Upper Limb Orthoses — MCQs

10 questions

What is the primary use of a knuckle bender splint?

After a brawl, a young male presented with inability to extend his distal interphalangeal joint. An X-ray was taken and was shown to be normal. What should be the next step in managing the patient?

Following a femoral shaft fracture, your consultant asks you to provide tibia traction. Which of the following will you request from the nurse? 1. Thomas splint 2. K-wire 3. Steinmann pin 4. Denham's pin 5. Bohler's stirrup 6. Bohler Braun splint

Which block is described as regional anesthesia of the arm:-

A 40-year old male after binge drinking slept on a chair. On the next day, he presented with weakness of the right arm and was not able to move his hand. Examination showed radial nerve palsy. What would be the management?

Lauge - Hansen classification belongs to:-

Ulnar nerve injury results in:

What is the MOST characteristic feature of low ulnar nerve palsy? a) Claw hand b) Sensory loss of medial four digits c) Weakness of grip d) Inability to abduct the thumb

Pronator drift is a sign of -

Q10

Differential cyanosis is seen in –

Upper Limb Orthoses Indian Medical PG Practice Questions and MCQs

Question 1: What is the primary use of a knuckle bender splint?

A. Ulnar nerve palsy (Correct Answer)
B. Radial nerve palsy
C. Median nerve palsy
D. Axillary nerve palsy

Explanation: ***Ulnar nerve palsy*** - A knuckle bender splint is primarily used to counteract the characteristic **claw hand deformity** seen in ulnar nerve palsy [1] by maintaining the **metacarpophalangeal (MCP) joints** in flexion. - This splint helps improve function by preventing hyperextension of the MCP joints, which commonly occurs due to the unopposed action of the extensor muscles when the ulnar nerve is compromised. *Radial nerve palsy* - Radial nerve palsy typically results in **wrist drop** and an inability to extend the wrist and fingers, which is managed with wrist extension splints, not knuckle benders. - The primary goal of splinting in radial nerve palsy is to support the wrist in extension to facilitate grasping and carrying objects. *Median nerve palsy* - Median nerve palsy causes problems with thumb opposition and sensation in the first three and a half digits, often leading to an **ape hand deformity**. - Splints for median nerve palsy focus on maintaining the thumb in opposition, such as a **thumb spica splint**, which differs from a knuckle bender. *Axillary nerve palsy* - Axillary nerve palsy primarily affects the **deltoid muscle**, leading to weakness in shoulder abduction and external rotation. - Splinting for axillary nerve palsy typically involves shoulder immobilizers or abduction splints, which address shoulder joint positioning rather than hand function.

Question 2: After a brawl, a young male presented with inability to extend his distal interphalangeal joint. An X-ray was taken and was shown to be normal. What should be the next step in managing the patient?

A. Splint (Correct Answer)
B. Wax bath
C. Ignore
D. Surgery

Explanation: ***Splint*** - The patient presents with **inability to extend the distal interphalangeal joint** after an injury, with a **normal X-ray**. This clinical picture is highly suggestive of a **mallet finger**. - **Splinting** the distal interphalangeal joint in **extension** for 6-8 weeks is the primary non-surgical treatment for mallet finger, aiming to allow the ruptured extensor tendon to heal. *Wax bath* - A **wax bath** is a form of thermotherapy used to relieve pain and stiffness in joints by applying heat. - While it can be helpful for chronic conditions like **arthritis**, it is not an appropriate initial treatment for an acute **tendon injury** like mallet finger, as it does not promote healing of the extensor mechanism. *Ignore* - **Ignoring** the symptoms would lead to a failure to treat the injury, potentially resulting in a **chronic extensor lag deformity** (mallet finger deformity). - Untreated, this condition can cause persistent functional impairment and cosmetic deformity of the affected finger. *Surgery* - **Surgery** is typically reserved for specific cases of mallet finger, such as those with a **large avulsion fracture** of the dorsal base of the distal phalanx (where the fragment involves more than 30-50% of the articular surface), or if non-surgical treatment fails. - Since the **X-ray was normal** in this case, indicating no significant bony avulsion, and it's an acute presentation, surgery is not the appropriate first-line management.

