This practice set contains high-yield board review questions covering key concepts in Nerve & Tendon. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.
Question 181
Topic: Nerve & Tendon
A 55-year-old diabetic female presents with a painful triggering of her right middle finger. She has failed a trial of splinting and one corticosteroid injection given 6 months ago. What is the most appropriate next step in management?
Correct Answer & Explanation
. A1 pulley release
Explanation
In diabetic patients, trigger finger is much less responsive to corticosteroid injections compared to the general population. Surgical release of the A1 pulley is the definitive and most appropriate next step after a failed initial injection in this demographic.
Question 182
Topic: Nerve & Tendon
A 48-year-old cellist presents with progressive weakness and clumsiness in his left hand. Examination reveals profound atrophy of the first dorsal interosseous muscle, weakness in finger abduction, and a positive Froment's sign. Which nerve and site of compression are most likely responsible?
Correct Answer & Explanation
. Ulnar nerve at the cubital tunnel
Explanation
Intrinsic wasting (first dorsal interosseous) and a positive Froment's sign (compensatory IP flexion via the median-innervated FPL due to adductor pollicis weakness) indicate an ulnar neuropathy. The cubital tunnel is the most common site of ulnar nerve entrapment.
Question 183
Topic: Nerve & Tendon
A 34-year-old basketball player presents 3 weeks after jamming his ring finger. Examination reveals PIP joint flexion and DIP joint hyperextension.
Which of the following anatomic structures is primarily injured in this deformity?
Correct Answer & Explanation
. Central slip of the extensor tendon
Explanation
A Boutonniere deformity is characterized by PIP flexion and DIP hyperextension. It is caused by a rupture or attenuation of the central slip of the extensor tendon, which allows the lateral bands to subluxate volarly.
Question 184
Topic: Nerve & Tendon
A sensate reverse radial forearm flap is planned for a patient with a massive first web space defect. To provide protective sensation to the reconstructed area, which nerve should be included in the flap harvest for coaptation?
Correct Answer & Explanation
. Lateral antebrachial cutaneous nerve
Explanation
The lateral antebrachial cutaneous nerve courses with the cephalic vein and provides sensation to the radial aspect of the forearm. It is routinely included when a sensate radial forearm flap is required.
Question 185
Topic: Nerve & Tendon
During the elevation of a reverse radial forearm flap, the surgeon dissects deep to the deep fascia. Which of the following neurological structures is most at risk of injury and must be carefully preserved along the deep surface of the brachioradialis?
Correct Answer & Explanation
. Superficial branch of the radial nerve
Explanation
The superficial branch of the radial nerve runs deep to the brachioradialis in the mid-forearm and emerges subcutaneously in the distal third. It is highly susceptible to injury during the radial dissection of the flap and must be visually identified and preserved.
Question 186
Topic: Nerve & Tendon
A 40-year-old mechanic presents with lateral elbow pain. Pain is reproduced with resisted active supination of the forearm with the elbow extended. Where is the most likely site of compression causing this patient's symptoms?
Correct Answer & Explanation
. Arcade of Frohse
Explanation
Resisted active supination reproducing lateral forearm pain suggests Radial Tunnel Syndrome, a major differential diagnosis for lateral epicondylitis. The posterior interosseous nerve is most commonly compressed at the proximal edge of the supinator, known as the Arcade of Frohse.
Question 187
Topic: Nerve & Tendon
Which physical examination finding most reliably differentiates Radial Tunnel Syndrome from Lateral Epicondylitis?
Correct Answer & Explanation
. Maximal tenderness 4 to 5 cm distal to the lateral epicondyle
Explanation
Radial Tunnel Syndrome typically presents with maximal point tenderness in the mobile wad 4 to 5 cm distal to the lateral epicondyle. In contrast, lateral epicondylitis presents with maximal tenderness directly over or just slightly distal to the epicondyle.
Question 188
Topic: Nerve & Tendon
A 42-year-old carpenter complains of aching pain in the lateral proximal forearm. Tenderness is maximal 4 cm distal to the lateral epicondyle in the mobile wad. Pain is exacerbated by resisted forearm supination with the elbow fully extended. Which nerve is most likely compressed?
