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Nerve & Tendon MCQs

Practice Set 15 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 281

Topic: Nerve & Tendon
A 35-year-old woman states that she stepped on a piece of glass 6 months ago and reports numbness and shooting pain along the plantar lateral forefoot. She had previously received steroid injections in the 3 to 4 webspace. Examination reveals mild tenderness along the plantar fascia; no Tinel’s sign is noted plantar medially and no Mulder’s click is noted distally. An MRI scan is shown in Figure 7. What is the most likely cause of the numbness?
. Residual foreign body
. Lateral plantar nerve laceration
. Impingement of Baxter’s nerve
. Interdigital neuroma
. Digital nerve laceration

Correct Answer & Explanation

. Lateral plantar nerve laceration

Explanation

The MRI scan reveals a laceration through the abductor hallucis musculature and lateral plantar nerve, producing numbness along its distribution. There is no evidence of a foreign body on the MRI scan. Baxter’s nerve, or nerve to the abductor digiti quinti muscle, is the first branch off the lateral plantar nerve and impingement of this nerve typically produces a Tinel’s sign along the nerve branch deep to the abductor hallucis muscle. Interdigital neuroma would be suggested by the presence of a Mulder’s click. A digital nerve laceration would exhibit isolated numbness more distally.

Question 282

Topic: Nerve & Tendon
  • A patient undergoes an acute repair of a laceration of the median nerve in the antecubital fossa. A lack of functional recovery 6 months later is most likely due to
. Retrograde collapse of the endoneurial tubes
. Irreversible atrophy of the denervated muscles
. Elongation of the axons across the zone of injury
. Sprouting of the axons at the neuromuscular junction
. Misdirection of the axons across the zone of injury

Correct Answer & Explanation

. Retrograde collapse of the endoneurial tubes

Explanation

Functional recovery after nerve injury-The outcome of peripheral nerve injuries is quite variable. Variables hypothesized to have an important role in determining the outcome of nerve repair include: (1) the age of the patient; (2) the type of nerve injured; (3) the distance the regenerating axons must grow to reach the target organ; (4) the length of the injured zone; (5) the timing of the nerve repair; (6) the status of the target organ at the time it is reinnervated; and (7) the technical excellence of the surgeon.Functional recovery is generally complete after a crush injury because the basement membrane and endoneurium are left intact, and the damaged axons can regenerate within their original endoneurial tubes and reinnervate their original target organ. After a complete lesion to the nerve, however, functional recovery of movement is often quite poor. The loss of functional recovery probably is related to the failure of the axons to regenerate and the misdirection of regenerating axons, which leads to inappropriate innervation of denervated muscles. Inappropriate innervation is thought to result in a loss in the ability to accurately recruit individual muscles and motor units within a muscle, resulting in the loss of motor control.

Question 283

Topic: Nerve & Tendon
Figures 1 and 2 show the intraoperative photographs obtained during surgical treatment for de Quervain tendonitis. For orientation purposes, dorsal is at the top. Figure 1 is obtained just after the initial first extensor compartment release, and Figure 2 shows the floor of the first extensor compartment. If the structure marked by the black dot is not addressed, the most common postoperative problem would be:
. persistent pain.
. tendon subluxation.
. altered sensation.
. tendon rupture.

Correct Answer & Explanation

. persistent pain.

Explanation

The black dot identifies an accessory compartment of the extensor pollicis brevis (EPB) tendon. The incidence of accessory EPB compartment in patients undergoing surgical treatment for de Quervain syndrome ranges from 46% to 60%. Failure to release this compartment at the time of initial surgery can cause persistent postoperative pain. The patient would not experience altered sensation if this compartment were not released. Altered sensation would most commonly occur following injury to the dorsal radial sensory nerve branch during surgery. EPB tendon subluxation also would not occur should the accessory compartment not be released. For EPB tendon subluxation to occur, its own compartment would need to be released first. Finally, EPB tendon rupture would be an extremely uncommon complication of failure to release the accessory compartment.

