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Nerve & Tendon MCQs

Practice Set 17 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 321

Topic: Nerve & Tendon

A 32-year-old carpenter sustains a severe volar forearm laceration resulting in a 4 cm segmental defect of the median nerve. After appropriate debridement, what is the most appropriate reconstructive strategy for this nerve gap?

. Primary end-to-end repair under tension
. Use of a synthetic polyglycolic acid nerve conduit
. Bridging with an acellular nerve allograft
. Reconstruction using an autologous nerve cable graft
. End-to-side neurorrhaphy to the ulnar nerve

Correct Answer & Explanation

. Reconstruction using an autologous nerve cable graft

Explanation

Autologous nerve cable grafting (e.g., using the sural nerve or medial antebrachial cutaneous nerve) remains the gold standard for peripheral nerve defects greater than 3 cm. Conduits and acellular nerve allografts are generally reserved for non-critical sensory nerves with gaps less than 3 cm due to poor outcomes in longer or mixed/motor nerve defects.

Question 322

Topic: Nerve & Tendon

When comparing the single-incision anterior approach to the two-incision approach for distal biceps tendon repair, the single-incision approach is associated with a statistically higher risk of injury to which of the following structures?

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

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve (LABC)

Explanation

The single-incision anterior approach carries a higher risk of lateral antebrachial cutaneous nerve (LABC) neuropraxia, as the LABC exits between the biceps and brachialis and runs directly in the superficial field of the anterior approach. The two-incision approach carries a higher risk of heterotopic ossification and radioulnar synostosis.

Question 323

Topic: Nerve & Tendon
A 25-year-old sustains a volar laceration to the index finger in Zone II. Surgical exploration reveals complete transection of the FDS and FDP tendons. Following a 4-strand core repair of the FDP and an epitendinous repair, there is noticeable catching of the repair site on the A2 pulley during passive flexion, limiting glide. What is the most appropriate next step?
. Perform a WALANT assessment postoperatively to intentionally break adhesions
. Resect the FDS slips completely to reduce volume and allow FDP gliding
. Vent the A2 pulley up to 50% of its length to accommodate the repair site
. Excise the A2 pulley completely and reconstruct it with a palmaris longus autograft
. Revise the repair to a 2-strand core suture to reduce bulk

Correct Answer & Explanation

. Vent the A2 pulley up to 50% of its length to accommodate the repair site

Explanation

Historically, preservation of the entire A2 and A4 pulleys was considered absolute to prevent bowstringing. However, modern flexor tendon repair protocols dictate that venting up to 50% or even 75% of the A2 pulley (typically the proximal or distal aspect) is acceptable and preferred to allow smooth tendon gliding and prevent triggering or repair rupture. 4-strand or 6-strand repairs are preferred for early active motion protocols, so downgrading to a weaker 2-strand repair is inappropriate.

Question 324

Topic: Nerve & Tendon

During an anterior subcutaneous transposition of the ulnar nerve for cubital tunnel syndrome, the nerve must be completely mobilized. Failure to release which of the following structures located approximately 8 cm proximal to the medial epicondyle can lead to new iatrogenic compression of the ulnar nerve?

. Osborne's fascia
. Arcade of Struthers
. Ligament of Struthers
. Medial intermuscular septum
. Aponeurosis of the flexor carpi ulnaris

Correct Answer & Explanation

. Arcade of Struthers

Explanation

The Arcade of Struthers is a fascial band extending from the medial head of the triceps to the medial intermuscular septum, located about 8 cm proximal to the medial epicondyle. If not divided during anterior transposition, it creates a new tethering point for the ulnar nerve. (Note: The Ligament of Struthers is associated with the median nerve and a supracondylar process, which is a classic distractor).

Question 325

Topic: Nerve & Tendon

A patient with an isolated, complete high ulnar nerve injury at the mid-arm level is evaluated. During physical examination, when asked to pinch a piece of paper between the thumb and index finger, the thumb IP joint hyperflexes while the MCP joint hyperextends. This finding (Froment's sign) occurs due to weakness of which muscle, and what muscle compensates to create the IP flexion?

. Weakness of Adductor Pollicis; compensation by Flexor Pollicis Brevis
. Weakness of Flexor Pollicis Brevis; compensation by Flexor Pollicis Longus
. Weakness of Adductor Pollicis; compensation by Flexor Pollicis Longus
. Weakness of First Dorsal Interosseous; compensation by Extensor Pollicis Longus
. Weakness of Abductor Pollicis Brevis; compensation by Adductor Pollicis

Correct Answer & Explanation

. Weakness of Adductor Pollicis; compensation by Flexor Pollicis Longus

Explanation

Froment's sign tests for ulnar nerve palsy. The primary thumb adductor is the adductor pollicis (ulnar nerve). When it is weak or paralyzed, the patient cannot execute a strong key pinch. They compensate by using the flexor pollicis longus (FPL), innervated by the anterior interosseous nerve (branch of median nerve), which causes hyperflexion at the thumb IP joint. The simultaneous MCP hyperextension is termed Jeanne's sign.

