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Nerve & Tendon MCQs

Practice Set 48 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 941

Topic: Nerve & Tendon

What nerve is at highest risk of injury during a medial approach to the elbow?

. Radial nerve
. Median nerve
. Ulnar nerve
. Musculocutaneous nerve
. Posterior interosseous nerve

Correct Answer & Explanation

. Ulnar nerve

Explanation

The ulnar nerve is located directly posterior to the medial epicondyle and within the cubital tunnel. Any medial approach to the elbow, especially those involving dissection around the medial epicondyle or the cubital tunnel, places the ulnar nerve at the highest risk of injury. Careful identification and protection of the nerve are paramount. The median nerve is more anterior. The radial and PIN are lateral/posterior. The musculocutaneous nerve is more anterior in the arm.

Question 942

Topic: Nerve & Tendon

A 4-year-old child presents with a minimally displaced medial epicondyle fracture. The ulnar nerve is intact, and the elbow is stable. What is the most appropriate management?

. Open reduction and internal fixation to prevent nonunion
. Closed reduction with percutaneous pinning
. Long arm cast immobilization in flexion for 4-6 weeks
. Sling immobilization with early protected range of motion
. Surgical exploration to rule out ulnar nerve entrapment

Correct Answer & Explanation

. Sling immobilization with early protected range of motion

Explanation

Minimally displaced medial epicondyle fractures in children, especially when the ulnar nerve is intact and the elbow is stable, are typically managed non-operatively with sling immobilization and early protected range of motion. Surgical intervention is usually reserved for significant displacement (e.g., >1 cm or intra-articular entrapment), ulnar nerve entrapment, or elbow instability. Immobilization for too long can lead to stiffness.

Question 943

Topic: Nerve & Tendon

Which of the following describes the anatomical course of the radial nerve at the elbow, making it vulnerable to certain injuries?

. It passes directly posterior to the medial epicondyle.
. It lies superficial to the bicipital aponeurosis.
. It branches into superficial radial and posterior interosseous nerves within the cubital fossa, anterior to the lateral epicondyle.
. It passes through the cubital tunnel with the ulnar nerve.
. It courses medial to the brachial artery in the antecubital fossa.

Correct Answer & Explanation

. It branches into superficial radial and posterior interosseous nerves within the cubital fossa, anterior to the lateral epicondyle.

Explanation

The radial nerve divides into its superficial radial (sensory) and posterior interosseous (motor) branches within the cubital fossa, anterior to the lateral epicondyle and often piercing the supinator muscle (arcade of Frohse). This anatomical arrangement makes it vulnerable to injury during lateral elbow approaches, supracondylar fractures, or forearm trauma. The ulnar nerve is posterior to the medial epicondyle. The median nerve is medial to the brachial artery.

Question 944

Topic: Nerve & Tendon

A patient with a history of elbow trauma presents with a fixed flexion deformity of 40 degrees and inability to supinate beyond neutral. Radiographs show a congruent joint with no loose bodies. What is the most appropriate surgical approach for a capsular release in this patient?

. Posterior approach with triceps sparing
. Anterior approach to release the median nerve
. Combined medial and lateral approaches
. Medial approach to address the ulnar nerve
. Lateral approach only

Correct Answer & Explanation

. Combined medial and lateral approaches

Explanation

For severe, fixed flexion deformities and significant loss of forearm rotation at the elbow, a combined medial and lateral approach is often required. This allows for comprehensive release of both the anterior and posterior capsule (often through a single posterior incision with lateral and medial extensions or separate incisions), excision of heterotopic ossification, and neurolysis of the ulnar nerve if needed. Isolated lateral or medial approaches are insufficient for global contracture. An anterior approach to release the median nerve is not the primary target for contracture release.

Question 945

Topic: Nerve & Tendon

In an anterior approach to the elbow, which major neurovascular structure is located medially and is at risk?

. Radial nerve
. Ulnar nerve
. Median nerve and brachial artery
. Musculocutaneous nerve
. Posterior interosseous nerve

Correct Answer & Explanation

. Median nerve and brachial artery

Explanation

In an anterior approach to the elbow (e.g., for distal humerus fractures or contracture release), the median nerve and brachial artery run together in the medial aspect of the antecubital fossa and are the primary neurovascular structures at risk. They should be identified and protected. The ulnar nerve is more medial and posterior. The radial nerve and its branches are more lateral.

Question 946

Topic: Nerve & Tendon

A patient is undergoing surgical repair of a distal biceps tendon rupture using a single anterior incision. Which nerve is most at risk during the drilling of the radial tuberosity for tendon reinsertion?