Question 284

Topic: Nerve & Tendon

An 8-year-old boy sustains a 100% displaced extension-type supracondylar humerus fracture. Examination reveals no sensory deficit. Capillary refill is approximately 1 second. The patient is unable to flex the index distal interphalangeal joint and the thumb interphalangeal joint. The remainder of the motor examination is normal. Which of the following best explains these physical findings? Review Topic

. Volkmann ischemic contracture
. Radial nerve palsy
. Ulnar nerve palsy
. Median nerve palsy
. Anterior interosseous nerve palsy

Correct Answer & Explanation

. Volkmann ischemic contracture

Explanation

Preoperative nerve deficit is common in children with displaced extension-type supracondylar humerus fractures (approximately 20%). Commonly injured nerves include the anterior interosseous nerve (a branch of the median nerve), the median nerve, and the radial nerve. The physical examination findings are most consistent with an anterior interosseous nerve palsy. The ulnar nerve is the most likely nerve to be injured in flexion-type supracondylar humerus fractures.

Question 285

Topic: Nerve & Tendon
A 17-year-old boy with left spastic hemiplegia secondary to cerebral palsy is being evaluated for persistent swan neck deformities of the affected hand. Splinting has been tried with some improvement, but the patient does not want to wear the splints any more. On physical examination, he demonstrates full extension of the metacarpophalangeal (MCP) joints, 30° of hyperextension of the proximal interphalangeal (PIP) joints, and flexion of the distal interphalangeal (DIP) joints when he attempts to actively extend his digits. He is able to initiate flexion at the PIP joints with his MCP joints held in neutral extension. He has equal PIP flexion when the MCP joints are extended and flexed. What is the most appropriate surgical treatment to address his swan neck deformity?
. Central slip tenotomy
. Terminal tendon release
. Dorsal rerouting of the lateral bands
. Intrinsic lengthening

Correct Answer & Explanation

. Central slip tenotomy

Explanation

EXPLANATION: This patient demonstrates full extension of the MCP joints when he actively extends his fingers, indicative of overpull of the extrinsic finger extensors. This clinical scenario can be corrected by a central slip tenotomy. A terminal tendon release is used to address a Boutonnière deformity. The patient does not demonstrate intrinsic tightness (equal PIP flexion while the MCP flexed and extended), therefore his swan neck would be unlikely to respond to intrinsic lengthening. Dorsal rerouting of the lateral bands is performed for a Boutonnière deformity. A central slip tenotomy would balance the extension forces between the PIP and DIP joints.

Question 286

Topic: Nerve & Tendon
The arrows in the axial T1-weighted MRI scan shown in Figure 25 show which of the following structures?
. Ulnar artery and accompanying vein
. Deep and superficial branches of the ulnar nerve
. Radial and ulnar digital nerves to the little finger
. Palmar cutaneous and thenar motor branch of the median nerve
. Dorsal cutaneous branch of the ulnar nerve and common digital artery to the fourth web

Correct Answer & Explanation

. Deep and superficial branches of the ulnar nerve

Explanation

DISCUSSION: The arrows in the figure show the deep branch of the ulnar nerve (more radial) and the superficial branch of the ulnar nerve within Guyon’s canal. Guyon’s canal is approximately 4 cm long beginning at the proximal extent of the transverse carpal ligament and ends at the aponeurotic arch of the hypothenar muscles. Many structures comprise the boundaries of Guyon’s canal. The floor, for example, consists of the transverse carpal ligament, the pisohamate and pisometacarpal ligaments, and the opponens digiti minimi. Within Guyon’s canal, the ulnar nerve bifurcates into the superficial and deep branches. The ulnar artery is immediately adjacent and radial to the ulnar nerve. The median nerve is visualized within the carpal tunnel, and the palmar cutaneous branch is more radial to Guyon’s canal and volar to the carpal tunnel. The radial and ulnar digital nerves to the little finger are branches off of the superficial branch of the ulnar nerve distal to its emergence from Guyon’s canal. The ulnar artery is the round structure located radial to the branches of the ulnar nerve within Guyon’s canal. Adjacent to the ulnar artery are two small veins. The dorsal cutaneous branch of the ulnar nerve branches from the ulnar nerve in the distal forearm, well proximal to Guyon’s canal. The common digital artery to the fourth web branches from the superficial palmar arch distal to Guyon’s canal. The hook of the hamate is clearly seen in the figure, orienting the observer to the ulnar side of the wrist. REFERENCES: Gross MS, Gelberman RH: The anatomy of the distal ulnar tunnel. Clin Orthop Relat Res 1985;196:238-247. Denman EE: The anatomy of the space of Guyon. The Hand 1978;10:69-76.

