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Nerve & Tendon MCQs

Practice Set 11 of 53

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 201

Topic: Nerve & Tendon
A 72-year-old female with severe osteoporosis presents with a comminuted olecranon fracture (Mayo Type III) requiring ORIF. The surgeon opts for a Kocher posterior approach with an olecranon osteotomy. During the closure phase, after fixation of the distal humerus fracture, the olecranon osteotomy must be meticulously reduced and fixed. Which of the following is a common complication specifically associated with olecranon osteotomy?
. Posterior Interosseous Nerve (PIN) injury.
. Lateral Ulnar Collateral Ligament (LUCL) avulsion.
. Nonunion or hardware prominence/irritation of the osteotomy site.
. Median nerve entrapment at the cubital tunnel.
. Radial head subluxation.

Correct Answer & Explanation

. Nonunion or hardware prominence/irritation of the osteotomy site.

Explanation

Nonunion and hardware prominence/irritation are specific issues associated with olecranon osteotomy. PIN injury is primarily associated with the Kaplan anterolateral approach, not the Kocher posterior approach.

Question 202

Topic: Nerve & Tendon

A patient sustains a complete transection of the ulnar nerve at the elbow. When discussing the prognosis for nerve regeneration, it is important to understand that Wallerian degeneration, the process of axonal degeneration distal to the injury, typically begins how long after axon transection?

. Immediately
. Within minutes
. Within 6-12 hours
. Within 24-48 hours
. After 72 hours

Correct Answer & Explanation

. Within 24-48 hours

Explanation

Correct Answer: DWallerian degeneration, the process of axonal degeneration distal to a site of injury, typically begins within 24-48 hours after axon transection. While some changes might be observed earlier, the complete breakdown of the axon and myelin sheath becomes evident within this timeframe. This process clears the debris to allow for potential regeneration, especially in the peripheral nervous system.

Question 203

Topic: Nerve & Tendon

A 28-year-old carpenter presents with a 4-month-old soft tissue mallet finger of his index finger. He initially tried splinting for 3 weeks but removed it due to work demands. He now has a fixed 25-degree extensor lag at the DIP joint and complains of difficulty picking up small objects. He is considering surgical intervention. Which of the following is a critical supporting structure of the extensor mechanism at the DIP joint that stabilizes the lateral bands and prevents their volar subluxation?

. Volar plate
. Annular pulleys
. Triangular ligament
. Sagittal bands
. Transverse retinacular ligament

Correct Answer & Explanation

. Triangular ligament

Explanation

Correct Answer: CThe 'Surgical Anatomy & Biomechanics' section clearly identifies theTriangular Ligamentas a crucial supporting structure. It states: 'Located dorsally, it stabilizes the lateral bands, preventing their volar subluxation and maintaining their position for efficient DIP joint extension.'Option A (Volar plate)is a ligamentous structure on the volar aspect of the joint that prevents hyperextension, but it is not involved in stabilizing the dorsal extensor mechanism.Option B (Annular pulleys)are part of the flexor tendon sheath system, crucial for maintaining the mechanical advantage of the flexor tendons, not the extensor mechanism.Option D (Sagittal bands)are located at the MCP joint level and stabilize the extensor digitorum communis tendon over the MCP joint, not the DIP joint.Option E (Transverse retinacular ligament)is mentioned as influencing joint movement and preventing dorsal migration of the lateral bands, but the triangular ligament is specifically highlighted for preventing volar subluxation and maintaining position for efficient DIP extension.

Question 204

Topic: Nerve & Tendon

A 42-year-old accountant presents with a 3-month history of a soft tissue mallet finger on his dominant middle finger. He initially attempted non-operative management with a Stack splint for 8 weeks, but he admits to removing it frequently for hygiene and work-related tasks. He now has a persistent 20-degree extensor lag at the DIP joint and is frustrated with his inability to fully extend his finger. He is considering surgical repair. Which of the following is a strong indication for surgical management in this patient?

. Acute presentation within 4-6 weeks of injury.
. Patient compliance with continuous splinting.
. Persistent extensor lag of more than 15-20 degrees after an adequate course of continuous splinting.
. Absence of secondary deformity like a fixed swan neck.
. Minimal initial extensor lag (e.g., <15 degrees).

Correct Answer & Explanation

. Persistent extensor lag of more than 15-20 degrees after an adequate course of continuous splinting.

