Menu

7. Hand and Wrist MCQs

Practice Set 185 of 266

This practice set contains high-yield board review questions covering key concepts in 7. Hand and Wrist. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 3681

Topic: Nerve & Tendon

A 32-year-old patient underwent FDP repair for a Type I Jersey finger 4 weeks ago. He is now in the early active motion phase of rehabilitation. He complains of pain and tenderness at the DIP joint with active flexion, but passive range of motion is full. What is the most common concern at this stage?

. Re-rupture of the FDP tendon.
. Persistent swelling and inflammation.
. Improper splint application causing pressure points.
. Developing adhesions limiting tendon glide.
. Early signs of infection.

Correct Answer & Explanation

. Developing adhesions limiting tendon glide.

Explanation

In the early active motion phase (typically starting around 3-4 weeks), pain with active motion combined with full passive range of motion is a common sign of developing adhesions within the flexor sheath. Adhesions restrict the smooth gliding of the tendon, causing pain when the patient attempts to actively move the digit against the resistance of the adhesions. Re-rupture would present with loss of active motion. Persistent swelling and infection would have more generalized symptoms. Improper splint application could cause pressure, but the specific presentation points to adhesions.

Question 3682

Topic: 7. Hand and Wrist

Which of the following describes the anatomical pathway of the FDP tendon from its muscle belly to its insertion?

. Originates from the medial epicondyle, passes through carpal tunnel, inserts on middle phalanx.
. Originates from the forearm interosseous membrane and ulna, passes through carpal tunnel, inserts on distal phalanx.
. Originates from the distal radius, passes through Guyon's canal, inserts on proximal phalanx.
. Originates from the lateral epicondyle, passes superficial to carpal tunnel, inserts on base of proximal phalanx.
. Originates from the deep forearm muscles, passes over the FDS, inserts on the base of the middle phalanx.

Correct Answer & Explanation

. Originates from the forearm interosseous membrane and ulna, passes through carpal tunnel, inserts on distal phalanx.

Explanation

The Flexor Digitorum Profundus (FDP) muscle originates from the anterior and medial surfaces of the ulna and the interosseous membrane. Its tendons pass through the carpal tunnel deep to the FDS tendons, and each tendon inserts onto the palmar base of the distal phalanx of the four medial fingers (index, long, ring, small). The other options describe incorrect origins, pathways, or insertions.

Question 3683

Topic: 7. Hand and Wrist

A 45-year-old professional pianist sustains a Jersey finger (Type I) of his long finger. He presents 6 weeks post-injury. What is the most appropriate treatment option at this delayed presentation?

. Primary repair with bone anchor, due to preserved tendon length.
. Non-operative management with extensive hand therapy to regain passive motion.
. FDP advancement, possibly with a flexor tenodesis of the FDS.
. Staged tendon reconstruction using a silicone rod and subsequent tendon graft.
. Amputation of the digit to prevent contracture.

Correct Answer & Explanation

. Staged tendon reconstruction using a silicone rod and subsequent tendon graft.

Explanation

At 6 weeks, a Type I Jersey finger is considered a chronic injury. Significant tendon retraction and shortening would have occurred, making direct primary repair or FDP advancement (which is typically for gaps <1cm) impossible without excessive tension leading to quadriga or re-rupture. Therefore, staged tendon reconstruction using a silicone rod followed by a tendon graft is the most appropriate option to reconstruct the flexor mechanism and restore function. Non-operative management will not restore active DIP flexion. Amputation is a last resort.

Question 3684

Topic: 7. Hand and Wrist
In a patient presenting with an acute Jersey finger, an X-ray is primarily useful for what purpose?
. To assess the extent of soft tissue swelling.
. To confirm the presence of a complete FDP tear.
. To identify an associated avulsion fracture of the distal phalanx.
. To visualize the retracted tendon and assess its position.
. To evaluate the integrity of the flexor pulley system.

Correct Answer & Explanation

. To identify an associated avulsion fracture of the distal phalanx.

Explanation

Plain radiographs (X-rays) are crucial in the initial evaluation of a Jersey finger to identify the presence and size of any associated avulsion fracture from the palmar aspect of the distal phalanx. This bony fragment helps classify the injury (e.g., Type III, IV, V) and influences treatment urgency and technique. X-rays are not good for assessing soft tissue swelling, confirming tendon tears (clinical exam or MRI better), visualizing retracted tendons (MRI better), or evaluating pulley integrity (MRI or dynamic ultrasound better).

