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Nerve & Tendon MCQs

Practice Set 19 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 361

Topic: Nerve & Tendon

A surgeon is performing a percutaneous trigger finger release of the index finger. The A1 pulley is being transected. If the cutting instrument strays too far radially during the release, which structure is at greatest risk of iatrogenic injury?

. Ulnar digital nerve of the index finger
. Radial digital nerve of the index finger
. Ulnar digital artery of the index finger
. Flexor digitorum superficialis tendon
. Proper palmar digital nerve to the thumb

Correct Answer & Explanation

. Radial digital nerve of the index finger

Explanation

During an A1 pulley release of the index finger, the radial digital nerve is at exceptional risk because it courses obliquely over the flexor sheath near the MP joint crease, crossing closer to the midline than in other digits. Similarly, the radial digital nerve of the thumb is at risk during thumb trigger release for the same anatomical reason.

Question 362

Topic: Nerve & Tendon
A 22-year-old rugby player grasps an opponent's jersey and forcefully extends his flexing ring finger, sustaining an avulsion of the flexor digitorum profundus (FDP) tendon. The avulsed tendon retracts proximally into the palm (Zone II/III). According to the Leddy and Packer classification, what type of injury is this, and what is the recommended timeframe for surgical repair?
. Type I; repair within 7-10 days
. Type II; repair within 3-4 weeks
. Type III; repair anytime within 3 months
. Type I; delayed reconstruction after 6 weeks
. Type IV; immediate primary arthrodesis of the DIP joint

Correct Answer & Explanation

. Type I; repair within 7-10 days

Explanation

This describes a Leddy and Packer Type I Jersey finger injury, where the FDP tendon retracts into the palm. This proximal retraction completely disrupts the vincula (the tendon's blood supply). To prevent tendon necrosis and irreversible myostatic contracture, early primary repair within 7-10 days is strictly recommended.

Question 363

Topic: Nerve & Tendon

A 40-year-old cyclist presents with numbness and tingling confined entirely to the volar aspect of the ring and small fingers, with profound weakness of the intrinsic hand muscles. Sensation on the dorsal aspect of the ulnar hand is completely normal.

At which anatomical location is the ulnar nerve most likely compressed?

. Cubital tunnel
. Arcade of Struthers
. Guyon's canal (Zone 1)
. Guyon's canal (Zone 2)
. Guyon's canal (Zone 3)

Correct Answer & Explanation

. Guyon's canal (Zone 1)

Explanation

The patient has signs of both motor weakness (intrinsics) and sensory deficits (volar ring/small fingers), but crucially, the dorsal ulnar sensory nerve (DUSN) territory is spared. The DUSN branches off the ulnar nerve approximately 5-8 cm proximal to the wrist. Therefore, the compression must be distal to this branch. Guyon's canal Zone 1 contains both the deep motor branch and the superficial sensory branch of the ulnar nerve. Compression here explains both motor and volar sensory findings while sparing dorsal sensation. Cubital tunnel or Arcade of Struthers compression would typically involve the DUSN. Zone 2 is motor only, and Zone 3 is sensory only.

Question 364

Topic: Nerve & Tendon

A 55-year-old female presents with chronic numbness and tingling in the ring and little fingers of her right hand, worse with prolonged elbow flexion. On examination, she has a positive Tinel's sign at the cubital tunnel and mild weakness of intrinsic hand muscles. What is the MOST appropriate initial management?

. Cubital tunnel release surgery
. Anterior ulnar nerve transposition
. Night splinting with the elbow in extension and activity modification
. Corticosteroid injection into the cubital tunnel
. Observation and reassurance

Correct Answer & Explanation

. Night splinting with the elbow in extension and activity modification

Explanation

The patient's symptoms are classic for cubital tunnel syndrome (ulnar nerve entrapment at the elbow). Initial management should always be conservative, focusing on activity modification (avoiding prolonged elbow flexion) and night splinting with the elbow in extension to relieve tension on the ulnar nerve. Surgical intervention (cubital tunnel release or anterior transposition) is reserved for cases that fail extensive conservative management, or for severe, progressive neurological deficits. Corticosteroid injections around nerves are generally not recommended due to potential nerve damage. Observation alone is insufficient given the progressive neurological symptoms.

Question 365

Topic: Nerve & Tendon

A 25-year-old male presents with a persistent feeling of arm 'heaviness' and fatigue, swelling, and discoloration of his right upper extremity, particularly after overhead activities. He also reports numbness in his ring and little fingers. A venous Doppler confirms subclavian vein thrombosis. What is the MOST likely underlying condition?