Question 287

Topic: Nerve & Tendon

A 28-year-old weightlifter undergoes repair of an acute distal biceps rupture via a single-incision anterior approach. Postoperatively, he reports numbness over the radial aspect of his forearm. Which nerve is most likely injured?

. Posterior interosseous nerve (PIN)
. Lateral antebrachial cutaneous nerve (LABC)
. Median nerve
. Ulnar nerve
. Anterior interosseous nerve (AIN)

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve (LABC)

Explanation

The LABC nerve is the most commonly injured nerve during a single-incision anterior distal biceps repair due to lateral retraction. The PIN is classically at risk during a two-incision approach if the forearm is not fully supinated during the deep dissection.

Question 288

Topic: Nerve & Tendon
Figure 1 shows an injury sustained by a 60-year-old man 4 weeks ago. Since that time he has had substantial pain and catching of his finger during attempts at range of motion. What is the most appropriate treatment at this point?
. Tendon debridement
. Release of the A2 pulley
. Tendon repair with core sutures
. Tendon repair with epitendinous sutures

Correct Answer & Explanation

. Tendon repair with epitendinous sutures

Explanation

Explanation: Approximately 70% laceration of the flexor digitorum profundus tendon with active locking is best treated with epitendinous sutures. Performing this procedure under local anesthetic allows for better assessment of whether the triggering has been resolved. Cyclic loading has been shown to increase with high-grade partial lacerations. Use of core sutures adds little strength to a partial laceration. Debridement alone is reserved for injuries involving less than 60% of the tendon diameter. Release of the A2 would compromise pulley function.

Question 289

Topic: Nerve & Tendon

A 65-year-old female sustains a closed, displaced intra-articular distal humerus fracture (AO type 13-C3).

Preoperatively, she reports numbness and tingling in her ring and small fingers. What is the most appropriate intraoperative management of the ulnar nerve during open reduction and internal fixation (ORIF)?

. In situ decompression without any mobilization to preserve blood supply.
. Routine anterior submuscular transposition for all complex distal humerus fractures.
. Identification and mobilization of the nerve, leaving it in situ if there is no tension or impingement over the hardware.
. Excision of the medial epicondyle to definitively relieve tension on the nerve.
. Repair and tightening of the cubital tunnel retinaculum after hardware placement.

Correct Answer & Explanation

. Identification and mobilization of the nerve, leaving it in situ if there is no tension or impingement over the hardware.

Explanation

In the surgical management of distal humerus fractures, the ulnar nerve must be identified and protected. Current evidence suggests that routine transposition is not required and may increase the risk of devascularization and subsequent neuropathy. The nerve should be mobilized enough to allow safe fracture fixation and then left in situ, provided it rests comfortably without tension or direct impingement by the implants.

Question 290

Topic: Nerve & Tendon

A 15-year-old gymnast sustains a medial epicondyle fracture that is displaced 15 mm into the joint, necessitating open reduction and internal fixation. During the surgical approach, the ulnar nerve is identified. According to current orthopedic literature, what is the most appropriate management of the ulnar nerve?

. Routine anterior sub-cutaneous transposition
. Leave the nerve in situ and perform fracture fixation
. Routine anterior sub-muscular transposition
. Routine epineurotomy to prevent post-operative swelling
. Resection of the medial intermuscular septum only

Correct Answer & Explanation

. Routine anterior sub-cutaneous transposition

Explanation

In the surgical treatment of pediatric medial epicondyle fractures, routine anterior transposition of the ulnar nerve is not recommended unless there is pre-existing significant nerve tension, instability, or the nerve impedes anatomical reduction. Standard practice involves identifying and protecting the nerve, leaving it in situ, and proceeding with fixation.

Question 291

Topic: Nerve & Tendon

A 12-year-old boy sustains a traumatic elbow dislocation that is reduced in the emergency department. Post-reduction radiographs show widening of the medial joint space, and the medial epicondyle ossification center is completely absent from its normal anatomic position. He has new-onset numbness in his small finger. What is the most likely pathomechanism?