. Ulnar nerve
. Median nerve
. Posterior interosseous nerve (PIN)
. Lateral cutaneous nerve of the forearm
. Anterior interosseous nerve (AIN)

Correct Answer & Explanation

. Posterior interosseous nerve (PIN)

Explanation

When performing a single anterior incision approach for distal biceps tendon repair, especially during drilling or placing anchors into the radial tuberosity, the posterior interosseous nerve (PIN) is at significant risk. The PIN wraps around the radial neck and passes through the supinator muscle, which lies directly over the radial tuberosity. Hyperpronation of the forearm during the procedure is critical to move the PIN away from the drilling path. The median and AIN are more medial, the ulnar nerve is posterior, and the lateral cutaneous nerve of the forearm is superficial and sensory.

Question 947

Topic: Nerve & Tendon

Which of the following conditions is LEAST likely to be confused with lateral epicondylitis based on clinical presentation and physical examination?

. Radial tunnel syndrome
. Cervical radiculopathy (C6/C7)
. Posterior interosseous nerve (PIN) entrapment
. Ulnar neuropathy at the elbow (cubital tunnel syndrome)
. Radiohumeral osteoarthritis

Correct Answer & Explanation

. Ulnar neuropathy at the elbow (cubital tunnel syndrome)

Explanation

Ulnar neuropathy at the elbow (cubital tunnel syndrome) primarily causes pain and paresthesias in the medial forearm and little/ring fingers, with motor weakness in ulnar-innervated intrinsic hand muscles. Its location and symptom distribution are distinct from lateral elbow pain, making it the least likely to be confused with lateral epicondylitis. Radial tunnel syndrome, PIN entrapment, cervical radiculopathy (which can refer pain to the lateral elbow/forearm), and radiohumeral osteoarthritis (with lateral elbow pain and mechanical symptoms) are all important differential diagnoses for lateral epicondylitis.

Question 948

Topic: Nerve & Tendon

Which factor has been shown to be a positive prognostic indicator for successful non-operative treatment of lateral epicondylitis?

. Long duration of symptoms (over 6 months)
. High pain intensity at presentation
. Presence of concomitant radial tunnel syndrome
. Early initiation of physical therapy within 6 weeks of symptom onset
. Significant tears on MRI

Correct Answer & Explanation

. Early initiation of physical therapy within 6 weeks of symptom onset

Explanation

Early initiation of physical therapy, especially eccentric strengthening, tends to be associated with better outcomes in non-operative management. Long duration of symptoms generally predicts a more difficult course. High pain intensity may correlate with greater pathology and potentially longer recovery. Concomitant radial tunnel syndrome complicates treatment and may require addressing both conditions. Significant tears on MRI might indicate a more severe condition that could be less responsive to non-operative treatment, though small tears can still heal conservatively.

Question 949

Topic: Nerve & Tendon

A patient is referred to you for chronic lateral elbow pain. You suspect radial tunnel syndrome as a differential. Which physical examination maneuver would be most helpful in differentiating radial tunnel syndrome from lateral epicondylitis?

. Pain with resisted wrist extension (Cozen's test).
. Pain with resisted middle finger extension (Maudsley's test).
. Tenderness over the lateral epicondyle.
. Pain with resisted supination of the forearm.
. Pain with passive wrist flexion with the elbow extended (Mill's test).

Correct Answer & Explanation

. Pain with resisted supination of the forearm.

Explanation

While there can be overlap, pain with resisted supination of the forearm, especially when the elbow is extended, specifically stresses the supinator muscle, under which the posterior interosseous nerve (PIN) passes, making it a key maneuver for diagnosing radial tunnel syndrome. The other tests (Cozen's, Maudsley's, Mill's, and lateral epicondyle tenderness) are classic signs of lateral epicondylitis, though some can be mildly positive in radial tunnel due to proximity or associated inflammation.

Question 950

Topic: Nerve & Tendon

Which of the following describes the most common anatomical site of compression for the posterior interosseous nerve (PIN) in radial tunnel syndrome?

. Arcade of Struthers
. Fibrous arch of the supinator muscle (Arcade of Frohse)
. Ligament of Struthers
. Medial intermuscular septum
. Between the two heads of the pronator teres

Correct Answer & Explanation

. Fibrous arch of the supinator muscle (Arcade of Frohse)

Explanation

The most common anatomical site of compression for the posterior interosseous nerve (PIN) in radial tunnel syndrome is the fibrous arch of the supinator muscle, known as the Arcade of Frohse. The Arcade of Struthers and Ligament of Struthers are associated with high median nerve compression. The medial intermuscular septum is relevant to the ulnar nerve. Compression between the two heads of the pronator teres is a site for median nerve entrapment (pronator syndrome).