. Cervical radiculopathy
. Cubital tunnel syndrome
. Thoracic Outlet Syndrome (TOS) - Venous Type (Paget-Schroetter)
. Brachial plexus injury
. Pancoast tumor

Correct Answer & Explanation

. Thoracic Outlet Syndrome (TOS) - Venous Type (Paget-Schroetter)

Explanation

The combination of arm heaviness, fatigue, swelling, discoloration, and subclavian vein thrombosis (Paget-Schroetter syndrome) in a young, active individual (often related to repetitive overhead activity) is highly characteristic of Venous Thoracic Outlet Syndrome (TOS). This results from compression of the subclavian vein in the costoclavicular space. Cervical radiculopathy causes nerve symptoms but not venous thrombosis. Cubital tunnel syndrome affects the ulnar nerve at the elbow. Brachial plexus injury can cause neurological deficits but typically not venous thrombosis. A Pancoast tumor is a malignancy in the lung apex causing TOS, but typically arterial or neurological, and less common in a young patient.

Question 366

Topic: Nerve & Tendon

A 42-year-old female requires open reduction and internal fixation of a Dubberley Type 2B coronal shear fracture of the capitellum extending into the trochlea. An extensile lateral approach (Kocher interval) is utilized. Distal extension of this exposure places which of the following neurologic structures at greatest risk?

. Ulnar nerve
. Median nerve
. Lateral antebrachial cutaneous nerve
. Posterior interosseous nerve
. Musculocutaneous nerve

Correct Answer & Explanation

. Posterior interosseous nerve

Explanation

The extensile lateral approach utilizes the Kocher or Kaplan interval. Distal extension of this exposure risks injury to the posterior interosseous nerve (PIN) as it courses within the supinator muscle. Supination of the forearm helps move the PIN further anteriorly and away from the surgical field.

Question 367

Topic: Nerve & Tendon

A 35-year-old carpenter presents with gradual onset of pain at the base of his thumb, worse with gripping and pinching. Examination reveals tenderness over the radial styloid and pain elicited by passively flexing the thumb into the palm and then ulnarly deviating the wrist. Which of the following conditions is most likely?

. Carpal Tunnel Syndrome
. Intersection Syndrome
. De Quervain's Tenosynovitis
. Thumb CMC Osteoarthritis
. Wartenberg's Syndrome

Correct Answer & Explanation

. De Quervain's Tenosynovitis

Explanation

The clinical presentation describes De Quervain's Tenosynovitis, an inflammatory condition affecting the abductor pollicis longus and extensor pollicis brevis tendons within the first dorsal compartment. The Finkelstein's test (flexing the thumb into the palm and then ulnarly deviating the wrist) specifically elicits pain in this condition. Carpal Tunnel Syndrome involves median nerve compression. Intersection Syndrome involves inflammation where the first and second dorsal compartment tendons cross. Thumb CMC OA pain is typically at the joint, with positive grind test. Wartenberg's Syndrome is superficial radial nerve irritation.

Question 368

Topic: Nerve & Tendon

A 60-year-old diabetic patient presents with a history of his ring finger catching and locking in flexion, especially in the morning. He describes needing to manually extend it with a 'pop'. Physical examination confirms a palpable nodule at the base of the ring finger on the palmar aspect, consistent with tenosynovitis of which tendon?

. Flexor Digitorum Superficialis
. Flexor Digitorum Profundus
. Extensor Digitorum Communis
. Flexor Pollicis Longus
. Palmaris Longus

Correct Answer & Explanation

. Flexor Digitorum Superficialis

Explanation

This classic presentation describes 'trigger finger' (stenosing tenosynovitis), which most commonly affects the flexor digitorum superficialis (FDS) and/or profundus (FDP) tendons at the A1 pulley level. The locking and palpable nodule are characteristic findings. While both FDS and FDP are involved, the FDS is often the primary culprit due to its more superficial location and larger bulk at this level. The FPL can be involved in trigger thumb. Extensor tendons are on the dorsum, and the Palmaris Longus has no role in finger flexion.

Question 369

Topic: Nerve & Tendon

A 65-year-old patient with rheumatoid arthritis develops a 'boutonniere deformity' in her middle finger. This deformity is characterized by which of the following?

. Hyperextension of the MCP joint and flexion of the PIP joint
. Flexion of the MCP joint and hyperextension of the PIP joint
. Flexion of the PIP joint and hyperextension of the DIP joint
. Hyperextension of the PIP joint and flexion of the DIP joint
. Flexion of the MCP, PIP, and DIP joints

Correct Answer & Explanation

. Hyperextension of the PIP joint and flexion of the DIP joint

Explanation

A boutonniere deformity is characterized by a fixed flexion deformity of the proximal interphalangeal (PIP) joint and compensatory hyperextension of the distal interphalangeal (DIP) joint. It results from disruption of the central slip of the extensor mechanism, allowing the lateral bands to migrate volarly and become PIP joint flexors.

Question 370

Topic: Nerve & Tendon

Which of the following conditions is an indication for surgical decompression in Carpal Tunnel Syndrome?