. The medial epicondyle is incarcerated within the joint, compressing the ulnar nerve
. The ulnar nerve was completely transected by a sharp bone fragment during reduction
. The posterior interosseous nerve is stretched over the lateral condyle
. The median nerve is entrapped in a supracondylar fracture hematoma
. An acute compartment syndrome of the forearm has developed

Correct Answer & Explanation

. The medial epicondyle is incarcerated within the joint, compressing the ulnar nerve

Explanation

Incarceration of the medial epicondyle within the elbow joint is a classic complication of pediatric elbow dislocations. It presents with a widened medial joint space, an 'absent' medial epicondyle on standard views, and often ulnar neuropathy due to entrapment of the nerve with the bone fragment.

Question 292

Topic: Nerve & Tendon

A 40-year-old male undergoes a single-incision anterior approach for repair of a distal biceps tendon rupture. Postoperatively, he complains of numbness and tingling along the radial border of his forearm. Which of the following is the most likely etiology of this complication?

. Injury to the posterior interosseous nerve (PIN)
. Injury to the superficial radial nerve
. Retraction injury to the lateral antebrachial cutaneous nerve (LABCN)
. Compression of the median nerve at the lacertus fibrosus
. Ulnar nerve transposition during the procedure

Correct Answer & Explanation

. Injury to the posterior interosseous nerve (PIN)

Explanation

The most common complication following a single-incision anterior repair of a distal biceps tendon rupture is a neurapraxia of the lateral antebrachial cutaneous nerve (LABCN), which occurs in approximately 10-25% of cases. The LABCN courses superficially in the lateral aspect of the antecubital fossa and is highly susceptible to traction or direct injury from retractors during this approach. Injury to the PIN is less common but is a severe complication associated with poor retractor placement or failure to keep the forearm in supination during the approach.

Question 293

Topic: Nerve & Tendon

Which of the following intraoperative techniques is most strongly recommended to minimize the risk of postoperative ulnar neuropathy during a total elbow arthroplasty for a patient with rheumatoid arthritis?

. In situ decompression of the ulnar nerve without mobilization
. Routine anterior subcutaneous transposition of the ulnar nerve
. Routine anterior submuscular transposition of the ulnar nerve
. Medial epicondylectomy
. Leaving the nerve in the cubital tunnel and protecting it with a retractor

Correct Answer & Explanation

. Routine anterior subcutaneous transposition of the ulnar nerve

Explanation

Postoperative ulnar neuropathy is a common complication after total elbow arthroplasty (TEA). Most high-volume elbow surgeons recommend routine identification, mobilization, and anterior subcutaneous transposition of the ulnar nerve during TEA to move it away from the surgical field, reduce tension during flexion, and prevent impingement by the implants or cement. In situ decompression or leaving it in the tunnel risks injury during the extensive capsular release and component preparation.

Question 294

Topic: Nerve & Tendon

During a single-incision anterior approach for distal biceps tendon repair, which nerve is at greatest risk of iatrogenic injury if retractors are placed too vigorously on the lateral aspect of the wound?

. Median nerve
. Ulnar nerve
. Posterior interosseous nerve (PIN)
. Superficial radial nerve
. Lateral antebrachial cutaneous nerve (LABC)

Correct Answer & Explanation

. Posterior interosseous nerve (PIN)

Explanation

The posterior interosseous nerve (PIN) is at significant risk with excessive lateral retraction during the single-incision anterior approach as it wraps around the radial neck. The LABC is also at risk but is typically injured more superficially during the initial exposure.

Question 295

Topic: Nerve & Tendon

A 45-year-old bodybuilder feels a sudden 'pop' in his antecubital fossa while lifting weights and presents with weakness in supination. A distal biceps tendon rupture is diagnosed, and surgical repair via a single-incision anterior approach is planned. What is the most common iatrogenic nerve injury associated with this specific surgical approach?

. Posterior interosseous nerve
. Lateral antebrachial cutaneous nerve
. Superficial radial nerve
. Median nerve
. Ulnar nerve

Correct Answer & Explanation

. Posterior interosseous nerve

Explanation

The lateral antebrachial cutaneous nerve (LABCN) is the most commonly injured nerve during the single-incision anterior approach for distal biceps tendon repair. It is at risk during superficial dissection laterally. The posterior interosseous nerve (PIN) is more commonly at risk during the two-incision technique, particularly if retractors are placed aggressively around the radial neck or if the arm is not fully pronated during the posterolateral dissection.