Question 3685

Topic: Nerve & Tendon

What is the typical timeframe within which a Leddy and Packer Type I Jersey finger repair should ideally be performed to achieve the best outcomes and prevent tendon necrosis?

. Within 24 hours.
. Within 7-10 days.
. Within 3 weeks.
. Within 6 weeks.
. Anytime within 3 months, as long as appropriate rehabilitation is followed.

Correct Answer & Explanation

. Within 7-10 days.

Explanation

A Type I Jersey finger involves the FDP tendon avulsing without a bony fragment and retracting into the palm, often losing its blood supply from the vincula. This puts the tendon at high risk of necrosis. Therefore, surgical repair is considered urgent and should ideally be performed within 7-10 days of injury to maximize the chances of tendon survival and good functional outcome. Delays beyond this window significantly increase the risk of poor healing, tendon shortening, and the need for more complex reconstructive procedures.

Question 3686

Topic: 7. Hand and Wrist

When reattaching the FDP tendon to the distal phalanx, what is the anatomical landmark for its insertion?

. The proximal edge of the A4 pulley.
. The palmar base of the middle phalanx.
. The dorsal base of the distal phalanx.
. The palmar base of the distal phalanx.
. The lateral aspect of the distal phalanx.

Correct Answer & Explanation

. The palmar base of the distal phalanx.

Explanation

The FDP tendon inserts onto the palmar base of the distal phalanx. This is the anatomical location where the tendon typically avulses in a Jersey finger injury, and it is the target for reattachment during surgical repair, whether directly to bone or to a bony fragment. The other options describe incorrect insertion points for the FDP tendon.

Question 3687

Topic: 7. Hand and Wrist
Which of the following statements about FDP advancement in Jersey finger repair is most accurate?
. It is the preferred technique for chronic ruptures with large gaps.
. It typically involves shortening the FDS tendon to compensate for FDP loss.
. It is suitable for acute ruptures with minimal tendon retraction (typically < 1 cm).
. It eliminates the risk of a quadriga effect.
. It is primarily used for Type III injuries with bony avulsion.

Correct Answer & Explanation

. It is suitable for acute ruptures with minimal tendon retraction (typically < 1 cm).

Explanation

FDP advancement involves pulling the FDP tendon distally and reattaching it to the distal phalanx. It is a viable technique for acute FDP ruptures, especially Type I, where the tendon has retracted but the gap is small (typically less than 1 cm), allowing for a tension-free repair. It is generally not suitable for chronic ruptures or large gaps due to the risk of excessive tension leading to a quadriga effect or re-rupture. It does not shorten the FDS, and it is not primarily for Type III injuries (which involve bony reattachment).

Question 3688

Topic: Nerve & Tendon

A patient is recovering from a FDP repair. He develops a 'swan neck deformity,' characterized by PIP hyperextension and DIP flexion. Which of the following is the most likely contributing factor in the context of a healed FDP repair?

. Flexor sheath adhesions limiting FDP excursion.
. Re-rupture of the FDP tendon.
. Laxity of the radial collateral ligament of the PIP joint.
. Chronic inflammation of the extensor mechanism.
. Over-tightening of the FDS tendon during surgery.

Correct Answer & Explanation

. Flexor sheath adhesions limiting FDP excursion.

Explanation

While swan neck deformity is classically associated with rheumatoid arthritis or other pathologies, it can occur after flexor tendon repair. If there are adhesions limiting the excursion of the FDP tendon, it can lead to a relative laxity of the FDP at the DIP joint. This laxity, combined with the normal pull of the extensor mechanism and potentially the intrinsic muscles, can result in PIP hyperextension and DIP flexion. Re-rupture would present with loss of active DIP flexion. The other options are less directly linked to FDP repair. Over-tightening of the FDS could lead to PIP flexion contracture, not hyperextension.

Question 3689

Topic: 7. Hand and Wrist

When using a pull-out suture technique for FDP repair, what is the primary purpose of the small button or plate on the dorsal aspect of the fingertip?

