **sural nerve** provides sensation to the **lateral aspect of the foot and ankle**. - Compression of this nerve would cause symptoms in a different distribution than described. *Superficial peroneal nerve* - The **superficial peroneal nerve** innervates the **dorsum of the foot**, excluding the first interdigital space and the area between the first and second toes. - Compression would typically result in sensory changes over the top of the foot. *Medial plantar nerve* - The **medial plantar nerve** provides sensation to the **medial two-thirds of the plantar foot** and the **first 3.5 toes** on the plantar surface, not the dorsal interdigital space. - Compression is often associated with symptoms similar to tarsal tunnel syndrome.

Q: A 23-year-old college student was playing basketball when he fell directly onto his left elbow. He had sudden, intense pain and was unable to move his elbow. He was taken immediately to the emergency room by his teammates. He has no prior history of trauma or any chronic medical conditions. His blood pressure is 128/84 mm Hg, the heart rate is 92/min, and the respiratory rate is 14/min. He is in moderate distress and is holding onto his left elbow. On physical examination, pinprick sensation is absent in the left 5th digit and the medial aspect of the left 4th digit. Which of the following is the most likely etiology of this patient’s condition?

Ulnar neuropathy. ***Ulnar neuropathy*** - Direct trauma to the elbow, combined with **pinprick sensation loss** in the **5th digit** and the **medial aspect of the 4th digit**, is highly indicative of **ulnar nerve injury**. - The ulnar nerve passes through the **cubital tunnel** at the elbow, making it vulnerable to compression or trauma from direct falls. *Axillary neuropathy* - An **axillary nerve injury** typically presents with weakness in **shoulder abduction** (deltoid muscle) and sensory loss over the **lateral aspect of the shoulder**. - This clinical picture does not match the patient's sensory deficits in the fingers. *Median neuropathy* - **Median nerve injury** at the elbow would typically cause sensory loss in the **first three fingers and the lateral half of the fourth finger**, along with **weakness in thumb opposition** and **flexion of the index and middle fingers**. - The sensory loss described in the patient does not align with median nerve distribution. *Radial neuropathy* - **Radial nerve injury** at the elbow level would primarily result in **wrist drop** and sensory loss over the **dorsal aspect of the hand**, particularly the **first three and a half digits**. - These are not the clinical findings presented by the patient. *Musculocutaneous neuropathy* - **Musculocutaneous nerve injury** would cause weakness in **elbow flexion** (biceps and brachialis muscles) and sensory loss over the **lateral forearm**. - The patient's reported sensory loss is in a different distribution and no specific motor deficits of elbow flexion are mentioned.

Q: A newborn infant is born at 42 weeks gestation to a healthy 36-year-old G1P0. The delivery was complicated by prolonged labor and shoulder dystocia. The child is in the 87th and 91st percentiles for height and weight at birth, respectively. The mother’s past medical history is notable for diabetes mellitus and obesity. Immediately after birth, the child’s temperature is 99°F (37.2°C), blood pressure is 90/50 mmHg, pulse is 120/min, and respirations are 24/min. The child demonstrates a strong cry and pink upper and lower extremities bilaterally. The right arm is adducted and internally rotated at the shoulder and extended at the elbow. Flexion and extension of the wrist and digits appear to be intact in the right upper extremity. Which of the following muscles would most likely have normal strength in this patient?

Triceps. ***Triceps*** - This clinical presentation is consistent with an **Erb-Duchenne palsy (Erb's palsy)**, which typically involves injury to the **upper brachial plexus roots (C5-C6)**. - The **triceps muscle**, innervated primarily by the **radial nerve (C6-C8)**, often maintains normal strength in Erb's palsy because its C7 and C8 innervation is usually spared. *Brachialis* - The **brachialis muscle**, a primary elbow flexor, is innervated by the **musculocutaneous nerve (C5-C6)**, making it highly susceptible to injury in Erb's palsy. - Weakness or paralysis of the brachialis contributes to the characteristic **extended elbow** posture. *Teres minor* - The **teres minor muscle**, responsible for external rotation and stabilization of the shoulder, is innervated by the **axillary nerve (C5-C6)**. - Damage to these roots in Erb's palsy would likely impair teres minor function, contributing to the **internal rotation** of the shoulder seen in the presentation. *Brachioradialis* - The **brachioradialis muscle** is another elbow flexor, innervated by the **radial nerve (C5-C6)**, and therefore would likely be affected in Erb's palsy. - Its involvement would contribute to weakness in elbow flexion, especially with the forearm in a neutral position. *Biceps* - The **biceps muscle**, another key elbow flexor and supinator, is innervated by the **musculocutaneous nerve (C5-C6)**. - Injury to these roots would directly impair biceps function, leading to significant weakness in elbow flexion and contributing to the **adducted and internally rotated shoulder** with an extended elbow presentation.