Question 3: Following a femoral shaft fracture, your consultant asks you to provide tibia traction. Which of the following will you request from the nurse? 1. Thomas splint 2. K-wire 3. Steinmann pin 4. Denham's pin 5. Bohler's stirrup 6. Bohler Braun splint

A. $1,2,3,4,5,6$
B. $3,5,6$ (Correct Answer)
C. $3,4,5$
D. $1,2,4$

Explanation: ***3,5,6*** - For **tibia traction** in a femoral shaft fracture, you would need a **Steinmann pin** for skeletal traction, a **Bohler's stirrup** to apply the traction force, and a **Bohler-Braun splint** to support the limb. - The **Steinmann pin** is inserted into the proximal tibia, the **Bohler's stirrup** attaches to the pin, and the **Bohler-Braun splint** provides a fixed structure for the traction system. *1,2,3,4,5,6* - This option incorrectly includes items not specifically used for applying **tibia traction** (e.g., K-wire is for internal fixation, Thomas splint is for early femur fracture management but not specifically for tibia traction application). - While some components might be used in general fracture management, not all are directly involved in setting up tibia traction as requested. *3,4,5* - This option correctly includes the **Steinmann pin** and **Bohler's stirrup** but incorrectly replaces the **Bohler-Braun splint** with a **Denham's pin**. - A **Denham's pin** is an alternative to a Steinmann pin for skeletal traction, but a **Bohler-Braun splint** is crucial for supporting the limb in this setup, which is missing here. *1,2,4* - This option includes a **Thomas splint** (used for femur fracture support, not tibia traction application), a **K-wire** (used for internal fixation, not traction), and a **Denham's pin** (an alternative to Steinmann pin, but lacks the necessary support and traction application equipment). - These items are not suitable for setting up comprehensive **tibia traction** for a femoral shaft fracture.

Question 4: Which block is described as regional anesthesia of the arm:-

A. Interscalene block
B. Infraclavicular block
C. Axillary block
D. Supraclavicular brachial plexus block (Correct Answer)

Explanation: ***Supraclavicular brachial plexus block*** - The **supraclavicular block** targets the **trunks of the brachial plexus** as they exit the scalene muscles, providing comprehensive anesthesia to the entire upper limb, including the shoulder, arm, forearm, and hand. - This block is particularly effective for procedures involving the arm due to its proximal location within the brachial plexus, covering multiple nerve distributions. *Interscalene block* - An **interscalene block** primarily targets the **roots or trunks of the brachial plexus** and is typically used for shoulder and upper arm surgery, but may spare the ulnar nerve. - While it anesthetizes the arm, it is primarily chosen for more proximal procedures and may not provide complete distal arm anesthesia compared to the supraclavicular approach. *Infraclavicular block* - An **infraclavicular block** targets the **cords of the brachial plexus** and is suitable for procedures involving the elbow, forearm, and hand, providing good coverage for these areas. - While it does anesthetize the distal arm, it is more distal than the supraclavicular block and may not provide full coverage for the entire upper arm and shoulder. *Axillary block* - An **axillary block** targets the **terminal branches of the brachial plexus** in the axilla, mainly anesthetizing the forearm and hand. - This block is often used for procedures distal to the elbow and provides less comprehensive coverage for the entire upper arm and shoulder compared to more proximal blocks.

Question 5: A 40-year old male after binge drinking slept on a chair. On the next day, he presented with weakness of the right arm and was not able to move his hand. Examination showed radial nerve palsy. What would be the management?

A. Neurolysis
B. Instant exploration
C. Electromyography after 2 days and decide after results
D. Give a knuckle bender splint (Correct Answer)

Explanation: ***Give a knuckle bender splint*** - This patient presents with features of **Saturday Night Palsy** (radial nerve compression from prolonged pressure), which is typically a **neurapraxia**. - Management for neurapraxia usually involves **conservative measures** like splinting to support the wrist and fingers, protecting the nerve, and allowing for spontaneous recovery, which typically occurs within weeks to months. *Neurolysis* - **Neurolysis** (surgical freeing of a nerve from scar tissue) is an invasive procedure generally reserved for cases of **nerve entrapment** or persistent compression that have failed conservative therapy or show signs of ongoing nerve damage. - Given the acute presentation and typical course of Saturday Night Palsy, it is too premature and often unnecessary for this type of injury, where spontaneous recovery is common. *Instant exploration* - **Instant surgical exploration** of the nerve is usually only indicated in cases of **acute, severe trauma** where nerve transection or severe crush injury is suspected, or when there are clear signs of progressive nerve dysfunction. - In Saturday Night Palsy, the injury is typically a **mild compression (neurapraxia)**, making immediate surgery unwarranted and potentially more harmful than beneficial. *Electromyography after 2 days and decide after results* - **Electromyography (EMG)** and **nerve conduction studies (NCS)** are valuable diagnostic tools but have limitations in the very acute phase of a nerve injury. - **EMG changes (denervation potentials)** typically take 2-3 weeks to develop after an injury, so performing it after only two days would likely yield normal results and not provide useful information for immediate management.