Correct Answer & Explanation
. Posterior interosseous nerve (PIN)
Explanation
This presentation describes radial tunnel syndrome, a compression neuropathy of the PIN. It is a critical differential for tennis elbow, characterized by tenderness more distal than the epicondyle and pain provoked by resisted supination.
Question 189
Topic: Nerve & Tendon
A 58-year-old female presents with a complex, comminuted intra-articular distal humerus fracture (AO/OTA Type C3) after a fall from standing height. Pre-operative CT scans confirm significant articular involvement and disruption of both medial and lateral columns. During surgical planning for a posterior approach, the surgeon decides to perform an olecranon osteotomy. Which of the following statements regarding the ulnar nerve and its management during this procedure is MOST accurate?
Correct Answer & Explanation
. Prophylactic anterior transposition of the ulnar nerve is widely recommended to reduce post-operative neuropathy rates, even in asymptomatic patients.
Explanation
Correct Answer: CThe case explicitly states, 'The ulnar nerve is identified proximal to the cubital tunnel, typically lying anterior to the medial head of the triceps. Trace the nerve distally through the cubital tunnel (between the medial epicondyle and olecranon). Perform an extensive neurolysis of the ulnar nerve... While not always strictly necessary in every case, anterior transposition of the ulnar nerve is generally recommended during open reduction internal fixation (ORIF) of DHFs via a posterior approach. This protects the nerve from direct injury during drilling, plating, and screw insertion, and prevents post-operative compression from hardware or scar tissue.' The 'Summary of Key Literature / Guidelines' section further reinforces this: 'Prophylactic anterior transposition of the ulnar nerve during posterior approaches for DHF ORIF is widely recommended. Studies have shown a significant reduction in post-operative ulnar neuropathy rates with routine transposition compared to in situ decompression or no specific management.'Option A is incorrectbecause prophylactic transposition is recommended regardless of pre-operative symptoms due to the high risk of iatrogenic injury or post-operative compression.Option B is incorrectbecause the ulnar nerve is located posteriorly to the medial epicondyle, within the cubital tunnel, not anteriorly, and the brachialis muscle is anterior to the humerus, not directly protecting the ulnar nerve in the cubital tunnel.Option D is incorrectbecause while the ulnar nerve can be at risk from hardware, its primary risk during a posterior approach is from direct injury during dissection, retraction, or compression from hardware/scar tissue in the cubital tunnel, not specifically from lateral column screw placement. Lateral column screws are more likely to endanger the radial nerve if excessively long or misplaced.Option E is incorrectbecause the cubital tunnel is formed by the medial epicondyle and the olecranon, with the arcuate ligament forming the roof, not the radial head.
Question 190
Topic: Nerve & Tendon
A 35-year-old male sustains a distal humerus fracture. During the physical examination, the orthopedic resident assesses the stability of the elbow joint. Which of the following combinations of structures provides the primary static stability to the elbow joint?
Correct Answer & Explanation
. Osseous congruence (trochlear notch with trochlea) and collateral ligaments (MCL, LCL complex).
Explanation
Correct Answer: CThe 'Surgical Anatomy & Biomechanics' section, under 'Biomechanics' and 'Elbow Joint Stability', states: 'The elbow derives its stability from a combination of osseous congruence (trochlear notch of ulna with trochlea of humerus), static ligamentous restraints (MCL, LCL complex), and dynamic muscular contributions.' Osseous congruence and static ligamentous restraints are the primary static stabilizers.Option A is incorrectbecause the triceps and anconeus are dynamic muscular stabilizers, not primary static stabilizers.Option B is incorrectbecause the radial and ulnar nerves are neurovascular structures, not stabilizers of the joint.Option D is incorrectbecause the brachialis muscle and biceps tendon are dynamic muscular stabilizers, not primary static stabilizers.Option E is incorrectbecause the median nerve and brachial artery are neurovascular structures, not stabilizers of the joint.
Question 191
Topic: Nerve & Tendon
During open reduction and internal fixation of a bicolumnar distal humerus fracture, the surgeon is exposing the ulnar nerve. Based on recent high-level evidence regarding ulnar nerve management in distal humerus ORIF, which of the following is the most appropriate strategy if the nerve does not subluxate and hardware does not impinge upon it?
Correct Answer & Explanation
. In situ decompression and retention in the cubital tunnel
Explanation
Recent studies suggest that routine anterior transposition of the ulnar nerve during distal humerus ORIF is associated with higher rates of ulnar neuritis. In situ decompression is preferred unless hardware impinges on the nerve or it is unstable.
