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 101
Topic: Nerve & Tendon
The ulnar nerve arises from:
Correct Answer & Explanation
. The medial cord of the brachial plexus containing fibers from the C 8 and T1 nerve roots.
Explanation
The ulnar nerve is the continuation of the medial cord of the brachial plexus containing fibers of the C 8 and T1 nerve roots. Radiculopathy at the C 8-T1 level may mimic a more distal compression of the nerve in the cubital tunnel. The axillary and radial nerves come off the posterior cord. There is no lateral trunk of the brachial plexus. The nerve to the rhomboids comes directly off of the C 5 nerve root and its presence is often helpful in differentiating pre-ganglionic from post-ganglionic lesions of the brachial plexus. The lateral cord forms the musculocutaneous nerve. The medial cord forms the ulnar nerve. The medial and lateral cords form the median nerve. The radial nerve arises from the posterior cord.
Question 102
Topic: Nerve & Tendon
Which of the following statements is true:
Correct Answer & Explanation
. Wartenberg's sign and Wartenberg's syndrome are both related to radial nerve compression.
Explanation
The PIN contains motor fibers to the EDC , EDQP, EC U, APL, EPB, EPL, and EIP. Occasionally it gives motor fibers to the EC RB. It terminates with a sensory branch to the carpus and wrist capsule. There is, however, no cutaneous sensation. In radial tunnel syndrome, the entire radial nerve is compressed, including a sensory component. The radial nerve passes posteriorly and laterally next to the humerus, but not with the radial artery. Wartenberg's sign is an isolated ulnar nerve palsy. This syndrome relates to the compression of the superficial branch of the radial nerve. The most common site of radial nerve compression is the arcade of Frohse.
Question 103
Topic: Nerve & Tendon
The treatment of stenosing tenosynovitis should include all of the following except:
Correct Answer & Explanation
. Release of the A1 pulley.
Explanation
The A2 pulley should not be released as part of the treatment for trigger finger. Its presence, along with the A4 pulley, is important in maintaining efficient flexor tendon function. The pathology usually involves the A1 pulley and its release is usually all that is necessary. Other modalities include NSAIDs, splinting, tenosynovectomy, and steroid injections.
Question 104
Topic: Nerve & Tendon
Which of the following identifies the clinical finding of inadvertent hyperextension of the thumb metacarpophalangeal joint during attempted thumb-index finger pinch?
Correct Answer & Explanation
. Jeanne's sign
Explanation
Jeanne's sign identifies thumb metacarpophalangeal joint hyperextension of 10° to 15° with key pinch or gross grip. Froment's sign refers to the exaggeration of thumb interphalangeal joint flexion during key pinch by the flexor pollicis longus in ulnar nerve palsies. Wartenberg's sign is the inability to adduct the extended small finger due to an ulnar nerve palsy. Duchenne's sign refers to clawing of the ring and small fingers. Pollock's sign is the inability to flex the distal interphalangeal joints of the ring and small fingers in high palsies.
Question 105
Topic: Nerve & Tendon
The following pair of tendons is affected in De Quervain disease:
Correct Answer & Explanation
. Abductor pollicis longus and extensor pollicis brevis
Explanation
De Quervain disease affects the tendons in the first dorsal compartment, the extensor pollicis brevis and the abductor pollicis longus (consisting of 2 to 7 individual tendon slips). The extensor pollicis longus traverses the third dorsal compartment. The abductor pollicis brevis and the opponens pollicis are thenar muscles and do not lie within any of the dorsal compartments.
Question 106
Topic: Nerve & Tendon
Poor or incomplete resolution of symptoms following first dorsal compartment release for De Quervain disease would most likely occur as a result of:
Correct Answer & Explanation
. Incomplete release
Explanation
The most common reason for recurrent or persistent symptoms of first dorsal compartment stenosis is failure to recognize and release a separate extensor pollicis brevis subsheath. The superficial radial sensory nerve may be injured in surgery for De Quervain disease, but the resulting neuroma is often more painful than the original symptoms and is of a different character. Abductor pollicis longus laceration would result in loss of radial abduction of the thumb. Early motion of the thumb is recommended following release of the first dorsal compartment.
Question 107
Topic: Nerve & Tendon
All of the following may be seen with preganglionic lesion EXC EPT:
Correct Answer & Explanation
. Tinel sign
Explanation
Tinel sign is seen with postganglionic lesions.
Question 108
Topic: Nerve & Tendon
A 6-year-old child sustains a severely displaced extension-type supracondylar fracture of the humerus. Which nerve is most commonly injured in this specific fracture pattern?
Correct Answer & Explanation
. Anterior interosseous nerve
Explanation
The anterior interosseous nerve (AIN), a branch of the median nerve, is the most commonly injured nerve in extension-type supracondylar humerus fractures due to the anterior displacement of the proximal fracture fragment.