Q: A 31-year-old woman presents with difficulty walking and climbing stairs for the last 3 weeks. She has no history of trauma. The physical examination reveals a waddling gait with the trunk swaying from side-to-side towards the weight-bearing limb. When she stands on her right leg, the pelvis on the left side falls. When she stands on her left leg, the pelvis remains level. Which of the following nerves is most likely injured in this patient?

Right superior gluteal nerve. ***Right superior gluteal nerve*** - The presentation of a **waddling gait** and the **Trendelenburg sign** (pelvis dropping on the unsupported side) is characteristic of **gluteus medius** and **minimus** weakness. - These muscles are innervated by the **superior gluteal nerve**. In this case, when the patient stands on her right leg, the left pelvis falls, indicating weakness of the right gluteus medius/minimus. *Right inferior gluteal nerve* - The **inferior gluteal nerve** innervates the **gluteus maximus**, which is primarily responsible for hip extension. - Damage to this nerve would primarily lead to difficulty with **climbing stairs** and rising from a seated position, but not typically the specific pelvic drop described. *Right obturator nerve* - The **obturator nerve** innervates the **adductor muscles** of the thigh. - Damage would result in weakness of hip adduction and **medial thigh sensory deficits**, which are not the primary symptoms here. *Right femoral nerve* - The **femoral nerve** innervates the **quadriceps femoris** and the **sartorius**, responsible for knee extension and hip flexion. - Injury would cause difficulty with **knee extension** and **hip flexion**, potentially leading to knee buckling or instability, which is not consistent with the Trendelenburg sign observed. *Left femoral nerve* - Injury to the left femoral nerve would affect the **left quadriceps** and **sartorius** muscles. - This would cause weakness in extending the left knee and flexing the left hip, which is not consistent with the observed **right-sided gluteal weakness** indicated by the Trendelenburg sign on the right.

Q: A 65-year-old man comes to a follow-up appointment with his surgeon 2 months after undergoing hip replacement surgery. His major concern at this visit is that he is still limping since the surgery even after the post-operative pain has subsided. Specifically, when he stands on his right leg, he feels that he has to lean further to the right in order to maintain balance. When standing on his left leg, he feels that he is able to step normally. Damage to which of the following nerves would most likely present with this patient's symptoms?

Superior gluteal nerve. ***Superior gluteal nerve*** - The superior gluteal nerve innervates the **gluteus medius** and minimus muscles, which are crucial for **hip abduction** and stabilizing the pelvis during gait. - Damage to this nerve or its muscles on one side (e.g., right side) would lead to a **Trendelenburg gait**, where the pelvis drops on the unaffected side when standing on the affected leg, and the patient compensates by leaning towards the affected side. *Common peroneal nerve* - The common peroneal nerve primarily innervates muscles responsible for **dorsiflexion** and **eversion of the foot**. - Damage to this nerve commonly results in **foot drop** and an inability to evert the foot, which is not the primary symptom described. *Tibial nerve* - The tibial nerve innervates muscles responsible for **plantarflexion** and **inversion of the foot**, as well as the intrinsic muscles of the sole. - Injury typically presents with difficulty walking on tiptoes, toe curling, and sensory loss in the sole of the foot, not pelvic instability. *Femoral nerve* - The femoral nerve innervates the **quadriceps femoris** and sartorius muscles, - Damage leads to weakness in **knee extension** and loss of sensation over the anterior thigh and medial leg. *Inferior gluteal nerve* - The inferior gluteal nerve innervates the **gluteus maximus** muscle, which is essential for **hip extension** and external rotation. - Damage would primarily affect activities like climbing stairs or standing up from a seated position, rather than the specific lateral pelvic instability described.

