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7. Hand and Wrist MCQs

Practice Set 39 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 761

Topic: 7. Hand and Wrist

Dupuytren's disease involves the pathological thickening and contracture of specific normal fascial structures of the hand. Which of the following fascial structures typically remains uninvolved and is spared in Dupuytren's disease?

. Pretendinous band
. Grayson's ligament
. Natatory ligament
. Cleland's ligament
. Lateral digital sheet

Correct Answer & Explanation

. Cleland's ligament

Explanation

Cleland's ligaments are located dorsal to the neurovascular bundle and are generally spared in Dupuytren's disease. In contrast, Grayson's ligaments, which are located volar to the neurovascular bundle, are frequently involved and contribute to the spiral cord.

Question 762

Topic: Nerve & Tendon

A 55-year-old woman presents with a chronic, untreated mallet finger injury of the small digit sustained 6 months ago. She has now developed a secondary deformity characterized by DIP joint flexion and PIP joint hyperextension. What is the primary pathophysiological mechanism causing the hyperextension at the PIP joint?

. Rupture of the volar plate at the PIP joint
. Proximal retraction of the extensor mechanism and lateral bands
. Spontaneous rupture of the flexor digitorum superficialis (FDS) tendon
. Contracture of the central slip
. Attentuation of the transverse retinacular ligament

Correct Answer & Explanation

. Proximal retraction of the extensor mechanism and lateral bands

Explanation

An untreated mallet finger can lead to a swan neck deformity due to the proximal retraction of the extensor mechanism. This proximal migration increases the extension force transmitted through the central slip at the PIP joint, leading to hyperextension.

Question 763

Topic: Nerve & Tendon

A 60-year-old man receives an injection of collagenase clostridium histolyticum for a prominent central cord causing an MCP joint contracture. When performing this injection, careful technique is required to prevent a severe complication associated with incorrect placement. Injecting the medication too deep poses the greatest risk of damage to which structure?

. Ulnar digital nerve
. Radial digital artery
. Flexor digitorum superficialis tendon
. A2 pulley
. Extensor digitorum communis tendon

Correct Answer & Explanation

. Flexor digitorum superficialis tendon

Explanation

Collagenase injections carry a risk of flexor tendon rupture if injected incorrectly. The needle must remain within the diseased fascial cord to avoid enzymatic degradation of the underlying flexor tendons or pulleys.

Question 764

Topic: 7. Hand and Wrist

A 68-year-old man with Dupuytren's disease complains of the inability to spread his index and long fingers apart, significantly limiting his ability to play the piano. Which pathological cord is primarily responsible for this digital web space contracture?

. Spiral cord
. Retrovascular cord
. Central cord
. Natatory cord
. Pretendinous cord

Correct Answer & Explanation

. Natatory cord

Explanation

The natatory cord arises from the normal natatory ligaments and crosses the web spaces. Contracture of the natatory cord restricts digit abduction and causes web space tightening.

Question 765

Topic: 7. Hand and Wrist

A 30-year-old patient is being treated with a continuous extension splint for a soft-tissue mallet finger. At the 4-week follow-up, the patient admits to removing the splint for 10 minutes to wash his hand, during which time the fingertip dropped into flexion. What is the most appropriate next step in management?

. Continue splinting for 2 more weeks as originally planned
. Discontinue splinting and begin range of motion exercises
. Restart the continuous extension splinting protocol for a full 6 to 8 weeks
. Refer the patient for immediate surgical repair
. Add a PIP extension splint to the current regimen

Correct Answer & Explanation

. Restart the continuous extension splinting protocol for a full 6 to 8 weeks

Explanation

If a patient with a soft-tissue mallet finger allows the DIP joint to fall into flexion at any point during the initial 6-8 week splinting period, the healing process is disrupted. The clock must be reset, and continuous splinting restarted for a full 6 to 8 weeks.

Question 766

Topic: 7. Hand and Wrist

A 45-year-old man of Scandinavian descent presents with severe, rapidly progressive, bilateral Dupuytren's contractures. He also mentions developing nodules on the soles of his feet. This presentation is highly characteristic of 'Dupuytren's diathesis'. Which of the following additional factors is considered a hallmark of this aggressive clinical phenotype?