. To provide counter-pressure for DIP joint immobilization.
. To serve as an anchor point for the suture to secure the tendon to the distal phalanx.
. To protect the nail bed during rehabilitation.
. To indicate the proper tension of the repair.
. To prevent inadvertent removal of the splint.

Correct Answer & Explanation

. To serve as an anchor point for the suture to secure the tendon to the distal phalanx.

Explanation

In the pull-out suture technique, sutures are passed through the repaired FDP tendon, through the distal phalanx, and exit dorsally through the fingertip. A small button or plate is then tied over the dorsal skin or nail, acting as an external anchor. This provides a secure fixation point for the suture, holding the FDP tendon against the distal phalanx until healing occurs. It's a method of securing the repair without needing internal hardware. It doesn't primarily immobilize the joint, protect the nail, or indicate tension.

Question 3690

Topic: Nerve & Tendon

Which of the following factors would most strongly favor consideration of primary arthrodesis of the DIP joint over FDP repair for a Jersey finger injury?

. Patient age of 25 years.
. Involvement of the ring finger.
. Acute Type II injury with good tendon quality.
. Chronic injury (>6 months) in a heavy manual laborer with severe DIP arthritis and high functional demands.
. Patient preference for early return to sports.

Correct Answer & Explanation

. Chronic injury (>6 months) in a heavy manual laborer with severe DIP arthritis and high functional demands.

Explanation

Primary arthrodesis of the DIP joint is considered for chronic flexor tendon injuries where tendon reconstruction is deemed unlikely to achieve good results, or in patients with pre-existing severe DIP joint arthritis, especially those with high demand for stable grip (like a heavy manual laborer). For a young, otherwise healthy patient with an acute injury, repair is almost always preferred. A chronic injury beyond 6 months, particularly if associated with significant joint degeneration and high functional demands for stability, can make arthrodesis a more predictable and functional outcome than a complex, multi-stage reconstruction. Early return to sports is not a reason for arthrodesis over repair.

Question 3691

Topic: Nerve & Tendon

What is the primary concern if an FDP repair is performed with excessive tension?

. Delayed wound healing.
. Increased risk of infection.
. Development of a quadriga effect.
. Formation of a swan neck deformity.
. Inability to achieve full passive extension of the PIP joint.

Correct Answer & Explanation

. Development of a quadriga effect.

Explanation

Repairing the FDP tendon with excessive tension is a known cause of the quadriga effect. Because the FDP tendons of the medial four fingers share a common muscle belly, overtensioning one FDP tendon can restrict the ability of the adjacent, normally functioning FDP tendons to fully flex their respective DIP joints. This results in limited flexion of the uninjured fingers when the repaired finger attempts to flex fully. The other options are less directly and uniquely linked to excessive tension during FDP repair.

Question 3692

Topic: 7. Hand and Wrist

A patient with a chronic Jersey finger (Type I, 3 months post-injury) presents with significant FDP tendon retraction and shortening. What surgical strategy, besides staged reconstruction, might be considered if the patient is older and has lower functional demands?

. FDP advancement with direct repair.
. Primary FDP repair with a bone anchor.
. FDS tenodesis to the distal phalanx.
. Extensor digitorum communis transfer to the distal phalanx.
. Immediate DIP joint arthrodesis.

Correct Answer & Explanation

. FDS tenodesis to the distal phalanx.

Explanation

For chronic FDP ruptures, especially in older patients with lower functional demands where staged reconstruction might be too extensive, or when direct repair/advancement is impossible, a flexor digitorum superficialis (FDS) tenodesis to the distal phalanx can be considered. This procedure uses one slip of the FDS tendon to provide some active flexion or at least prevent hyperextension at the DIP joint. FDP advancement is for acute small gaps. Primary repair with bone anchor assumes the tendon can be brought to length. EDC transfer is for extensor deficit. Immediate DIP arthrodesis is an option, but FDS tenodesis offers some motion. Therefore, FDS tenodesis is a valid alternative for selected cases.

Question 3693

Topic: 7. Hand and Wrist

When surgically repairing a Type I Jersey finger, which maneuver can help achieve a tension-free repair if there is moderate retraction but not enough to necessitate a graft?

. Extensive release of the A2 and A4 pulleys.
. Aggressive tenolysis of the FDS tendons.
. Hyperflexion of the wrist and MCP joints.
. Sectioning the lumbrical insertion to the extensor hood.
. Lengthening of the FDS tendon.