Explanation

Correct Answer: CThe 'Indications & Contraindications' section explicitly lists 'Failed Non-Operative Management: Persistent extensor lag of more than 15-20 degrees after an adequate course of continuous splinting (typically 8 weeks, followed by night splinting)' as a primary indication for surgical management. This patient fits this criterion, having a 20-degree lag after an attempted 8-week splinting course (albeit with poor compliance).Option A (Acute presentation within 4-6 weeks of injury)is an indication for non-operative management, not surgical.Option B (Patient compliance with continuous splinting)is a factor for successful non-operative management, not an indication for surgery.Option D (Absence of secondary deformity like a fixed swan neck)would typically favor non-operative management if the injury is acute and correctable, or it means the surgery would be less complex if performed for other reasons. The presence of a fixed swan neck, however, would be an indication for surgery.Option E (Minimal initial extensor lag)would typically favor non-operative management.

Question 205

Topic: Nerve & Tendon
A 60-year-old diabetic patient presents with a chronic soft tissue mallet finger of 8 months duration, complicated by a fixed swan neck deformity of the same finger. She is scheduled for surgical repair. During pre-operative planning, the surgeon reviews imaging. Which of the following imaging modalities is considered mandatory for initial evaluation of a mallet finger to rule out bony involvement?
. Magnetic Resonance Imaging (MRI) of the finger.
. Computed Tomography (CT) scan of the finger.
. Standard AP, lateral, and oblique plain radiographs of the affected digit.
. Ultrasound of the extensor tendon.
. Bone scan.

Correct Answer & Explanation

. Standard AP, lateral, and oblique plain radiographs of the affected digit.

Explanation

Standard AP, lateral, and oblique views of the affected digit are mandatory. These are crucial to rule out bony avulsion fractures (Doyle Type II, III, IV), DIP joint subluxation, and pre-existing arthritis. A true lateral view is essential to accurately assess the joint alignment and presence of bony avulsion.

Question 206

Topic: Nerve & Tendon

A 25-year-old professional musician undergoes surgical repair for a chronic soft tissue mallet finger with significant tendon retraction. The surgeon decides to perform a tendon-to-bone reattachment using drill holes and a pull-out suture technique. Post-operatively, the DIP joint is immobilized with a transarticular K-wire. The image below shows a typical K-wire placement for this procedure.

What is the primary purpose of this K-wire fixation in the immediate post-operative period?

. To provide dynamic compression across the DIP joint to promote bone healing.
. To allow early active range of motion of the DIP joint while protecting the repair.
. To protect the tendon repair and maintain the DIP joint in full extension or slight hyperextension.
. To prevent volar plate injury during rehabilitation exercises.
. To facilitate tendon gliding and prevent adhesions.

Correct Answer & Explanation

. To protect the tendon repair and maintain the DIP joint in full extension or slight hyperextension.

Explanation

Correct Answer: CThe 'Internal Fixation (K-wire)' section states: 'After the tendon repair, transarticular K-wire fixation of the DIP joint is almost always performed to protect the repair and maintain the joint in the desired position during healing.' It further specifies: 'The DIP joint is gently placed in full extension or slight hyperextension (0-10 degrees).' The image clearly depicts a K-wire traversing the DIP joint, holding it in extension.Option A is incorrectbecause the K-wire is not primarily for dynamic compression or bone healing in a soft tissue injury. Its role is static immobilization.Option B is incorrectbecause the K-wire prevents active range of motion at the DIP joint, which is crucial to protect the healing tendon. Early active motion is contraindicated.Option D is incorrectbecause while over-extension should be avoided to prevent volar plate injury, the primary purpose of the K-wire is not to prevent this specific injury during rehabilitation, but rather to immobilize the joint for tendon healing.Option E is incorrectbecause the K-wire immobilizes the joint and tendon, which can actually contribute to stiffness if not managed properly in rehabilitation. It does not facilitate tendon gliding or prevent adhesions directly.

Question 207

Topic: Nerve & Tendon

A 48-year-old painter undergoes surgical repair of a chronic soft tissue mallet finger. Post-operatively, the DIP joint is immobilized with a K-wire as shown in the image. During the rehabilitation phase, which of the following is the MOST critical instruction for the patient during the initial 6-week immobilization period?

. Actively flex the DIP joint to 30 degrees daily to prevent stiffness.
. Perform passive DIP joint extension exercises to maintain full range of motion.
. Ensure absolutely no active or passive DIP joint flexion is permitted.
. Begin light resistive exercises for DIP extension at 3 weeks post-op.
. Remove the K-wire at home if it becomes uncomfortable.