Question 192
Topic: Nerve & Tendon
The orthopedic surgeon proceeds with open reduction internal fixation (ORIF) of the displaced proximal humerus surgical neck fracture in the 45-year-old active male, utilizing a deltopectoral approach. During this approach, which of the following neurovascular structures is most directly at risk of iatrogenic injury?
Correct Answer & Explanation
. C. Axillary nerve
Explanation
Correct Answer: CThe axillary nerve is the neurovascular structure most directly at risk during a deltopectoral approach to the proximal humerus, especially when dissecting laterally or extending the approach distally. The axillary nerve wraps around the surgical neck of the humerus, approximately 5-7 cm distal to the acromion, and innervates the deltoid and teres minor muscles. Care must be taken to protect it during plate application and screw insertion, particularly with bicortical screws.Option A (Radial nerve)is primarily at risk with humeral shaft fractures, particularly in the spiral groove, and is less directly exposed or at risk during a standard deltopectoral approach to the proximal humerus.Option B (Ulnar nerve)is located medially at the elbow (cubital tunnel) and is not typically at risk during a deltopectoral approach to the proximal humerus.Option D (Median nerve)is located in the anterior compartment of the arm and forearm and is not typically at risk during a deltopectoral approach to the proximal humerus.Option E (Long thoracic nerve)innervates the serratus anterior muscle and runs along the lateral chest wall. While it can be injured in shoulder girdle trauma or surgery involving the scapula, it is not directly at risk during a deltopectoral approach to the proximal humerus.
Question 193
Topic: Nerve & Tendon
During surgical exposure for an olecranon fracture, the ulnar nerve is identified. What is the *most appropriate* management strategy if the nerve is found to be intact but compressed by surrounding hematoma or scar tissue, especially in a fracture requiring internal fixation?
Correct Answer & Explanation
. Anterior transposition of the ulnar nerve
Explanation
Correct Answer: CIf the ulnar nerve is found to be compressed or at high risk of post-operative compression/irritation (e.g., due to hardware placement or significant swelling, or pre-existing cubital tunnel syndrome), anterior transposition (C) is often performed prophylactically or therapeutically. This moves the nerve out of the cubital tunnel and into a less constrained anterior position, reducing the risk of neuropathy. Neurolysis in situ (B) may be considered for milder cases but is less definitive if significant risk factors for ongoing compression are present. No intervention (A) would be inappropriate if compression is present or anticipated. Posterior interosseous nerve release (D) is for radial nerve issues. Immediate nerve graft (E) is for transected nerves.
Question 194
Topic: Nerve & Tendon
During a posterior approach to the distal humerus for fracture fixation, the ulnar nerve is identified, mobilized, and protected. After successful fracture reduction and plating, what is the most common and often recommended management strategy for the ulnar nerve to prevent post-operative complications?
Correct Answer & Explanation
. It is commonly transposed anteriorly, either subcutaneously or submuscularly.
Explanation
Correct Answer: CAfter identification and protection during distal humerus fracture surgery, the ulnar nerve iscommonly transposed anteriorly. This is done to prevent potential entrapment in scar tissue, hardware, or malunion post-operatively, as well as to accommodate for any changes in the cubital tunnel anatomy during fixation. Anterior transposition (either subcutaneously or submuscularly, under the flexor-pronator mass) moves the nerve to a less vulnerable position. This is a proactive measure to prevent delayed ulnar nerve neuropathy.Option A (Resection)is highly detrimental and would cause permanent neurological deficit; it is never performed for nerve protection.Option B (Leaving it in situ)carries a significant risk of post-operative entrapment, especially after extensive dissection, hardware placement, or if the cubital tunnel anatomy is altered.Option D (Repairing it to the triceps muscle)is not a recognized procedure for ulnar nerve management in this context.Option E (Rarely identified)is incorrect; the ulnar nerve is superficial in the cubital tunnel and is routinely identified and protected during posterior approaches to the distal humerus.
Question 195
Topic: Nerve & Tendon
A 19-year-old basketball player presents with a suspected Jersey finger of his small finger. On examination, he has full active flexion of his PIP joint but lacks active flexion of his DIP joint. A modified tabletop test reveals a normal cascade for all fingers except the small finger, which remains extended at the DIP joint. What is the most reliable maneuver to confirm an FDP rupture in this digit?