Question 326

Topic: Nerve & Tendon

Following a Zone II flexor tendon repair of the middle finger, a patient is started on an early active motion protocol. What is the primary biomechanical advantage of early active motion compared to passive motion protocols?

. Decreased work of flexion due to reduced edema
. Increased repair site gap formation to stimulate secondary healing
. Enhanced tendon excursion leading to fewer restricting adhesions
. Reduced stress on the A2 pulley
. Prevention of intrinsic muscle contracture

Correct Answer & Explanation

. Enhanced tendon excursion leading to fewer restricting adhesions

Explanation

Early active motion protocols aim to increase tendon excursion. This minimizes the formation of restrictive peritendinous adhesions and improves functional outcomes, though careful adherence is required to prevent tendon rupture.

Question 327

Topic: Nerve & Tendon

A 50-year-old female undergoes an anterior subcutaneous transposition of the ulnar nerve for severe cubital tunnel syndrome. Postoperatively, she reports worsened ulnar neuropathy symptoms. Surgical exploration reveals a new site of compression. If the initial surgeon failed to release all potential sites of tethering during the transposition, what is the most likely anatomic structure causing this new compression?

. Guyon's canal
. Arcade of Frohse
. Medial intermuscular septum
. Osborne's ligament
. Ligament of Struthers

Correct Answer & Explanation

. Medial intermuscular septum

Explanation

During an anterior transposition of the ulnar nerve, the medial intermuscular septum must be excised. If it is left intact, routing the nerve anteriorly over the septum creates a sharp angulation and a new point of tethering/compression. Osborne's ligament is the primary site of compression in in situ entrapment, but is divided during the approach. The ligament of Struthers (associated with the supracondylar process) compresses the median nerve, not the ulnar nerve (arcade of Struthers is ulnar).

Question 328

Topic: Nerve & Tendon

During a single-incision anterior approach for the repair of a retracted distal biceps tendon rupture, the surgeon places Hohmann retractors around the radial neck to facilitate visualization of the radial tuberosity. Which nerve is at the highest risk of injury with this maneuver?

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

Correct Answer & Explanation

. Posterior interosseous nerve (PIN)

Explanation

The posterior interosseous nerve (PIN), which is the deep branch of the radial nerve, courses through the two heads of the supinator muscle around the lateral aspect of the proximal radius. Blind or overly aggressive placement of retractors (such as Hohmann retractors) around the radial neck during the anterior single-incision approach to the distal biceps firmly compresses the PIN against the bone, putting it at high risk for a neuropraxia or structural injury.

Question 329

Topic: Nerve & Tendon

During an open in situ decompression of the ulnar nerve at the elbow, the surgeon must release a tough fascial band that bridges the two heads of the flexor carpi ulnaris (FCU) muscle to prevent entrapment. What is the name of this anatomic structure?

. Arcade of Struthers
. Osborne's ligament
. Ligament of Struthers
. Arcade of Frohse
. Lacertus fibrosus

Correct Answer & Explanation

. Osborne's ligament

Explanation

Osborne's ligament (or Osborne's fascia) forms the roof of the cubital tunnel proper, spanning between the olecranon and the medial epicondyle (connecting the humeral and ulnar heads of the FCU). The Arcade of Struthers is a fascial band located ~8 cm proximal to the medial epicondyle. The Ligament of Struthers is an anomalous band compressing the median nerve. The Arcade of Frohse compresses the posterior interosseous nerve (PIN).

Question 330

Topic: Nerve & Tendon

A 55-year-old diabetic woman presents with triggering and locking of her middle finger. Non-operative management has failed, and surgical release of the stenosing tenosynovitis is planned. Which annular pulley must be completely incised to reliably resolve this condition?

. A1 pulley
. A2 pulley
. A3 pulley
. A4 pulley
. A5 pulley

Correct Answer & Explanation

. A1 pulley

Explanation

Trigger finger (stenosing tenosynovitis) is caused by a size mismatch between the flexor tendon (often involving a nodule) and the A1 pulley, which lies over the metacarpophalangeal (MCP) joint. Complete surgical release of the A1 pulley resolves the triggering. The A2 and A4 pulleys must be preserved to prevent bowstringing of the flexor tendon.

Question 331

Topic: Nerve & Tendon

The median nerve provides motor innervation to the majority of the thenar musculature via its recurrent motor branch. Which of the following intrinsic thumb muscles is typically innervated by the deep branch of the ulnar nerve?