Correct Answer & Explanation

. Ensure absolutely no active or passive DIP joint flexion is permitted.

Explanation

Correct Answer: CThe 'Post-Operative Rehabilitation Protocols' section, under 'Phase 1: Immobilization (Weeks 0-6),' explicitly states for DIP Joint Immobilization: 'Crucial Principle: Absolutely no active or passive DIP joint flexion is permitted. The patient must be meticulously educated on this, particularly for activities of daily living.' This is the most critical instruction to protect the healing tendon repair.Option A is incorrectbecause active DIP flexion would directly stress and likely rupture the healing tendon.Option B is incorrectbecause passive DIP extension is already maintained by the K-wire/splint, and passive flexion is contraindicated.Option D is incorrectbecause light resistive exercises for DIP extension are typically introduced much later, in Phase 3 (Weeks 12+), after the tendon has had significant time to heal.Option E is incorrectbecause K-wires should only be removed by a medical professional, typically at 6 weeks post-operatively, not by the patient at home due to discomfort, as this could lead to complications like infection or re-injury.

Question 208

Topic: Nerve & Tendon

A 70-year-old retired teacher presents with a persistent 25-degree extensor lag after 10 weeks of continuous splinting for an acute soft tissue mallet finger. She is now developing a mild, flexible hyperextension of her PIP joint. The surgeon is considering surgical intervention. Which of the following complications is most commonly associated with unsatisfactory outcomes after soft tissue mallet finger repair, and what is a potential salvage strategy for a severe, irreparable case?

. Infection; Salvage with aggressive physical therapy.
. Stiffness / Loss of Motion; Salvage with early active DIP flexion.
. Extensor Lag / Re-rupture; Salvage with DIP joint arthrodesis (fusion).
. Nail Deformity; Salvage with nerve release/neurolysis.
. Skin Necrosis; Salvage with prolonged splinting.

Correct Answer & Explanation

. Extensor Lag / Re-rupture; Salvage with DIP joint arthrodesis (fusion).

Explanation

Correct Answer: CThe 'Complications & Management' section identifies 'Extensor Lag / Re-rupture' as the 'Most common (5-20%), higher in chronic cases' and 'the most common reason for unsatisfactory outcomes.' For salvage strategies, it states: 'For persistent, functionally significant lag, revision surgery may be considered. Options include repeat direct repair, tendon advancement (if proximal tissue allows), tenodesis (using a portion of the lateral band or a small palmaris longus graft), or, in cases of severe, irreparable damage with significant functional impairment, DIP joint arthrodesis (fusion) in a functional position (typically 10-15 degrees of flexion).'Option A (Infection)is a complication, but its incidence is low (1-5%), and aggressive physical therapy is not the primary salvage for infection.Option B (Stiffness / Loss of Motion)is common, but early active DIP flexion is contraindicated and would worsen the outcome, not salvage it.Option D (Nail Deformity)is often cosmetic and not typically salvaged with nerve release/neurolysis, which is for nerve irritation/neuroma.Option E (Skin Necrosis)is low incidence (1-3%), and prolonged splinting is not a salvage for skin necrosis; it requires wound care, debridement, or skin grafting.

Question 209

Topic: Nerve & Tendon

A 35-year-old construction worker presents with an acute open mallet finger injury to his small finger, sustained from a laceration over the DIP joint. On examination, there is a clear disruption of the extensor tendon, and he has a significant extensor lag. Which of the following statements best reflects the consensus on managing this specific type of mallet finger injury?

. Open mallet injuries are typically managed non-operatively with continuous splinting, similar to closed injuries.
. Surgical debridement and primary repair are required to prevent infection and restore tendon integrity.
. The primary concern is the development of a swan neck deformity, which should be addressed first.
. MRI is mandatory to assess the extent of tendon retraction before any intervention.
. DIP joint arthrodesis is the preferred initial treatment for open mallet injuries to ensure stability.

Correct Answer & Explanation

. Surgical debridement and primary repair are required to prevent infection and restore tendon integrity.