Question 6: Lauge - Hansen classification belongs to:-

A. Ankle fracture (Correct Answer)
B. Femur fracture
C. Shoulder fracture
D. Elbow fracture

Explanation: ***Ankle fracture*** - The **Lauge-Hansen classification system** is specifically used to categorize **ankle fractures** based on the position of the foot at the time of injury and the deforming force. - This system describes the mechanism of injury (e.g., supination-adduction, pronation-abduction) and the resulting fracture patterns of the **distal fibula, medial malleolus, and posterior malleolus**. *Femur fracture* - **Femur fractures** are typically classified by other systems, such as the **AO/OTA classification** for long bone fractures or specific patterns like **intertrochanteric** or **subtrochanteric fractures**. - The Lauge-Hansen system is **not applicable** to injuries of the femur. *Shoulder fracture* - **Shoulder fractures** (e.g., proximal humerus fractures) are commonly classified using systems like the **Neer classification**, which describes the number of displaced parts. - The Lauge-Hansen system is **not used** for classifying shoulder injuries. *Elbow fracture* - **Elbow fractures** involve the distal humerus, proximal ulna, or radial head and are classified by various systems depending on the specific bone involved (e.g., **Mason classification for radial head fractures**). - The Lauge-Hansen system is **irrelevant** to elbow an injuries.

Question 7: Ulnar nerve injury results in:

A. Pointing index
B. Ape thumb deformity
C. Clawing of fingers (Correct Answer)
D. Wrist drop

Explanation: ***Clawing of fingers*** - An ulnar nerve injury, particularly at the elbow, often leads to **paralysis of the interossei muscles** and the **medial two lumbricals**. [1] - This results in **hyperextension at the metacarpophalangeal joints** and **flexion at the interphalangeal joints** of the 4th and 5th fingers (and sometimes 3rd), creating the characteristic claw hand deformity. [1] *Pointing index* - **Pointing index**, also known as the **sign of benediction** or **preacher's hand**, occurs with **high median nerve lesions** affecting the lateral lumbricals and flexor digitorum superficialis. - The patient is unable to flex the index and middle fingers, especially when attempting to make a fist. *Ape thumb deformity* - **Ape thumb deformity** is caused by a **median nerve injury**, specifically affecting the **thenar muscles** (abductor pollicis brevis, opponens pollicis, and superficial head of flexor pollicis brevis). - This paralysis leads to the thumb being pulled laterally and into the same plane as the other fingers, losing its ability to oppose. *Wrist drop* - **Wrist drop** is a classic sign of **radial nerve injury**, which paralyzes the **extensor muscles of the wrist and fingers**. - This prevents the patient from extending their wrist and metacarpophalangeal joints.

Question 8: What is the MOST characteristic feature of low ulnar nerve palsy? a) Claw hand b) Sensory loss of medial four digits c) Weakness of grip d) Inability to abduct the thumb

A. Claw hand (Correct Answer)
B. Sensory loss of lateral three digits
C. Weakness of wrist flexion
D. Inability to oppose the thumb
E. Inability to extend at M.C.P. joint