. Female sex
. Onset of disease after age 70
. Positive family history and early age of onset
. Isolated involvement of the index finger
. Absence of ectopic fascial lesions

Correct Answer & Explanation

. Positive family history and early age of onset

Explanation

Dupuytren's diathesis indicates an aggressive form of the disease with a high recurrence rate. Hallmarks include a strong family history, early age of onset (often <50 years), bilateral involvement, and ectopic lesions such as Ledderhose disease (plantar fibromatosis) or Peyronie's disease.

Question 767

Topic: 7. Hand and Wrist

A patient with long-standing Dupuytren's disease presents with a flexion contracture exclusively at the distal interphalangeal (DIP) joint, without significant MCP or PIP involvement. While uncommon, which of the following pathological cords is primarily responsible for a contracture at the DIP joint?

. Spiral cord
. Central cord
. Natatory cord
. Pretendinous cord
. Retrovascular cord

Correct Answer & Explanation

. Retrovascular cord

Explanation

The retrovascular cord is unique in that it travels deep to the neurovascular bundle and inserts onto the distal phalanx. It is the primary fascial structure responsible for DIP joint flexion contractures in Dupuytren's disease.

Question 768

Topic: Nerve & Tendon

A 42-year-old office worker presents to the clinic 8 weeks after suffering a soft-tissue mallet finger injury to her right ring finger. She never sought medical treatment and currently has a 40-degree extensor lag at the DIP joint. The joint is completely passively correctable. What is the most appropriate initial treatment recommendation?

. Tenodermodesis
. Central slip tenotomy (Fowler procedure)
. A trial of continuous DIP extension splinting for 8 weeks
. DIP joint arthrodesis
. Observation and reassurance

Correct Answer & Explanation

. A trial of continuous DIP extension splinting for 8 weeks

Explanation

Even in chronic settings (up to 12 weeks or more post-injury), a trial of continuous extension splinting for 8 weeks remains the recommended first-line treatment for a passively correctable soft-tissue mallet finger, as it still yields successful outcomes in many patients.

Question 769

Topic: 7. Hand and Wrist

A 65-year-old man presents with his third recurrence of severe Dupuytren's contracture in his left small finger. The overlying skin is heavily involved, macerated, and firmly adherent to the underlying fascial cords. To minimize the risk of yet another recurrence, which surgical procedure is most appropriate?

. Percutaneous needle aponeurotomy
. Collagenase injection
. Limited regional fasciectomy
. Dermofasciectomy with full-thickness skin grafting
. Total palmar fasciectomy

Correct Answer & Explanation

. Dermofasciectomy with full-thickness skin grafting

Explanation

Dermofasciectomy involves wide excision of the diseased fascia along with the involved overlying skin, followed by placement of a full-thickness skin graft. This procedure is indicated for recurrent, severe disease with skin involvement and carries the lowest recurrence rate.

Question 770

Topic: 7. Hand and Wrist

During the examination of a patient with early Dupuytren's disease, a distinct palpable cord is noted in the palm leading to a 45-degree flexion contracture of the metacarpophalangeal (MCP) joint of the ring finger. The PIP joint is fully extendable. Which specific pathological cord is primarily causing this isolated MCP joint contracture?

. Central cord
. Spiral cord
. Natatory cord
. Lateral cord
. Retrovascular cord

Correct Answer & Explanation

. Central cord

Explanation

The central cord arises from the pretendinous bands and inserts onto the base of the proximal phalanx or the tendon sheath. It is the primary structure responsible for isolated MCP joint flexion contractures in Dupuytren's disease.

Question 771

Topic: 7. Hand and Wrist

The spiral cord is a critical structure to identify during Dupuytren's surgery due to its predictable displacement of the digital nerve. Which of the following normal anatomical structures is NOT one of the four precursors that amalgamate to form the spiral cord?