Question 296

Topic: Nerve & Tendon

A 35-year-old male presents with severe elbow stiffness 6 months following operative fixation of an elbow fracture-dislocation. Radiographs show mature heterotopic ossification (HO) bridging the medial humerus and ulna. He requests surgical intervention to improve his motion. Which of the following is true regarding surgical excision of HO in this setting?

. Surgery should be delayed until 18 months post-injury to prevent recurrence.
. Prophylaxis with local radiation or oral indomethacin is contraindicated postoperatively.
. The ulnar nerve is at low risk and does not routinely require exposure or transposition.
. A normal serum alkaline phosphatase level and mature trabecular pattern on radiographs indicate the HO is safe to excise.
. Continuous passive motion (CPM) machines postoperatively have been shown to drastically increase HO recurrence.

Correct Answer & Explanation

. A normal serum alkaline phosphatase level and mature trabecular pattern on radiographs indicate the HO is safe to excise.

Explanation

Surgical excision of heterotopic ossification (HO) around the elbow should be performed when the bone is mature to decrease the risk of recurrence. Clinical signs of maturity include normalization of alkaline phosphatase levels and a sharply defined, mature trabecular pattern on radiographs, typically occurring 6 to 9 months post-injury. Postoperative prophylaxis (radiation or indomethacin) is commonly used to prevent recurrence. The ulnar nerve is at high risk and must be carefully identified and often transposed.

Question 297

Topic: Nerve & Tendon

A 24-year-old weightlifter complains of a snapping sensation and medial elbow pain during triceps extensions. Examination reveals a snapping structure over the medial epicondyle during elbow flexion. Ultrasound demonstrates ulnar nerve subluxation as well as an additional snapping muscular structure. What is the most likely diagnosis?

. Snapping triceps syndrome
. Subluxation of the flexor carpi ulnaris
. Medial collateral ligament insufficiency
. Anconeus epitrochlearis
. Cubital tunnel syndrome with isolated nerve subluxation

Correct Answer & Explanation

. Snapping triceps syndrome

Explanation

Snapping triceps syndrome involves the subluxation of the medial head of the triceps over the medial epicondyle during active elbow flexion. It is frequently associated with concurrent ulnar nerve subluxation and can cause ulnar neuritis.

Question 298

Topic: Nerve & Tendon
What are the two terminal branches of the lateral cord of the brachial plexus?
. Musculocutaneous and median
. Musculocutaneous and axillary
. Median and axillary
. Ulnar and median
. Ulnar and medial pectoral

Correct Answer & Explanation

. Musculocutaneous and median

Explanation

The lateral cord divides into the musculocutaneous and median nerves. The posterior cord terminates into the axillary and radial nerves. The medial cord divides into the ulnar and median nerves.

Question 299

Topic: Nerve & Tendon

During a routine carpal tunnel release, the surgeon notes an anomalous neural connection between the median and ulnar nerves in the forearm, known as the Martin-Gruber anastomosis. What is the typical directional flow of these crossing fibers?

. Ulnar to median nerve in the distal forearm
. Median to ulnar nerve in the proximal forearm
. Median to ulnar nerve in the deep palm
. Ulnar to median nerve in the deep palm
. Radial to median nerve in the distal forearm

Correct Answer & Explanation

. Median to ulnar nerve in the proximal forearm

Explanation

The Martin-Gruber anastomosis is a common anatomical variant in the forearm where motor nerve fibers cross from the median nerve (or anterior interosseous nerve) to the ulnar nerve. It typically innervates intrinsic hand muscles.

Question 300

Topic: Nerve & Tendon

A patient with severe cubital tunnel syndrome demonstrates a positive Froment sign when attempting to pinch a piece of paper. This sign is caused by compensatory hyperflexion of the thumb interphalangeal joint driven by a muscle innervated by which nerve?

. Recurrent motor branch of the median nerve
. Anterior interosseous nerve
. Deep branch of the ulnar nerve
. Posterior interosseous nerve
. Superficial branch of the radial nerve

Correct Answer & Explanation

. Anterior interosseous nerve

Explanation

Froment sign occurs due to weakness of the ulnar-innervated adductor pollicis. The patient compensates by utilizing the flexor pollicis longus (FPL) to pinch, resulting in thumb IP joint hyperflexion. The FPL is innervated by the anterior interosseous nerve.

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