. Abductor pollicis brevis
. Opponens pollicis
. Superficial head of the flexor pollicis brevis
. Deep head of the flexor pollicis brevis
. First lumbrical

Correct Answer & Explanation

. Deep head of the flexor pollicis brevis

Explanation

The thenar eminence consists of the abductor pollicis brevis (APB), opponens pollicis, and flexor pollicis brevis (FPB). The APB, opponens pollicis, and the superficial head of the FPB are innervated by the median nerve. The deep head of the FPB (along with the adductor pollicis) is innervated by the deep branch of the ulnar nerve.

Question 332

Topic: Nerve & Tendon

A 50-year-old male undergoes in situ ulnar nerve decompression for cubital tunnel syndrome. To ensure complete decompression, the surgeon must check for several potential sites of entrapment. Which of the following is the most distal structure that commonly compresses the ulnar nerve in this region?

. Arcade of Struthers
. Medial intermuscular septum
. Osborne's ligament
. Fascia of the flexor carpi ulnaris (FCU) aponeurosis
. Ligament of Struthers

Correct Answer & Explanation

. Ligament of Struthers

Explanation

The potential sites of ulnar nerve compression around the elbow, from proximal to distal, are: the Arcade of Struthers, the medial intermuscular septum, the medial epicondyle, Osborne's ligament (cubital tunnel retinaculum), and the aponeurosis of the two heads of the flexor carpi ulnaris (FCU). The ligament of Struthers is associated with median nerve compression in the distal humerus.

Question 333

Topic: Nerve & Tendon

To prevent significant biomechanical bowstringing of the flexor pollicis longus (FPL) tendon and loss of thumb interphalangeal flexion strength, which pulley within the thumb flexor pulley system is considered the most critical to preserve during surgery?

. A1 pulley
. A2 pulley
. Oblique pulley
. Annular pulley
. Palmar aponeurosis pulley

Correct Answer & Explanation

. Oblique pulley

Explanation

The thumb flexor pulley system consists of the A1, oblique, and A2 pulleys. The oblique pulley is classically considered the most biomechanically critical pulley in the thumb to prevent bowstringing of the FPL tendon and maintain effective excursion and flexion of the IP joint. Loss of the oblique pulley, especially in combination with the A1 pulley, leads to significant bowstringing.

Question 334

Topic: Nerve & Tendon

A 21-year-old rugby player presents with an inability to actively flex the distal interphalangeal (DIP) joint of his ring finger after grabbing an opponent's jersey. Examination shows tenderness in the palm. Imaging confirms a Type 1 flexor digitorum profundus (FDP) avulsion (Jersey finger) retracted into the palm. What is the most critical timing consideration for surgical repair of this specific injury type?

. Repair must be performed within 7 to 10 days
. Repair should be delayed until 6 weeks post-injury
. Repair must be performed within 24 hours as an emergency
. Nonoperative management in an extension splint for 8 weeks
. Immediate two-stage tendon grafting is required

Correct Answer & Explanation

. Repair must be performed within 7 to 10 days

Explanation

A Type 1 Jersey finger involves retraction of the FDP tendon into the palm, disrupting both vincula and depriving the tendon of its blood supply. Surgical repair must be performed within 7 to 10 days to prevent permanent tendon necrosis and contracture.

Question 335

Topic: Nerve & Tendon

A patient with severe chronic cubital tunnel syndrome is asked to pinch a piece of paper between their thumb and index finger. The examiner notes compensatory hyperflexion of the thumb interphalangeal (IP) joint (a positive Froment's sign). This clinical finding is driven by the weakness of which of the following specific muscles?

. Adductor pollicis
. Abductor pollicis brevis
. Flexor pollicis longus
. Opponens pollicis
. First dorsal interosseous

Correct Answer & Explanation

. Adductor pollicis

Explanation

Froment's sign occurs due to weakness of the ulnar-innervated adductor pollicis muscle. To compensate for the inability to strongly adduct the thumb during pinch, the patient recruits the median-innervated flexor pollicis longus, leading to thumb IP hyperflexion.

Question 336

Topic: Nerve & Tendon

A 25-year-old professional baseball pitcher reports a 4-month history of gradually increasing medial elbow pain that occurs during the late cocking and acceleration phases of throwing. The pain occasionally refers distally along the ulnar aspect of the forearm. He denies any weakness; however, he notes occasional paresthesias. A nerve conduction velocity study demonstrates increased latency across the cubital tunnel. Management consisting of 6 weeks of rest and rehabilitation fails to provide relief as the symptoms returned when he resumed throwing. What is the best course of action?