. Pretendinous band
. Spiral band
. Lateral digital sheet
. Grayson's ligament
. Cleland's ligament

Correct Answer & Explanation

. Cleland's ligament

Explanation

The spiral cord is formed by the pathological involvement of four structures: the pretendinous band, spiral band, lateral digital sheet, and Grayson's ligament. Cleland's ligament is dorsal to the neurovascular bundle and is not involved.

Question 772

Topic: 7. Hand and Wrist

A 55-year-old man undergoes an uncomplicated regional fasciectomy for Dupuytren's contracture. Two weeks postoperatively, he presents with severe diffuse pain, exquisite hypersensitivity, disproportionate swelling, and profound stiffness of the entire hand. No signs of purulent infection are present. What is the most appropriate management for this complication?

. Immediate surgical exploration and debridement
. Intravenous antibiotics for 7 days
. Aggressive hand therapy, NSAIDs, and a tapering dose of oral corticosteroids
. Immobilization in a static functional position splint for 4 weeks
. Local injection of collagenase clostridium histolyticum

Correct Answer & Explanation

. Aggressive hand therapy, NSAIDs, and a tapering dose of oral corticosteroids

Explanation

The patient is experiencing a 'flare reaction' (complex regional pain syndrome-like response), which occurs in roughly 10% of fasciectomy patients. Management includes intensive hand therapy, NSAIDs, sympathetic blocks, or a short course of oral corticosteroids.

Question 773

Topic: Nerve & Tendon

A 34-year-old male presents with a tendinous mallet finger injury sustained while catching a baseball 2 days ago. He is prescribed a DIP extension splint. Which of the following is the most critical patient instruction regarding the splinting protocol?

. Remove the splint daily for 10 minutes to perform active DIP flexion exercises.
. Keep the splint on continuously for 6 to 8 weeks, restarting the timeline if the DIP joint falls into flexion.
. Transition to nighttime-only splinting after 3 weeks of continuous wear.
. Maintain the PIP joint in 30 degrees of flexion while the DIP is extended.
. Surgically pin the joint if extension is not achieved within 2 weeks.

Correct Answer & Explanation

. Keep the splint on continuously for 6 to 8 weeks, restarting the timeline if the DIP joint falls into flexion.

Explanation

Treatment of a tendinous mallet finger requires strict, continuous DIP extension splinting for 6-8 weeks. Any lapse allowing the DIP joint to flex disrupts healing and requires the 6-8 week timeline to be restarted.

Question 774

Topic: 7. Hand and Wrist

During a regional fasciectomy for Dupuytren's contracture, a spiral cord is identified causing a severe proximal interphalangeal (PIP) joint contracture. This cord alters the normal course of the neurovascular bundle. Which of the following structures is NOT a component of the spiral cord?

. Pretendinous band
. Spiral band
. Lateral digital sheet
. Cleland's ligament
. Grayson's ligament

Correct Answer & Explanation

. Cleland's ligament

Explanation

The spiral cord is composed of the pretendinous band, spiral band, lateral digital sheet, and Grayson's ligament. Cleland's ligament passes dorsal to the neurovascular bundle and is typically spared in Dupuytren's disease.

Question 775

Topic: 7. Hand and Wrist
A 65-year-old man undergoes collagenase Clostridium histolyticum injection for a 45-degree metacarpophalangeal (MCP) joint Dupuytren's contracture. Which of the following best describes the mechanism of action of this pharmacological treatment?
. Inhibition of transforming growth factor-beta (TGF-beta) signaling
. Apoptosis induction in differentiating myofibroblasts
. Targeted cleavage of type I and III collagen by AUX-I and AUX-II enzymes
. Competitive inhibition of alpha-smooth muscle actin cross-linking
. Stimulation of matrix metalloproteinase (MMP) endogenous production

Correct Answer & Explanation

. Targeted cleavage of type I and III collagen by AUX-I and AUX-II enzymes

Explanation

Collagenase Clostridium histolyticum consists of a purified mixture of two distinct collagenases (AUX-I and AUX-II). These enzymes work synergistically to cleave the triple-helical structures of type I and type III collagen, weakening the Dupuytren's cord.