Correct Answer & Explanation

. Hyperflexion of the wrist and MCP joints.

Explanation

Hyperflexion of the wrist and MCP joints places the flexor tendon system in a more relaxed position, which can help to gain several millimeters of length and allow for a tension-free repair of a moderately retracted FDP tendon. This is a common intraoperative maneuver. Extensive pulley release can lead to bowstringing. Tenolysis of FDS is generally not necessary or desirable. Sectioning the lumbrical might address a lumbrical plus but won't gain length for the FDP repair itself. Lengthening the FDS is not for FDP repair.

Question 3694

Topic: 7. Hand and Wrist
A 22-year-old patient presents with a Type III Jersey finger of the index finger. During repair, the bony fragment is securely reattached to the distal phalanx. What is the appropriate post-operative management strategy regarding mobilization?
. Immediate active range of motion of the DIP joint to prevent stiffness.
. Rigid immobilization of the DIP joint for 6 weeks followed by passive range of motion.
. Early protected passive motion with a dorsal blocking splint.
. Active resistance exercises starting at 2 weeks post-op.
. Buddy taping to the adjacent finger for support and immediate full activity.

Correct Answer & Explanation

. Early protected passive motion with a dorsal blocking splint.

Explanation

For most flexor tendon repairs, including those involving bony reattachment (like Type III Jersey finger), early protected passive motion with a dorsal blocking splint is the standard of care. This protocol allows for controlled tendon gliding to prevent adhesions while protecting the healing repair. Immediate active motion or active resistance exercises would place too much stress on the repair, risking re-rupture or bone fragment displacement. Rigid immobilization for 6 weeks leads to significant stiffness and adhesions.

Question 3695

Topic: 7. Hand and Wrist

In a case of acute Jersey finger, if an MRI is performed, what is its primary advantage over plain radiographs?

. Superior visualization of bone fragments and articular involvement.
. Ability to quantify inflammatory changes in the soft tissues.
. Accurate assessment of tendon retraction, tendon quality, and presence of associated soft tissue injuries.
. Faster and less expensive imaging modality.
. Better at ruling out concomitant fractures of the proximal phalanx.

Correct Answer & Explanation

. Accurate assessment of tendon retraction, tendon quality, and presence of associated soft tissue injuries.

Explanation

MRI offers superior soft tissue resolution, allowing for accurate assessment of the FDP tendon's exact location, the degree of retraction, its quality (e.g., presence of fraying or degeneration), and whether there are associated injuries to the flexor sheath, vincula, or surrounding soft tissues. While X-rays are good for bone, MRI provides detailed information about the tendon itself, which is crucial for surgical planning. MRI is not faster or less expensive than X-ray, and X-rays are generally sufficient for proximal phalanx fractures.

Question 3696

Topic: Nerve & Tendon

A 60-year-old patient with an acute Jersey finger (Type I) and a history of poorly controlled diabetes presents for surgical repair. What is the most significant concern regarding his prognosis compared to a healthy individual?

. Increased risk of the quadriga effect.
. Higher likelihood of lumbrical plus phenomenon.
. Significantly impaired wound healing and increased infection risk.
. Inability to tolerate early active motion protocols.
. Greater chance of associated nerve injury.

Correct Answer & Explanation

. Significantly impaired wound healing and increased infection risk.

Explanation

Poorly controlled diabetes significantly impairs wound healing due to microvascular disease, neuropathy, and compromised immune function. This leads to a substantially increased risk of surgical site infection, delayed tendon healing, and overall poorer outcomes in flexor tendon repair. While other complications can occur, impaired healing and infection risk are paramount concerns in diabetic patients. The other options are not specifically heightened by diabetes more than by general factors of tendon repair or intrinsic to the injury type.

Question 3697

Topic: 7. Hand and Wrist

What is the primary goal of using a dorsal blocking splint in the immediate post-operative period after flexor tendon repair?

. To prevent active extension of the DIP and PIP joints beyond a safe limit.
. To encourage immediate active flexion exercises.
. To apply continuous passive motion to the repaired tendon.
. To protect the dorsal aspect of the finger from trauma.
. To allow full passive extension while preventing active flexion.