. Mild symptoms responding to night splinting
. Intermittent paresthesias for less than 3 months
. Thenar muscle atrophy with objective motor weakness
. Positive Phalen's and Tinel's signs without nocturnal symptoms
. Sensory deficits confirmed by nerve conduction studies but without motor involvement

Correct Answer & Explanation

. Thenar muscle atrophy with objective motor weakness

Explanation

Thenar muscle atrophy with objective motor weakness (strength less than M4/5) is a strong indication for surgical decompression of the median nerve to prevent irreversible motor loss. Mild symptoms, intermittent paresthesias, or purely sensory deficits without motor involvement can often be managed conservatively initially. While nerve conduction studies confirming severe sensory deficits can indicate surgery, motor involvement is a more urgent indicator.

Question 371

Topic: Nerve & Tendon

A 25-year-old presents with a 'mallet finger' injury after jamming his finger while playing basketball. This injury involves disruption of which anatomical structure?

. Central slip of the extensor tendon at the PIP joint
. Flexor digitorum profundus tendon insertion at the DIP joint
. Extensor digitorum communis tendon insertion at the DIP joint
. Ulnar collateral ligament of the thumb MCP joint
. Radial collateral ligament of the index finger PIP joint

Correct Answer & Explanation

. Extensor digitorum communis tendon insertion at the DIP joint

Explanation

A mallet finger results from disruption of the extensor digitorum communis (EDC) tendon insertion into the dorsal base of the distal phalanx (Zone 1 extensor injury), leading to an inability to actively extend the DIP joint. This can be a tendinous avulsion or an osseous avulsion. The central slip is involved in boutonniere deformity. FDP tendon avulsion is a 'jersey finger'. Ligament injuries are different pathologies.

Question 372

Topic: Nerve & Tendon

A patient with a high median nerve injury (e.g., at the elbow) would typically present with a characteristic 'ape hand' deformity. Which muscle is primarily responsible for the thenar eminence wasting seen in this deformity?

. Adductor Pollicis
. Flexor Pollicis Longus
. Abductor Pollicis Brevis
. First Dorsal Interosseous
. Extensor Pollicis Brevis

Correct Answer & Explanation

. Abductor Pollicis Brevis

Explanation

The 'ape hand' deformity, characterized by the inability to abduct and oppose the thumb and wasting of the thenar eminence, results from median nerve palsy. The abductor pollicis brevis (APB) is the most superficial and often the first thenar muscle to show atrophy due to median nerve compression, playing a crucial role in thumb abduction and opposition. Adductor Pollicis is ulnar nerve innervated. FPL is median nerve (AIN branch) but less related to thenar bulk. Interossei are ulnar nerve. EPB is radial nerve.

Question 373

Topic: Nerve & Tendon

Which of the following describes a typical finding of a 'Swan Neck' deformity of a finger?

. Flexion of the PIP joint and hyperextension of the DIP joint
. Hyperextension of the MCP joint and flexion of the PIP joint
. Hyperextension of the PIP joint and flexion of the DIP joint
. Flexion of the MCP, PIP, and DIP joints
. Fixed abduction of the thumb

Correct Answer & Explanation

. Hyperextension of the PIP joint and flexion of the DIP joint

Explanation

A Swan Neck deformity is characterized by hyperextension of the proximal interphalangeal (PIP) joint and compensatory flexion of the distal interphalangeal (DIP) joint. This deformity is often seen in rheumatoid arthritis due to imbalances in the extensor mechanism. The boutonniere deformity has the opposite PIP/DIP joint positions.

Question 374

Topic: Nerve & Tendon

In a patient presenting with a fractured hook of the hamate, which of the following nerves is at greatest risk of injury?

. Radial nerve
. Median nerve
. Ulnar nerve
. Anterior interosseous nerve
. Posterior interosseous nerve

Correct Answer & Explanation

. Ulnar nerve

Explanation

The ulnar nerve and artery pass through Guyon's canal, which is bounded radially by the hook of the hamate. Fractures of the hook of the hamate can directly injure or cause compression of the ulnar nerve, leading to symptoms such as paresthesias in the small finger and ulnar half of the ring finger, and weakness of ulnar-innervated intrinsic muscles. Median and radial nerves are not in direct proximity.

Question 375

Topic: Nerve & Tendon

A patient is unable to make an 'OK' sign, with compensatory hyperextension of the MCP joint of the thumb and index finger. This is indicative of a lesion to which nerve branch?