Question 776

Topic: 7. Hand and Wrist

A patient with Dupuytren's contracture is evaluated for surgical intervention. Which of the following clinical factors is most strongly predictive of aggressive disease progression and a higher rate of postoperative recurrence?

. Female sex
. Onset of disease after the age of 60
. Presence of unilateral disease
. Presence of Ledderhose disease or Garrod's pads
. Smoking history of less than 10 pack-years

Correct Answer & Explanation

. Presence of Ledderhose disease or Garrod's pads

Explanation

Dupuytren's diathesis indicates aggressive disease with a high rate of recurrence. It is characterized by early age of onset, bilateral involvement, strong family history, and ectopic manifestations like Ledderhose disease, Peyronie's disease, or Garrod's pads.

Question 777

Topic: 7. Hand and Wrist

A 25-year-old mechanic sustains a hyperflexion injury to his dominant index finger. Radiographs reveal a bony mallet finger with an avulsion fracture involving 40% of the dorsal articular surface of the distal phalanx, accompanied by volar subluxation of the distal phalanx. What is the most appropriate treatment?

. Stack splinting for 8 weeks
. Buddy taping to the middle finger
. Surgical reduction and fixation (e.g., extension block pinning)
. Primary DIP joint arthrodesis
. Excision of the bony fragment and tendon advancement

Correct Answer & Explanation

. Surgical reduction and fixation (e.g., extension block pinning)

Explanation

Surgical intervention for a bony mallet finger is indicated when there is volar subluxation of the distal phalanx or when the articular fragment is large (typically >30-50%). Extension block pinning or closed reduction and percutaneous pinning are standard surgical options.

Question 778

Topic: 7. Hand and Wrist

A 58-year-old man undergoes regional fasciectomy for a severe Dupuytren's contracture of the ring finger. During dissection of the spiral cord, the surgeon must identify the neurovascular bundle to prevent iatrogenic injury.

In relation to its normal anatomical position, how does the spiral cord displace the neurovascular bundle?

. Dorsal, lateral, and distal
. Central, superficial, and proximal
. Palmar, medial, and distal
. Dorsal, medial, and proximal
. Central, deep, and distal

Correct Answer & Explanation

. Central, superficial, and proximal

Explanation

The spiral cord displaces the neurovascular bundle centrally, superficially, and proximally, placing it at high risk of iatrogenic injury during surgical release. The spiral cord is formed by the pretendinous band, spiral band, lateral digital sheet, and Grayson's ligament.

Question 779

Topic: 7. Hand and Wrist
Biochemical analysis of the palmar fascia in a patient with Dupuytren's contracture will most likely reveal which of the following alterations in collagen composition compared to normal palmar fascia?
. Decreased ratio of Type III to Type I collagen
. Increased ratio of Type III to Type I collagen
. Complete absence of Type IV collagen
. Increased ratio of Type II to Type I collagen
. Decreased ratio of Type I to Type IV collagen

Correct Answer & Explanation

. Increased ratio of Type III to Type I collagen

Explanation

Dupuytren's disease is characterized by a significant increase in the ratio of Type III to Type I collagen. While Type I collagen normally predominates in normal palmar fascia, myofibroblasts in the diseased cords primarily deposit Type III collagen.

Question 780

Topic: 7. Hand and Wrist

A 28-year-old basketball player sustains a forced flexion injury to his extended right middle finger. Radiographs reveal a dorsal avulsion fracture of the distal phalanx involving 40% of the articular surface. The distal interphalangeal (DIP) joint remains congruous with no volar subluxation. What is the most appropriate initial management?

. Closed reduction and percutaneous pinning
. Open reduction and internal fixation with a hook plate
. Continuous extension splinting of the DIP joint for 6-8 weeks
. Primary arthrodesis of the DIP joint
. Figure-of-eight splinting of the PIP joint

Correct Answer & Explanation

. Continuous extension splinting of the DIP joint for 6-8 weeks

Explanation

Bony mallet fingers involving up to 50% of the articular surface without volar subluxation of the distal phalanx can be successfully treated nonoperatively. Continuous extension splinting of the DIP joint for 6-8 weeks yields outcomes comparable to surgical fixation.

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