Question 951

Topic: Nerve & Tendon

Which intrinsic muscle of the hand is innervated by the ulnar nerve and commonly tested for weakness in cases of suspected ulnar neuropathy, a condition distinct from lateral epicondylitis?

. Abductor pollicis brevis
. Flexor pollicis longus
. First dorsal interosseous
. Opponens pollicis
. Flexor digitorum profundus to the index finger

Correct Answer & Explanation

. First dorsal interosseous

Explanation

The first dorsal interosseous muscle is a key intrinsic hand muscle innervated by the ulnar nerve. Weakness here, along with other ulnar-innervated intrinsic muscles, is a hallmark of ulnar neuropathy (e.g., cubital tunnel syndrome). The abductor pollicis brevis, opponens pollicis, and flexor pollicis longus are primarily innervated by the median nerve. Flexor digitorum profundus is median and ulnar nerve-innervated, but the specific finger innervation varies.

Question 952

Topic: Nerve & Tendon

A patient with lateral epicondylitis symptoms also describes numbness and tingling in the thumb and index finger. Which additional diagnostic consideration becomes critical?

. Ulnar nerve entrapment
. Median nerve entrapment (e.g., carpal tunnel syndrome or pronator syndrome)
. Cervical radiculopathy
. Thoracic outlet syndrome
. All of the above

Correct Answer & Explanation

. All of the above

Explanation

Numbness and tingling in the thumb and index finger suggest involvement of the median nerve (e.g., carpal tunnel, pronator syndrome) or cervical radiculopathy at C6 or C7. While ulnar nerve entrapment affects the little and ring fingers, and thoracic outlet syndrome can affect various nerves, the specific distribution (thumb and index finger) makes median nerve and cervical radiculopathy particularly critical to consider alongside lateral epicondylitis. Therefore, to ensure a comprehensive differential, 'All of the above' encompasses the potential for multiple etiologies or concomitant conditions.

Question 953

Topic: Nerve & Tendon

When performing an elbow examination for lateral epicondylitis, which nerve should be assessed for potential concurrent entrapment or irritation that might contribute to lateral elbow pain?

. Ulnar nerve
. Median nerve
. Musculocutaneous nerve
. Posterior interosseous nerve (PIN)
. Anterior interosseous nerve (AIN)

Correct Answer & Explanation

. Posterior interosseous nerve (PIN)

Explanation

The Posterior Interosseous Nerve (PIN), a motor branch of the radial nerve, passes through the supinator muscle in the radial tunnel, an area anatomically close to the common extensor origin. Entrapment of the PIN (or the radial nerve proper in the radial tunnel) is a key differential diagnosis for lateral epicondylitis and can sometimes coexist or mimic it, causing lateral elbow pain and forearm symptoms. Therefore, assessing for PIN involvement (e.g., specific motor weakness) is crucial. The ulnar, median, musculocutaneous, and anterior interosseous nerves are located more medially or anteriorly and are less directly implicated in lateral epicondyle pain etiology, though all upper extremity nerves should be considered in a comprehensive exam if symptoms warrant.

Question 954

Topic: Nerve & Tendon

A surgeon performs a primary distal biceps tendon repair utilizing a single-incision anterior approach. Postoperatively, the patient reports numbness and tingling along the radial aspect of the forearm. Which nerve is most likely injured?

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

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve (LABC)

Explanation

The lateral antebrachial cutaneous nerve (LABC) is the most commonly injured nerve during a single-incision anterior approach to the distal biceps. It courses just lateral to the biceps tendon in the subcutaneous tissue. The PIN is more at risk during a two-incision approach or if retractors are placed too deeply on the radial neck.

Question 955

Topic: Nerve & Tendon

During surgical decompression of the ulnar nerve for cubital tunnel syndrome, a tight fascial band spanning between the olecranon and the medial epicondyle is identified overlying the two heads of the flexor carpi ulnaris (FCU). What is the anatomical name of this structure?

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

Correct Answer & Explanation

. Osborne's ligament

Explanation

Osborne's ligament (or the cubital tunnel retinaculum) forms the roof of the cubital tunnel, bridging the olecranon and medial epicondyle over the two heads of the FCU. The Arcade of Struthers is a fascial band approximately 8 cm proximal to the medial epicondyle. The Ligament of Struthers is associated with the median nerve and a supracondylar process.