Q: A 38-year-old man comes to the physician because of a 3-week history of right-sided knee pain. He works as a bricklayer and reports that the pain worsens when he kneels. He has no history of trauma. Examination of the right knee shows erythema, fluctuant swelling, and tenderness on palpation of the kneecap. Passive flexion of the right knee elicits pain. Which of the following structures is most likely affected in this patient?

Prepatellar bursa. ***Prepatellar bursa*** - The patient's profession as a **bricklayer** and the associated pain when **kneeling** strongly suggest inflammation of the prepatellar bursa, often called "housemaid's knee." - **Erythema**, **fluctuant swelling**, and **tenderness** directly over the kneecap (patella) are classic signs of prepatellar bursitis. *Synovial membrane* - Inflammation of the synovial membrane (**synovitis**) typically presents with more diffuse joint swelling, stiffness, and pain with active and passive range of motion. - While it can cause pain, the localized, fluctuant swelling directly over the kneecap is less characteristic of primary synovitis. *Medial meniscus* - A **meniscal injury** would typically cause localized pain along the joint line, clicking or locking sensations, and pain with specific twisting or squatting movements. - It would not typically present with the described erythema and fluctuant swelling directly over the patella. *Anserine bursa* - The anserine bursa is located on the **medial side of the knee**, about 2-3 inches below the joint line, where the sartorius, gracilis, and semitendinosus tendons insert. - Inflammation here would cause pain and tenderness along the medial aspect of the knee rather than directly over the kneecap. *Suprapatellar bursa* - The suprapatellar bursa is located **above the patella**, deep to the quadriceps tendon. - While it can swell, its inflammation is usually associated with intra-articular conditions or direct trauma to the quadriceps tendon area, and not typically from occupational kneeling that directly irritates the patella itself.

Question 1

A 33-year-old woman presents to the emergency department with pain in her right wrist. She says she was walking on the sidewalk a few hours ago when she suddenly slipped and landed forcefully on her outstretched right hand with her palm facing down. The patient is afebrile, and vital signs are within normal limits. Physical examination of her right wrist shows mild edema and tenderness on the lateral side of the right hand with a decreased range of motion. Sensation is intact. The patient is able to make a fist and OK sign with her right hand. A plain radiograph of her right wrist is shown in the image. Which of the following bones is most likely fractured in this patient?

Accepted Answer

Bone labeled 'D'

Answer

Bone labeled 'A'

Answer

Bone labeled 'C'

Answer

Bone labeled 'E'

Answer

Bone labeled 'B'

Question 2

A 41-year-old woman comes to the doctor because of gradually progressive weakness in her right hand over the past few weeks. She goes to the gym to lift weights 5 times a week. With the dorsum of the right hand on a flat surface, the patient is unable to move her thumb to touch a pen held 2 cm above the interphalangeal joint of the thumb. An MRI of the right arm shows compression of a nerve that passes through the pronator teres muscle. Based on the examination findings, loss of innervation of which of the following muscles is most likely in this patient?

Accepted Answer

Abductor pollicis brevis

Answer

Opponens pollicis

Answer

First dorsal interosseus

Answer

Flexor pollicis longus

Answer

Adductor pollicis

Question 3

A 26-year-old woman comes to the physician because of painful paresthesias in her foot. Examination shows decreased sensation in the first interdigital space and a hallux valgus deformity. This patient's paresthesias are most likely caused by compression of which of the following nerves?

Accepted Answer

Deep peroneal nerve

Answer

Saphenous nerve

Answer

Sural nerve

Answer

Superficial peroneal nerve

Answer

Medial plantar nerve

Question 4

A newborn infant is born at 41 weeks gestation to a healthy G1P0 mother. The delivery was complicated by shoulder dystocia. The infant is in the 89th and 92nd percentiles for height and weight, respectively. The mother's past medical history is notable for diabetes mellitus and obesity. Immediately after birth, the child's temperature is 99°F (37.2°C), blood pressure is 90/50 mmHg, pulse is 120/min, and respirations are 24/min. The child demonstrates a strong cry and pink upper and lower extremities bilaterally. The left arm is adducted and internally rotated at the shoulder and extended at the elbow. Extension at the elbow and flexion and extension of the wrist appear to be intact in the left upper extremity. The right upper extremity appears to have normal strength and range of motion in all planes. Which of the following sets of nerves or nerve roots is most likely affected in this patient?