Explanation

Correct Answer: BThe 'Indications & Contraindications' section, under 'Operative Indications,' lists 'Open Mallet Injuries: Lacerations over the DIP joint with extensor tendon disruption, which require surgical debridement and primary repair to prevent infection and facilitate healing.' The 'Summary of Key Literature / Guidelines' further reinforces this: 'Acute open mallet finger lacerations require surgical debridement and primary repair, irrespective of the degree of lag, to prevent infection and restore tendon integrity.'Option A is incorrectbecause open injuries carry a high risk of infection and require surgical intervention, unlike most closed injuries.Option C is incorrectbecause while swan neck deformity is a potential secondary complication, the immediate priority for an open injury is infection prevention and primary tendon repair.Option D is incorrectbecause MRI is generally not indicated for routine mallet finger, and for an acute open injury, surgical exploration and repair are more urgent than advanced imaging.Option E is incorrectbecause DIP joint arthrodesis is a salvage procedure for severe, irreparable cases, not the preferred initial treatment for an acute open mallet finger, especially in a young, active patient.

Question 210

Topic: Nerve & Tendon

A 35-year-old musician presents with a soft-tissue mallet finger of the little finger. You decide to treat him conservatively with a custom thermoplastic splint. To optimize healing and prevent complications, what is the ideal position for splinting the affected digit?

. DIP joint in 30 degrees of flexion, PIP joint in full extension
. DIP joint in slight hyperextension, PIP joint immobilized in full extension
. DIP joint in neutral to slight hyperextension, PIP joint left free to mobilize
. DIP joint in neutral, PIP joint in 30 degrees of flexion
. Both DIP and PIP joints in slight flexion

Correct Answer & Explanation

. DIP joint in neutral to slight hyperextension, PIP joint left free to mobilize

Explanation

The ideal splint for a mallet finger immobilizes the DIP joint in neutral to slight hyperextension to approximate the torn tendon ends. The PIP joint must be left free to range to prevent stiffness and secondary deformities.

Question 211

Topic: Nerve & Tendon

What is the most frequently encountered complication of conservative management (continuous extension splinting) for soft tissue mallet finger injuries?

. Terminal tendon rupture
. Infection of the nail bed
. Permanent swan neck deformity
. Complex regional pain syndrome
. Dorsal skin maceration and necrosis

Correct Answer & Explanation

. Dorsal skin maceration and necrosis

Explanation

Dorsal skin maceration, ulceration, and necrosis are the most common complications of mallet splints. Careful monitoring, keeping the splint dry, and ensuring the splint does not exert excessive pressure over the dorsal DIP joint are essential.

Question 212

Topic: Nerve & Tendon

A 55-year-old patient presents with a 5-week-old soft tissue mallet injury to the small finger. He has not received any prior treatment and has a 40-degree extensor lag. According to current literature, what is the most appropriate initial management for this delayed presentation?

. Immediate surgical repair of the terminal tendon
. Surgical tenodermodesis
. Full-time extension splinting of the DIP joint for 8 weeks
. DIP joint arthrodesis
. Observation and physical therapy only

Correct Answer & Explanation

. Full-time extension splinting of the DIP joint for 8 weeks

Explanation

Even with delayed presentation up to 3 months, full-time extension splinting for 6-8 weeks remains the first-line treatment for soft tissue mallet fingers. Studies show comparable, though slightly less predictable, outcomes compared to acute splinting.

Question 213

Topic: Nerve & Tendon

A 45-year-old male sustains a soft tissue mallet finger injury to his right index finger. He is treated with a strict continuous DIP joint extension splint. During his 4-week follow-up, he admits the splint slipped off for 10 minutes while showering, causing the finger to flex. What is the most appropriate next step in management?

. Continue splinting for 2 more weeks
. Restart the 6-week continuous splinting protocol from day zero
. Discontinue the splint and start active range of motion
. Schedule the patient for surgical repair of the terminal tendon
. Transition to nighttime splinting only

Correct Answer & Explanation

. Restart the 6-week continuous splinting protocol from day zero

Explanation

Treatment of a soft tissue mallet finger requires continuous, uninterrupted extension splinting for 6 to 8 weeks. Any flexion of the DIP joint during this period stretches the healing tendon and requires restarting the entire 6-week continuous splinting protocol.

Question 214

Topic: Nerve & Tendon

A patient with an untreated chronic mallet finger presents with a new secondary deformity consisting of PIP joint hyperextension and DIP joint flexion. What is the primary biomechanical cause of this secondary PIP hyperextension?