Question 109
Topic: Nerve & Tendon
A patient sustains a severe laceration to the proximal forearm, completely transecting the median nerve. However, clinical examination reveals intact intrinsic function of the hand typically supplied by the ulnar nerve, and unexpectedly, intact thenar muscle function. Which of the following anatomical anomalies best explains this physical examination finding?
Correct Answer & Explanation
. Martin-Gruber anastomosis
Explanation
The Martin-Gruber anastomosis is a communication between the median and ulnar nerves in the forearm. It typically carries motor fibers from the median nerve to the ulnar nerve, preserving thenar and intrinsic muscle function despite a proximal median nerve injury.
Question 110
Topic: Nerve & Tendon
A 30-year-old male presents with a displaced spiral fracture of the distal third of the humeral shaft. He is scheduled for open reduction and internal fixation via an anterolateral approach. During the deep dissection, the surgeon carefully identifies the interval between the biceps and brachialis muscles. As the dissection proceeds distally to expose the fracture, which critical neurovascular structure must be meticulously identified and protected as it pierces the lateral intermuscular septum to enter the anterior compartment?
Correct Answer & Explanation
. D. Radial nerve
Explanation
Correct Answer: DThe case content explicitly states: 'The radial nerve is the most frequently injured nerve in humeral shaft fractures. It courses in the spiral groove posteriorly, crossing from medial to lateral. Approximately 10-14 cm proximal to the lateral epicondyle, it pierces the lateral intermuscular septum to enter the anterior compartment, lying between the brachialis and brachioradialis muscles in the distal arm. For direct anterior or anterolateral approaches to the shaft, the radial nerve is generally posterior to the plane of dissection (i.e., posterior to the brachialis). However, extensive distal anterior dissection or inadvertent posterior extension of the plane places the nerve at risk.'Option A (Musculocutaneous nerve):The musculocutaneous nerve pierces the coracobrachialis more proximally and lies between the biceps and brachialis. While important, it is not the nerve that pierces the lateral intermuscular septum in the distal arm.Option B (Median nerve):The median nerve lies medially within the neurovascular bundle and does not pierce the lateral intermuscular septum.Option C (Ulnar nerve):The ulnar nerve also lies medially and then courses posteriorly around the medial epicondyle distally; it does not pierce the lateral intermuscular septum.Option E (Brachial artery):The brachial artery lies medially with the median nerve and does not pierce the lateral intermuscular septum.
Question 111
Topic: Nerve & Tendon
A 55-year-old female presents with insidious onset of pain at the base of her right thumb, exacerbated by pinch and grasp. She reports similar, milder symptoms in her left thumb. Her mother also suffered from "thumb arthritis." Which of the following is the most accurate statement regarding the epidemiology and risk factors for this condition?
Correct Answer & Explanation
. The prevalence of thumb CMC OA is estimated to be between 16% and 25% in the general adult population, with a notable female predominance.
Explanation
Correct Answer: CThe case states: "Epidemiological studies estimate its prevalence to be between 16% and 25% in the general adult population, with a notable increase with age, affecting over 30% of women and 10% of men over 50 years. Women are disproportionately affected..." This directly supports option C.Option A is incorrect as the prevalence is higher in women. Option B is incorrect; the case lists generalized ligamentous laxity as a risk factor, not a protective factor. Option D is incorrect; the case explicitly states, "Repetitive thumb use... are also implicated" as risk factors for thumb CMC OA. Option E is incorrect; prior trauma is a risk factor for developing CMC OA, but it is not listed as an absolute contraindication to surgical management, although it might influence the choice of procedure or prognosis.
Question 112
Topic: Nerve & Tendon
A 32-year-old man presents with a painful, swollen PIP joint after a sports injury. Examination reveals a volar PIP dislocation. Which of the following complications is most likely if the primary injured structure is not properly treated?
Correct Answer & Explanation
. Boutonniere deformity
Explanation
Volar PIP dislocations frequently result in injury to the central slip of the extensor tendon. If untreated, the lateral bands subluxate volarly, leading to a Boutonniere deformity (PIP flexion and DIP hyperextension).
Question 113
Topic: Nerve & Tendon
A 20-year-old collegiate baseball player sustains a hook of the hamate fracture. Nonoperative management has failed. During surgical excision of the hook, which nerve is at greatest risk of iatrogenic injury?
Correct Answer & Explanation
. Deep motor branch of the ulnar nerve
Explanation
The deep motor branch of the ulnar nerve curves directly around the distal aspect of the hook of the hamate. It is highly susceptible to injury during excision of the hamate hook.
Question 114
Topic: Nerve & Tendon
If surgical intervention is warranted for the 42-year-old female with a stiff elbow, and she has a limitation of elbow flexion of 90 to 100 degrees, which of the following structures needs to be prophylactically addressed when performing an osteocapsular release?