Correct Answer & Explanation

. To prevent active extension of the DIP and PIP joints beyond a safe limit.

Explanation

A dorsal blocking splint is designed to prevent active extension of the rehabilitated finger(s) beyond a safe, predetermined limit (typically with the wrist in slight flexion, MCPs in flexion, and IPs near full extension). This position protects the healing flexor tendon repair from excessive tension during early motion and prevents re-rupture, particularly during active extension, which could over-stretch the repair. It does not encourage immediate active flexion, nor does it apply continuous passive motion. It facilitates protected passive flexion and controlled active flexion within its limits.

Question 3698

Topic: Nerve & Tendon

During examination of a suspected Jersey finger, how would you best differentiate an FDP rupture from a central slip rupture?

. An FDP rupture causes loss of DIP flexion, while a central slip rupture causes a boutonniere deformity (PIP flexion, DIP hyperextension).
. An FDP rupture involves the PIP joint, while a central slip rupture involves the DIP joint.
. An FDP rupture presents with a palpable gap in the palm, while a central slip rupture does not.
. An FDP rupture requires an MRI for diagnosis, while a central slip rupture is diagnosed clinically.
. An FDP rupture is acute, while a central slip rupture is always chronic.

Correct Answer & Explanation

. An FDP rupture causes loss of DIP flexion, while a central slip rupture causes a boutonniere deformity (PIP flexion, DIP hyperextension).

Explanation

The key differentiation lies in the affected joint and associated deformity. A complete FDP rupture leads to an inability to actively flex the DIP joint. A central slip rupture, by contrast, leads to disruption of the extensor mechanism at the PIP joint, eventually resulting in a boutonniere deformity (PIP joint flexion and compensatory DIP joint hyperextension). FDP involves the DIP, central slip involves PIP mechanics primarily. Palpable gaps are not universally present in FDP ruptures. Both can be diagnosed clinically, though imaging can confirm. Both can be acute.

Question 3699

Topic: Nerve & Tendon

After surgical repair of a Type II Jersey finger, the patient develops a flexion contracture of the PIP joint. What is the most likely cause of this complication?

. Re-rupture of the FDP tendon.
. Adhesions between the FDS tendon and its sheath.
. Over-tightening of the F FDP repair causing a quadriga effect.
. Insufficient mobilization during the early post-operative period.
. Chronic inflammation of the extensor mechanism.

Correct Answer & Explanation

. Adhesions between the FDS tendon and its sheath.

Explanation

While the FDP was repaired, adhesions can occur between the FDS tendon and its sheath, or between the FDP and FDS, or the FDS to its own sheath. If the FDS tendon develops adhesions, it can limit PIP extension and lead to a flexion contracture of the PIP joint. Re-rupture of the FDP primarily affects DIP flexion. Quadriga effect limits flexion of adjacent fingers. Insufficient mobilization usually leads to global stiffness, but if specifically the FDS is adhered, it creates PIP flexion. Extensor inflammation would more likely cause an extensor lag or pain, not a contracture in flexion of PIP.

Question 3700

Topic: Nerve & Tendon

A patient sustained a Jersey finger and is unable to undergo surgery for 5 weeks due to systemic illness. The injury is a Type I FDP avulsion of the ring finger. What is the most likely surgical approach to consider given this delayed presentation?

. Primary repair using a pull-out suture.
. FDP advancement, as the gap is still manageable.
. Staged tendon reconstruction with a silicone rod.
. Direct repair using bone anchors without any lengthening procedures.
. DIP joint arthrodesis as a primary procedure.

Correct Answer & Explanation

. Staged tendon reconstruction with a silicone rod.

Explanation

At 5 weeks, a Type I Jersey finger is already significantly delayed. The FDP tendon would have retracted considerably and undergone shortening and likely degenerative changes due to loss of blood supply. Primary repair with pull-out sutures or bone anchors would likely be impossible without excessive tension. FDP advancement is for smaller, acute gaps. Therefore, staged tendon reconstruction using a silicone rod to create a pseudosheath, followed by a tendon graft, becomes the most viable option to restore active flexion. DIP joint arthrodesis is a salvage procedure, typically considered after failed repairs or in very specific chronic cases.

Test Yourself

Switch to an interactive, timed exam simulation to truly master this topic.

On this Page