. Rupture of the volar plate at the PIP joint
. Proximal retraction of the extensor mechanism concentrating force on the central slip
. Attenuation of the transverse retinacular ligaments
. Contracture of the flexor digitorum superficialis
. Tear of the sagittal bands at the MCP joint

Correct Answer & Explanation

. Proximal retraction of the extensor mechanism concentrating force on the central slip

Explanation

A swan neck deformity in the setting of a chronic mallet finger is caused by proximal retraction of the extensor mechanism following terminal tendon rupture. This increases extensor tension at the central slip insertion, leading to PIP hyperextension.

Question 215

Topic: Nerve & Tendon

A 30-year-old laborer presents with an 8-week-old soft tissue mallet finger of the ring finger. He has had no previous treatment. What is the recommended initial management?

. Primary surgical repair with suture anchors
. Terminal tendon reconstruction using a palmaris longus graft
. Continuous DIP joint extension splinting for 8 weeks
. Arthrodesis of the DIP joint
. Fowler central slip tenotomy

Correct Answer & Explanation

. Continuous DIP joint extension splinting for 8 weeks

Explanation

Even in chronic soft tissue mallet fingers presenting up to 12 weeks post-injury, continuous extension splinting for 8 weeks (followed by a weaning period) has been shown to have success rates comparable to acute splinting. Surgery is reserved for splinting failures.

Question 216

Topic: Nerve & Tendon

What is the most common complication associated with non-operative extension splinting of a mallet finger?

. Infection
. Nail bed deformity
. Dorsal skin maceration and ulceration
. Complex regional pain syndrome
. Tendon rupture

Correct Answer & Explanation

. Dorsal skin maceration and ulceration

Explanation

Dorsal skin maceration, blistering, or necrosis over the DIP joint is the most common complication of mallet finger splinting, often caused by poor splint fit or excessive hyperextension.

Question 217

Topic: Nerve & Tendon

In the Doyle classification of mallet finger injuries, a Type IVC injury is defined by which of the following characteristics?

. Closed soft tissue injury
. Laceration of the tendon
. Deep abrasion with skin loss
. Fracture involving >50% of the articular surface
. Fracture involving <20% of the articular surface

Correct Answer & Explanation

. Fracture involving >50% of the articular surface

Explanation

According to the Doyle classification, Type IVC is a mallet fracture involving greater than 50% of the articular surface, which typically indicates a high risk of volar subluxation.

Question 218

Topic: Nerve & Tendon

A 65-year-old woman presents with a painful, stiff DIP joint secondary to an untreated chronic mallet finger sustained 10 years ago. Radiographs show severe osteoarthritis of the DIP joint. What is the most reliable definitive treatment?

. Terminal tendon reconstruction
. Central slip tenotomy
. DIP joint arthrodesis
. DIP joint arthroplasty
. Oblique retinacular ligament reconstruction

Correct Answer & Explanation

. DIP joint arthrodesis

Explanation

In the setting of a chronic mallet finger with end-stage post-traumatic osteoarthritis and pain, DIP joint arthrodesis is the most reliable procedure to eliminate pain and provide a stable pinch.

Question 219

Topic: Nerve & Tendon

During the physical examination of a suspected mallet finger, what clinical finding most accurately distinguishes a terminal tendon rupture from a central slip rupture (boutonniere deformity)?

. Inability to actively extend the PIP joint
. Inability to actively extend the DIP joint with the PIP joint stabilized in extension
. Hyperextension of the DIP joint
. Flexion of the MCP joint
. Volar subluxation of the PIP joint

Correct Answer & Explanation

. Inability to actively extend the DIP joint with the PIP joint stabilized in extension

Explanation

A mallet finger presents with an inability to actively extend the DIP joint. Stabilizing the PIP joint in extension isolates the terminal tendon function, confirming the diagnosis and ruling out central slip involvement (which presents with a PIP extension lag).

Question 220

Topic: Nerve & Tendon

A 32-year-old woman presents 5 weeks after sustaining a closed soft-tissue mallet finger injury to her small finger. She has not received any prior treatment and currently has a 45-degree extensor lag. Which of the following is the most appropriate initial management?

. Surgical repair of the terminal tendon using a micro-bone anchor
. Arthrodesis of the distal interphalangeal (DIP) joint
. Continuous DIP joint extension splinting for 8 weeks
. Nighttime only DIP extension splinting for 6 weeks
. Surgical tenodermodesis

Correct Answer & Explanation

. Continuous DIP joint extension splinting for 8 weeks

Explanation

Delayed presentation of a soft-tissue mallet finger (up to 3 months post-injury) can still be successfully treated with conservative management. The protocol remains strict continuous DIP joint extension splinting for a full 8 weeks.

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