Explanation: ***Claw hand*** - A **claw hand** (specifically an **ulnar claw**) is a classic sign of low ulnar nerve palsy, resulting from paralysis of the **interossei** and **medial two lumbricals**. - This leads to hyperextension at the **metacarpophalangeal (MCP) joints** and flexion at the **interphalangeal (IP) joints** of the 4th and 5th digits. *Sensory loss of lateral three digits* - Sensory loss in the **lateral three digits** (thumb, index, middle fingers) is characteristic of **median nerve palsy**, not ulnar nerve palsy. - The ulnar nerve supplies sensation to the **medial 1.5 digits** (half of the ring finger and the little finger). *Weakness of wrist flexion* - While the ulnar nerve contributes to wrist flexion via the **flexor carpi ulnaris**, significant weakness in overall wrist flexion alone is not its most characteristic distinguishing feature. - The median nerve and radial nerve also play crucial roles in wrist flexion and extension, respectively. *Inability to oppose the thumb* - The inability to **oppose the thumb** (touch the thumb to the tips of the other fingers) is a hallmark of **median nerve palsy**, specifically affecting the **opponens pollicis** muscle. - The ulnar nerve primarily affects adduction of the thumb via the **adductor pollicis**. *Inability to extend at M.C.P. joint* - The inability to extend at the **metacarpophalangeal (MCP) joint** is more characteristic of **radial nerve palsy**, which affects the **extensor muscles** of the fingers. - Ulnar nerve palsy causes increased extension at the MCP joints due to paralysis of the lumbricals and interossei.

Question 9: Pronator drift is a sign of -

A. Dorsal syringomyelia
B. UMN lesion of upper limb (Correct Answer)
C. Carpal tunnel syndrome
D. LMN lesion

Explanation: ***UMN lesion of upper limb*** - **Pronator drift** indicates a **pyramidal tract lesion** (Upper Motor Neuron lesion) affecting the contralateral corticospinal tract, resulting in weakness in supinator muscles. - The affected arm, when extended forward with palms up, will involuntarily pronate and drift downwards due to stronger arm pronator muscles and weaker arm supinator muscles. *Dorsal syringomyelia* - **Syringomyelia** can cause **dissociated sensory loss** (loss of pain and temperature sensation with preserved touch) and muscle weakness, but pronator drift is not a characteristic or primary sign. - It involves a **fluid-filled cyst** (syrinx) within the spinal cord, primarily affecting crossing spinothalamic fibers [1]. *Carpal tunnel syndrome* - This condition involves **compression of the median nerve** at the wrist, leading to **numbness, tingling**, and weakness in the hand muscles innervated by the median nerve. - It does not typically cause pronator drift, which is a sign of central nervous system involvement. *LMN lesion* - A **Lower Motor Neuron (LMN) lesion** causes **flaccid paralysis**, muscle atrophy, fasciculations, and **diminished or absent reflexes** [1]. - While it causes weakness, it does not typically manifest as pronator drift, which is indicative of a specific pattern of weakness seen in UMN lesions.

Question 10: Differential cyanosis is seen in –

A. PDA (Correct Answer)
B. VSD
C. TAPVC
D. TGV

Explanation: ***PDA*** - **Differential cyanosis** occurs in **patent ductus arteriosus (PDA)** with severe **pulmonary hypertension** leading to **right-to-left shunting** (reversed PDA/Eisenmenger syndrome). - Since the PDA connects the pulmonary artery to the descending aorta **below the origin of the left subclavian artery**, deoxygenated blood from the pulmonary artery perfuses the **lower body** (lower limbs cyanosed) while the **upper body** receives oxygenated blood from the left ventricle (upper limbs and head pink). - This creates the classic pattern: **pink upper extremities, cyanosed lower extremities**. *VSD* - A **ventricular septal defect (VSD)** typically causes **left-to-right shunting**, leading to increased pulmonary blood flow, and does not result in differential cyanosis. - While VSD can eventually lead to **Eisenmenger syndrome** with **generalized cyanosis** (affecting entire body uniformly), it does not specifically cause differential cyanosis because the shunt occurs before blood reaches the systemic circulation. *TAPVC* - **Total anomalous pulmonary venous connection (TAPVC)** is a congenital heart defect where all pulmonary veins drain into the systemic venous circulation, leading to **generalized cyanosis** as mixed blood is delivered throughout the body. - It does not present with differential cyanosis, as the venous return is uniformly deoxygenated and mixes before systemic distribution. *TGV* - **Transposition of the great vessels (TGV)** involves the aorta originating from the right ventricle and the pulmonary artery from the left ventricle, creating two parallel circulations. - This condition presents with **severe generalized cyanosis** shortly after birth unless there is mixing between the two circulations (via PDA, ASD, or VSD), and does not cause differential cyanosis.

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