Correct Answer & Explanation
. Ulnar nerve
Explanation
Correct Answer: AProphylactic treatment of the ulnar nerve (typically decompression or transposition) should be performed before an osteocapsular release in patients with significant elbow stiffness, especially if flexion is limited to 90-100 degrees or less. Anatomic studies have demonstrated that the cubital tunnel significantly decreases in size with elbow flexion greater than 90 degrees, leading to a corresponding increase in pressure on the ulnar nerve. After an osteocapsular release, the elbow's range of motion, particularly flexion, is expected to improve. This increased flexion can place the ulnar nerve under greater tension or compression, potentially exacerbating pre-existing neuropathy or inducing new symptoms. Given the patient's history of previous ulnar nerve surgery, the nerve is already vulnerable, making prophylactic management even more critical. The other structures listed are important for elbow stability or anatomy but are not typically prophylactically addressed in the same manner to prevent iatrogenic nerve compression from increased range of motion.
Question 115
Topic: Nerve & Tendon
Which median nerve symptom is most common in the acute phase following a Colles fracture?
Correct Answer & Explanation
. Paresthesia in the thumb, index, and middle fingers
Explanation
Correct Answer: CIn the acute phase following a Colles fracture, compression or contusion of the median nerve at the carpal tunnel level is common due to swelling and hematoma. This typically presents as paresthesia (numbness and tingling) in the median nerve distribution: the thumb, index finger, middle finger, and radial half of the ring finger. Thenar muscle atrophy is a sign of chronic median nerve compression. Sensory loss in the ulnar digits indicates ulnar nerve involvement. Wrist drop indicates radial nerve palsy. Tinel's sign over the cubital tunnel relates to ulnar nerve compression at the elbow.
Question 116
Topic: Nerve & Tendon
A 6-year-old boy falls from the monkey bars and sustains an extension-type supracondylar humerus fracture. Upon neurologic examination, he is unable to flex the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger. Which nerve has most likely been injured?
Correct Answer & Explanation
. Anterior interosseous nerve
Explanation
The anterior interosseous nerve (AIN), a branch of the median nerve, is the most commonly injured nerve in extension-type supracondylar humerus fractures. Injury presents as the inability to make an 'OK' sign due to weakness of the flexor pollicis longus and flexor digitorum profundus to the index finger.
Question 117
Topic: Nerve & Tendon
The origin of the lumbrical muscles from the flexor digitorum profundus (FDP) tendons serves as the functional anatomic boundary between which two flexor tendon zones in the hand?
Correct Answer & Explanation
. Zones II and III
Explanation
Zone II begins at the proximal edge of the A1 pulley, which corresponds to the distal palmar crease where the lumbrical muscles originate from the FDP tendons. Zone III is located proximal to this boundary, strictly within the palm.
Question 118
Topic: Nerve & Tendon
A 21-year-old rugby player presents with an inability to actively flex the distal interphalangeal joint of his ring finger after grabbing an opponent's jersey. Examination reveals a tender mass in the palm. According to the Leddy-Packer classification, what is the recommended timeframe for surgical intervention for this specific injury pattern?
Correct Answer & Explanation
. Within 7 to 10 days
Explanation
This is a Type I FDP avulsion (jersey finger) where the tendon retracts into the palm, completely disrupting its vincula blood supply. Early surgical repair within 7 to 10 days is critical to prevent tendon necrosis and fixed contracture.
Question 119
Topic: Nerve & Tendon
A 28-year-old carpenter sustains a deep laceration to the volar aspect of his index finger precisely at the level of the proximal interphalangeal (PIP) joint, severing both the FDS and FDP tendons. In which flexor tendon zone did this injury occur?
Correct Answer & Explanation
. Zone II
Explanation
Zone II extends from the proximal edge of the A1 pulley to the insertion of the flexor digitorum superficialis (FDS) tendon near the PIP joint. Historically called 'no man's land', injuries here involve both FDS and FDP within the tight fibro-osseous sheath.
Question 120
Topic: Nerve & Tendon
During the deltopectoral approach for open reduction and internal fixation of a proximal humerus fracture, as planned for the patient in the case, which of the following anatomical structures is most susceptible to iatrogenic injury?
Correct Answer & Explanation
. C. Axillary nerve
Explanation
Correct Answer: CThe axillary nerve is the most vulnerable neurovascular structure during a deltopectoral approach for proximal humerus plating. It courses around the surgical neck of the humerus, approximately 5-7 cm distal to the acromion, and innervates the deltoid and teres minor muscles. Retraction of the deltoid or placement of screws too distally can put this nerve at significant risk of injury, leading to deltoid weakness and sensory deficits over the lateral shoulder.Option A (Radial nerve):The radial nerve is primarily at risk with humeral shaft fractures or approaches to the posterior humerus, not typically the deltopectoral approach for the proximal humerus.Option B (Ulnar nerve):The ulnar nerve is located medially in the arm and elbow, far from the surgical field of a deltopectoral approach.Option D (Median nerve):The median nerve is also located medially in the arm, distant from the proximal humerus surgical site.Option E (Long thoracic nerve):The long thoracic nerve innervates the serratus anterior and is located on the chest wall, not typically at risk during a deltopectoral approach to the proximal humerus.
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