Accepted Answer

C5 and C6 nerve roots

Answer

Axillary nerve only

Answer

Suprascapular nerve only

Answer

C5, C6, and C7 nerve roots

Answer

Musculocutaneous nerve only

Question 5

A 23-year-old college student was playing basketball when he fell directly onto his left elbow. He had sudden, intense pain and was unable to move his elbow. He was taken immediately to the emergency room by his teammates. He has no prior history of trauma or any chronic medical conditions. His blood pressure is 128/84 mm Hg, the heart rate is 92/min, and the respiratory rate is 14/min. He is in moderate distress and is holding onto his left elbow. On physical examination, pinprick sensation is absent in the left 5th digit and the medial aspect of the left 4th digit. Which of the following is the most likely etiology of this patient’s condition?

Accepted Answer

Ulnar neuropathy

Answer

Axillary neuropathy

Answer

Median neuropathy

Answer

Radial neuropathy

Answer

Musculocutaneous neuropathy

Question 6

A newborn infant is born at 42 weeks gestation to a healthy 36-year-old G1P0. The delivery was complicated by prolonged labor and shoulder dystocia. The child is in the 87th and 91st percentiles for height and weight at birth, respectively. The mother’s past medical history is notable for diabetes mellitus and obesity. Immediately after birth, the child’s temperature is 99°F (37.2°C), blood pressure is 90/50 mmHg, pulse is 120/min, and respirations are 24/min. The child demonstrates a strong cry and pink upper and lower extremities bilaterally. The right arm is adducted and internally rotated at the shoulder and extended at the elbow. Flexion and extension of the wrist and digits appear to be intact in the right upper extremity. Which of the following muscles would most likely have normal strength in this patient?

Accepted Answer

Triceps

Answer

Brachialis

Answer

Teres minor

Answer

Brachioradialis

Answer

Biceps

Question 7

A 31-year-old woman presents with difficulty walking and climbing stairs for the last 3 weeks. She has no history of trauma. The physical examination reveals a waddling gait with the trunk swaying from side-to-side towards the weight-bearing limb. When she stands on her right leg, the pelvis on the left side falls. When she stands on her left leg, the pelvis remains level. Which of the following nerves is most likely injured in this patient?

Accepted Answer

Right superior gluteal nerve

Answer

Right inferior gluteal nerve

Answer

Right obturator nerve

Answer

Right femoral nerve

Answer

Left femoral nerve

Question 8

A 65-year-old man comes to a follow-up appointment with his surgeon 2 months after undergoing hip replacement surgery. His major concern at this visit is that he is still limping since the surgery even after the post-operative pain has subsided. Specifically, when he stands on his right leg, he feels that he has to lean further to the right in order to maintain balance. When standing on his left leg, he feels that he is able to step normally. Damage to which of the following nerves would most likely present with this patient's symptoms?

Accepted Answer

Superior gluteal nerve

Answer

Common peroneal nerve

Answer

Tibial nerve

Answer

Femoral nerve

Answer

Inferior gluteal nerve

Question 9

A 38-year-old man comes to the physician because of a 3-week history of right-sided knee pain. He works as a bricklayer and reports that the pain worsens when he kneels. He has no history of trauma. Examination of the right knee shows erythema, fluctuant swelling, and tenderness on palpation of the kneecap. Passive flexion of the right knee elicits pain. Which of the following structures is most likely affected in this patient?

Accepted Answer

Prepatellar bursa

Answer

Synovial membrane

Answer

Medial meniscus

Answer

Anserine bursa

Answer

Suprapatellar bursa

Question 10

A 12-year-old boy is brought to the physician because of a 6-day history of gradually worsening left knee pain. The pain is exacerbated by movement and kneeling. There is no pain at rest and no history of trauma to the knee. He is concerned because his soccer tryouts are in a few days. Vital signs are within normal limits. Examination shows mild swelling and tenderness to palpation of the left anterior, superior tibia. Extension of the left knee against resistance reproduces the knee pain; flexion is limited by pain. There is no local erythema or effusion of the left knee. A lateral view of an x-ray of his left knee is shown. Which of the following is the most likely underlying cause of this patient's symptoms?

Accepted Answer

Traction apophysitis of the tibial tubercle

Answer

Inflammation of the infrapatellar bursa

Answer

Chondromalacia patella

Answer

Impingement of the infrapatellar fat pad

Answer

Osteochondritis dissecans of the knee

Upper/Lower Limb — MCQs

Upper/Lower Limb — MCQs

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