. Ulnar nerve
. Median nerve at the wrist
. Anterior interosseous nerve (AIN)
. Radial nerve
. Posterior interosseous nerve (PIN)

Correct Answer & Explanation

. Anterior interosseous nerve (AIN)

Explanation

Inability to make a proper 'OK' sign (often appearing as a flattened or 'pincer' grasp, not a true circle) with compensatory hyperextension of the MCP joints of the thumb and index finger suggests weakness of the flexor pollicis longus (FPL) and the flexor digitorum profundus (FDP) to the index finger. Both of these muscles are innervated by the Anterior Interosseous Nerve (AIN), a pure motor branch of the median nerve. A high median nerve injury would also cause this, but the AIN syndrome specifically refers to this isolated motor deficit without sensory loss.

Question 376

Topic: Nerve & Tendon

Which intrinsic muscle of the thumb is innervated by both the median and ulnar nerves in a variable proportion?

. Abductor Pollicis Brevis
. Flexor Pollicis Brevis
. Opponens Pollicis
. Adductor Pollicis
. Extensor Pollicis Brevis

Correct Answer & Explanation

. Flexor Pollicis Brevis

Explanation

The Flexor Pollicis Brevis (FPB) muscle of the thumb thenar eminence is classically described as having dual innervation. Its superficial head is typically innervated by the median nerve, while its deep head often receives innervation from the ulnar nerve. This dual supply is responsible for variations in clinical findings in median or ulnar nerve palsies. APB and Opponens Pollicis are primarily median. Adductor Pollicis is solely ulnar. EPB is radial (extrinsic).

Question 377

Topic: Nerve & Tendon

A cyclist presents with numbness in the volar aspect of the small finger and ulnar half of the ring finger, along with intrinsic muscle weakness. Sensation on the dorsoulnar aspect of the hand is preserved. Where is the most likely site of ulnar nerve compression?

. Cubital tunnel
. Arcade of Struthers
. Guyon's canal (Zone 1)
. Guyon's canal (Zone 2)
. Guyon's canal (Zone 3)

Correct Answer & Explanation

. Guyon's canal (Zone 1)

Explanation

Compression in Guyon's canal spares the dorsal ulnar cutaneous nerve, which branches off proximally to the wrist. Zone 1 compression causes mixed motor and sensory deficits, whereas Zone 2 is purely motor and Zone 3 is purely sensory.

Question 378

Topic: Nerve & Tendon

A 30-year-old cyclist presents with weakness in thumb adduction, finger abduction, and finger adduction. Sensation over the entire hand, including the small finger, is completely normal. Where is the most likely site of nerve compression?

. Cubital tunnel
. Guyon's canal Zone 1
. Guyon's canal Zone 2
. Guyon's canal Zone 3
. Arcade of Struthers

Correct Answer & Explanation

. Guyon's canal Zone 2

Explanation

Guyon's canal Zone 2 contains only the deep motor branch of the ulnar nerve. Compression here causes isolated weakness of ulnar-innervated intrinsic muscles with perfectly spared sensation.

Question 379

Topic: Nerve & Tendon

A 21-year-old rugby player sustained a "jersey finger" injury. Exploration reveals a Type I Leddy-Packer avulsion of the flexor digitorum profundus (FDP). What is the defining characteristic of this injury and its required timing for repair?

. Tendon retracted to the PIP joint; requires repair within 3 weeks
. Tendon retracted into the palm; requires repair within 7-10 days
. Bony avulsion caught at the A4 pulley; requires repair within 4 weeks
. Tendon retracted to the distal palmar crease; requires repair within 3 months
. Bony avulsion caught at the A2 pulley; delayed repair is acceptable

Correct Answer & Explanation

. Tendon retracted into the palm; requires repair within 7-10 days

Explanation

Type I jersey finger involves the FDP retracting all the way into the palm, which ruptures both the short and long vincula. Because the tendon loses its blood supply, it must be repaired early (within 7-10 days) before it undergoes irreversible necrosis and contracture.

Question 380

Topic: Nerve & Tendon

A 55-year-old male presents with a neglected mallet finger deformity (flexion deformity of the DIP joint) that occurred 6 months ago. He complains of pain and difficulty with fine motor tasks. Which of the following is the most appropriate management?

. Continued splinting for another 6 weeks.
. DIP joint fusion.
. Surgical reconstruction of the extensor tendon.
. PIP joint manipulation and casting.
. Steroid injection into the DIP joint.

Correct Answer & Explanation

. Surgical reconstruction of the extensor tendon.

Explanation

A neglected mallet finger (extensor tendon rupture at the DIP joint) of 6 months duration, causing pain and functional deficit, is unlikely to resolve with continued splinting. Surgical reconstruction of the extensor tendon is the most appropriate management in such cases, often involving tendon repair or grafting, potentially with K-wire stabilization. This aims to restore active extension at the DIP joint. DIP joint fusion is a salvage procedure for severe arthritis or failed reconstructions, sacrificing motion. PIP joint manipulation is not relevant to a DIP joint injury. Steroid injections are not indicated for tendon ruptures.

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