. Further rehabilitation
. Corticosteroid injection
. Reconstruction of the medial collateral ligament
. Subcutaneous transposition of the ulnar nerve
. Arthroscopic debridement of medial osteophytes

Correct Answer & Explanation

. Subcutaneous transposition of the ulnar nerve

Explanation

In the thrower's elbow, ulnar neuritis is felt to result from both chronic compression and traction on the nerve that occurs during the throwing motion. Occasionally, subluxation of the nerve also can lead to symptoms. If nonsurgical management fails to provide relief, transposition of the nerve to an anterior subcutaneous location is the surgical procedure of choice. The nerve is held in its new position by one or two fascial slings created from the fascia of the common flexor origin. Schickendantz MS: Diagnosis and treatment of elbow disorders in the overhead athlete. Hand Clin 2002;18:65-75.

Question 337

Topic: Nerve & Tendon

The arrow in the axial T1-weighted MRI scan shown in Figure 18 is pointing to which of the following structures?

Anatomy Board Review 2005: High-Yield MCQs (Set 2) - Figure 6

. Ulnar artery
. Ulnar nerve in Guyon's canal
. Deep branch of the ulnar nerve only
. Median nerve
. Radial artery

Correct Answer & Explanation

. Ulnar nerve in Guyon's canal

Explanation

The arrow is pointing to 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 ending 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, with the deep branch of the ulnar nerve persisting distal to the canal. The ulnar artery is immediately adjacent and radial to the ulnar nerve. The median nerve is visualized within the carpal tunnel. The radial artery is on the radial side of the wrist. The hook of the hamate is clearly seen in the figure, orienting the observer to the ulnar side of the wrist. Goss MS, Gelberman RH: The anatomy of the distal ulnar tunnel. Clin Orthop 1985;196:238-247.

Question 338

Topic: Nerve & Tendon

The arrows in the axial T1-weighted MRI scan shown in Figure 25 show which of the following structures?

Anatomy Board Review 2008: High-Yield MCQs (Set 2) - Figure 23

. 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

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. Gross MS, Gelberman RH: The anatomy of the distal ulnar tunnel. Clin Orthop Relat Res 1985;196:238-247.

Question 339

Topic: Nerve & Tendon
A 20-year-old college pitcher reports medial elbow pain after 3 innings of hard throwing. He recalls no injury and reports no pain with light throwing. The examination shown in the clinical photograph in Figure 48 reproduces the elbow pain. What is the most likely diagnosis?
. Flexor-pronator avulsion
. Ulnar nerve subluxation
. Medial collateral ligament injury
. Lateral ulnar collateral ligament rupture
. Triceps tendon subluxation

Correct Answer & Explanation

. Medial collateral ligament injury

Explanation

The milking test, as seen in the photograph, elicits pain when a tear is present in the medial collateral ligament. Complete rupture is possible but unlikely when there is no history of trauma and the patient is able to throw pain-free for several innings. Subluxation of the ulnar nerve and triceps tendon subluxation present as a painful snapping over the medial aspect of the elbow. Williams RJ III, Urquhart ER, Altchek DW: Medial collateral ligament tears in the throwing athlete. Instr Course Lect 2004;53:579-586.

Question 340

Topic: Nerve & Tendon

Which of the following statements best describes why the ulnar nerve is most prone to neuropathy at the elbow?

Shoulder 2002 Practice Questions: Set 1 (Solved) - Figure 1

. It has the least longitudinal excursion required to accommodate elbow range of motion.
. It is subjected to both compression and traction during elbow motion.
. It passes between two muscle heads as it enters the forearm.
. The dimensions of the entrance of the cubital tunnel do not change with elbow motion.
. The vascular supply leaves a watershed area of diminished arterial supply.

Correct Answer & Explanation

. It has the least longitudinal excursion required to accommodate elbow range of motion.

Explanation

The ulnar nerve is more prone to neuropathy than the radial or median nerves for many reasons. It has the greatest longitudinal excursion required to accommodate elbow range of motion, subjecting it to potential traction forces. The dimensions of the entrance of the cubital tunnel change with elbow motion, potentially causing compression in flexion. For these two reasons, the ulnar nerve is subjected to both compression and traction during elbow motion. Although it passes between two muscle heads as it enters the forearm, so do the median and radial nerves. Finally, the vascular supply is adequate because of the anastamoses between the superior ulnar collateral artery, the posterior ulnar recurrent artery, and the inferior ulnar collateral artery. Norris TR (ed): Orthopaedic Knowledge Update: Shoulder and Elbow. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp 369-378. Prevel CD, Matloub HS, Ye Z, Sanger JR, Yousif NJ: The extrinsic blood supply of the ulnar nerve at the elbow: An anatomic study. J Hand Surg Am 1993;18:433-438.

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