Question 956

Topic: Nerve & Tendon

A 42-year-old recreational weightlifter undergoes an anterior single-incision approach for a distal biceps tendon repair. Which of the following is the most common neurologic complication specifically associated with this surgical approach?

. Posterior interosseous nerve palsy
. Lateral antebrachial cutaneous nerve neuropraxia
. Median nerve injury
. Ulnar nerve entrapment
. Superficial radial nerve palsy

Correct Answer & Explanation

. Lateral antebrachial cutaneous nerve neuropraxia

Explanation

The lateral antebrachial cutaneous nerve (LABCN) is the most frequently injured nerve during a single-incision anterior approach to the distal biceps, due to its proximity to the cephalic vein and the superficial dissection plane. Posterior interosseous nerve (PIN) injury is also a severe risk if retractors are placed too deeply or blindly on the radial neck, but LABCN neuropraxia is significantly more common.

Question 957

Topic: Nerve & Tendon

A 40-year-old carpenter presents with numbness in his small finger and the ulnar half of the ring finger. During an in situ decompression for cubital tunnel syndrome, the surgeon releases a thick fascial band spanning between the olecranon and the medial epicondyle (connecting the two heads of the flexor carpi ulnaris). What is the eponym for this specific structure?

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

Correct Answer & Explanation

. Osborne's ligament

Explanation

Osborne's ligament (or the arcuate ligament) forms the roof of the cubital tunnel. It is a fibrous band connecting the humeral and ulnar heads of the flexor carpi ulnaris (FCU), spanning from the medial epicondyle to the olecranon. Release of this structure is the key step in surgical decompression of the ulnar nerve at the elbow. The Arcade of Struthers is a different potential compression site located 8-10 cm proximal to the medial epicondyle.

Question 958

Topic: Nerve & Tendon

A 28-year-old competitive weightlifter presents with medial elbow pain and parasthesias in the ring and small fingers. He describes feeling two distinct 'snaps' at the posteromedial elbow when moving from flexion to extension under load. The first snap corresponds to the ulnar nerve dislocating over the medial epicondyle. What anatomical structure is responsible for the second snap?

. Subluxation of the anterior band of the MUCL
. Subluxation of the medial head of the triceps
. Dislocation of the anconeus epitrochlearis
. Snapping of the common flexor tendon
. Subluxation of the lateral head of the triceps

Correct Answer & Explanation

. Subluxation of the medial head of the triceps

Explanation

Snapping triceps syndrome involves the sequential dislocation of the ulnar nerve and the medial head of the triceps over the medial epicondyle during elbow flexion, creating two distinct palpable and audible snaps. Hypertrophy of the medial head of the triceps in weightlifters is a common predisposing factor. Management often requires surgical transposition of the ulnar nerve and excision of the subluxating portion of the medial triceps head.

Question 959

Topic: Nerve & Tendon

A 28-year-old weightlifter presents with medial elbow pain and a snapping sensation when moving from flexion to extension. Examination shows ulnar neuropathy symptoms and a palpable 'double snap' over the medial epicondyle during flexion. Ultrasound demonstrates dynamic subluxation of the ulnar nerve along with an adjacent muscular structure. What is the involved muscular structure?

. Anconeus epitrochlearis
. Medial head of the triceps
. Brachialis
. Pronator teres
. Flexor carpi ulnaris

Correct Answer & Explanation

. Medial head of the triceps

Explanation

Snapping triceps syndrome occurs when the medial head of the triceps dynamically subluxates over the medial epicondyle during elbow flexion. It often pushes the ulnar nerve out of the cubital tunnel ahead of it, causing a characteristic 'double snap' (first the nerve, then the triceps) and secondary ulnar neuropathy.

Question 960

Topic: Nerve & Tendon

A 40-year-old male presents with cubital tunnel syndrome. During surgical decompression, the surgeon explores potential sites of ulnar nerve compression. Which of the following anatomic structures is located approximately 8 cm proximal to the medial epicondyle?

. Osborne's ligament
. Medial intermuscular septum
. Arcade of Frohse
. Lacertus fibrosus
. Arcade of Struthers

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 approximately 8 cm proximal to the medial epicondyle. It is a known potential site of ulnar nerve compression, especially if the nerve is transposed anteriorly without adequate proximal release. Osborne's ligament is at the level of the epicondyle (spanning the two heads of FCU).

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