Correct Answer & Explanation
. Stabilizing the PIP joint and asking the patient to flex the DIP joint.
Explanation
Correct Answer: CThe most reliable maneuver to confirm an FDP rupture is to isolate the action of the FDP tendon. This is done by stabilizing the PIP joint in full extension and asking the patient to actively flex the DIP joint. If the FDP is ruptured, active DIP flexion will be absent. Assessing passive range of motion will typically be full, as the FDP rupture is an active deficit. Palpating a tender gap can be indicative but is not always reliable, especially with swelling. Grip strength is a global measure and not specific enough. Finkelstein's test is for De Quervain's and irrelevant here.
Question 196
Topic: Nerve & Tendon
A 28-year-old rock climber presents with chronic stiffness and an inability to fully extend her ring finger DIP joint 8 months after a surgically repaired Jersey finger. Radiographs show no fracture or hardware issues. This is most likely due to:
Correct Answer & Explanation
. Adhesions within the flexor sheath.
Explanation
Correct Answer: CChronic stiffness and limited range of motion, particularly an inability to fully extend, following flexor tendon repair are most commonly due to adhesions forming within the flexor sheath. This restricts the smooth gliding of the repaired tendon. Re-rupture would present with loss of active flexion, not stiffness in extension. Quadriga effect limits flexion of adjacent fingers. Lumbrical plus phenomenon involves paradoxical DIP extension with attempted strong grip. Insufficient extensor strength would primarily affect active extension, not passive range of motion if adhesions are the cause.
Question 197
Topic: Nerve & Tendon
A 16-year-old athlete presents with an acute Jersey finger (Type I Leddy and Packer) of his long finger. He is scheduled for surgical repair. What is the most common approach to access the FDP tendon and achieve primary repair?
Correct Answer & Explanation
. A zigzag incision over the volar aspect of the finger (Brunner's approach).
Explanation
Correct Answer: EThe Brunner's zigzag incision is the most common and preferred approach for surgical access to the flexor tendons in the finger. This incision provides excellent exposure, allows for good visualization of the flexor sheath and tendon, and minimizes the risk of creating a longitudinal scar that could lead to flexion contracture. A midaxial incision is typically used for bony procedures or accessing the neurovascular bundles, not direct flexor tendon repair. Transverse incisions would limit exposure. A straight volar incision is contraindicated due to the high risk of contracture. A dorsal approach is for extensor tendon or dorsal bony injuries.
Question 198
Topic: Nerve & Tendon
When utilizing the dorsal Thompson approach to expose the proximal third of the radius, which nerve is at highest risk of iatrogenic injury, and how is it biomechanically protected during the procedure?
Correct Answer & Explanation
. Posterior interosseous nerve; by keeping the forearm pronated
Explanation
The posterior interosseous nerve (PIN) lies within the supinator muscle. Pronating the forearm pulls the PIN anteriorly and medially, safely displacing it away from the surgical field during the dorsal Thompson approach to the proximal radius.
Question 199
Topic: Nerve & Tendon
During a Thompson (dorsal) approach to the proximal radius for plate fixation of a comminuted fracture, the surgeon develops the interval between the extensor carpi radialis brevis (ECRB) and the extensor digitorum communis (EDC). Which nerve is at greatest risk during this exposure and requires careful protection?
Correct Answer & Explanation
. Posterior interosseous nerve (PIN)
Explanation
The Thompson approach accesses the proximal radius via the interval between the ECRB and EDC. The posterior interosseous nerve (PIN) is at significant risk as it courses directly through the supinator muscle in this operative field.
Question 200
Topic: Nerve & Tendon
When performing ORIF for a complex distal humerus fracture, the management of the ulnar nerve is debated. According to recent randomized controlled trials, how does routine anterior transposition of the ulnar nerve compare to in situ decompression?
Correct Answer & Explanation
. Routine transposition is associated with a higher rate of postoperative ulnar neuritis compared to in situ decompression
Explanation
Recent studies suggest that routine anterior transposition of the ulnar nerve during distal humerus ORIF increases the incidence of postoperative ulnar neuritis. Therefore, leaving the nerve in situ after releasing compression points is often preferred unless hardware placement demands transposition.
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