Tendon Injuries — MCQs
Which type of collagen is predominantly present in the skin?
Which among the following is TRUE regarding mallet finger?
After a brawl, a young male presented with inability to extend his distal interphalangeal joint. An X-ray was taken and was shown to be normal. What should be the next step in managing the patient?
The patient is presenting with pain around the base of the thumb. Which tendons are likely involved?
In a vehicle accident, the musculocutaneous nerve was completely severed, but still the person was able to weakly flex the elbow joint. All of the following muscles are responsible for this flexion, EXCEPT:
In combined tendon and nerve injuries, the preferred sequence of repair is:
A 30-year-old man involved in a fisticuff, injured his middle finger and noticed slight flexion of the distal interphalangeal (DIP) joint. X-rays were normal. The most appropriate management at this stage is:
No man's land in palm corresponds to -
A 45-year-old man visits the outpatient clinic after a digit of his left hand was injured when a door was slammed on his hand. A superficial cut on his middle finger has been sutured, but functional deficits are observed in the finger: The proximal interphalangeal joint is pulled into constant flexion, whereas the distal interphalangeal joint is held in a position of hyperextension. What is the most likely diagnosis?
Flexor Digitorum Profundus tendon avulsion injury leads to -
Tendon Injuries Indian Medical PG Practice Questions and MCQs
Question 1: Which type of collagen is predominantly present in the skin?
- A. Type II
- B. Type I (Correct Answer)
- C. Type III
- D. Type IV
Explanation: ***Type I*** - **Type I collagen** is the most abundant collagen in the human body, constituting about 90% of the body's collagen and is predominantly found in the skin, bones, tendons, and ligaments [1]. - It plays a crucial role in providing **tensile strength** and structural integrity to these tissues [1]. *Type II* - **Type II collagen** is primarily found in **cartilage**, providing resistance to pressure [1]. - It forms a network of fine fibrils in cartilage that helps withstand compressive forces. *Type III* - **Type III collagen** is often found alongside Type I collagen in organs like the skin, but it is prevalent in **reticular fibers** in tissues such as blood vessels, intestine, and uterus. - It is particularly important in early wound healing and gives tissues their elasticity and extensibility. *Type IV* - **Type IV collagen** is primarily found in the **basement membranes**, forming a mesh-like network [2]. - It provides structural support to epithelial and endothelial cells and acts as a filter in tissues like the kidney glomeruli [2].
Question 2: Which among the following is TRUE regarding mallet finger?
- A. Fracture of distal phalanx
- B. Fracture of the proximal phalanx
- C. Avulsion of extensor tendon at the base of the distal phalanx (Correct Answer)
- D. Avulsion of tendon at the base of the middle phalanx
Explanation: ***Avulsion of extensor tendon at the base of the distal phalanx*** - **Mallet finger** occurs when the **extensor tendon** is avulsed (torn away) from its insertion point at the base of the **distal phalanx**. - This injury results in an inability to actively extend the **distal interphalangeal (DIP) joint**, leading to a characteristic droop of the fingertip. *Fracture of distal phalanx* - While a fracture of the distal phalanx can occur, **mallet finger specifically refers to a tendon injury**, not necessarily a bone fracture. - A fracture might be present in some cases if the tendon pulls off a piece of bone (**bony mallet**), but the primary pathology is the tendon avulsion. *Fracture of the proximal phalanx* - A fracture of the **proximal phalanx** would affect the **metacarpophalangeal (MCP) joint** or the **proximal interphalangeal (PIP) joint**, not the distal interphalangeal (DIP) joint which is characteristic of mallet finger. - This injury would lead to different functional limitations and deformities. *Avulsion of tendon at the base of the middle phalanx* - An avulsion at the base of the **middle phalanx** would involve the insertion of the **central slip of the extensor tendon**, leading to a **Boutonnière deformity**, which affects the **PIP joint**. - This is distinct from mallet finger, which involves the **DIP joint**.
Question 3: After a brawl, a young male presented with inability to extend his distal interphalangeal joint. An X-ray was taken and was shown to be normal. What should be the next step in managing the patient?
- A. Splint (Correct Answer)
- B. Wax bath
- C. Ignore
- D. Surgery
Explanation: ***Splint*** - The patient presents with **inability to extend the distal interphalangeal joint** after an injury, with a **normal X-ray**. This clinical picture is highly suggestive of a **mallet finger**. - **Splinting** the distal interphalangeal joint in **extension** for 6-8 weeks is the primary non-surgical treatment for mallet finger, aiming to allow the ruptured extensor tendon to heal. *Wax bath* - A **wax bath** is a form of thermotherapy used to relieve pain and stiffness in joints by applying heat. - While it can be helpful for chronic conditions like **arthritis**, it is not an appropriate initial treatment for an acute **tendon injury** like mallet finger, as it does not promote healing of the extensor mechanism. *Ignore* - **Ignoring** the symptoms would lead to a failure to treat the injury, potentially resulting in a **chronic extensor lag deformity** (mallet finger deformity). - Untreated, this condition can cause persistent functional impairment and cosmetic deformity of the affected finger. *Surgery* - **Surgery** is typically reserved for specific cases of mallet finger, such as those with a **large avulsion fracture** of the dorsal base of the distal phalanx (where the fragment involves more than 30-50% of the articular surface), or if non-surgical treatment fails. - Since the **X-ray was normal** in this case, indicating no significant bony avulsion, and it's an acute presentation, surgery is not the appropriate first-line management.
Question 4: The patient is presenting with pain around the base of the thumb. Which tendons are likely involved?
- A. APB & EPL
- B. APL & EPB (Correct Answer)
- C. APB & EPB
- D. APL & EPL
Explanation: ***APL & EPB*** - Pain around the base of the thumb, especially with movement, is characteristic of De Quervain's tenosynovitis [1]. This condition involves the **abductor pollicis longus (APL)** and **extensor pollicis brevis (EPB)** tendons [1]. - These two tendons share a common synovial sheath as they pass through the first dorsal compartment of the wrist, making them susceptible to inflammation and friction [1]. *APB & EPL* - **APB (Abductor Pollicis Brevis)** is an intrinsic hand muscle found in the thenar eminence, primarily involved in thumb abduction, and is not typically associated with De Quervain's tenosynovitis. - **EPL (Extensor Pollicis Longus)** is part of the third dorsal compartment and its tendon crosses over the other thumb tendons, and is not inflamed in De Quervain's tenosynovitis. *APB & EPB* - As mentioned, **APB (Abductor Pollicis Brevis)** is an intrinsic hand muscle, not involved in De Quervain's tenosynovitis. - While **EPB (Extensor Pollicis Brevis)** is involved, its combination with APB incorrectly identifies the primary tendons affected in the first dorsal compartment. *APL & EPL* - **APL (Abductor Pollicis Longus)** is one of the correct tendons involved. - **EPL (Extensor Pollicis Longus)** belongs to the third dorsal compartment of the wrist and is not typically affected in De Quervain's tenosynovitis, differentiating it from the tendons in the first dorsal compartment [1].
Question 5: In a vehicle accident, the musculocutaneous nerve was completely severed, but still the person was able to weakly flex the elbow joint. All of the following muscles are responsible for this flexion, EXCEPT:
- A. Flexor carpi ulnaris
- B. Flexor carpi radialis
- C. Pronator quadratus (Correct Answer)
- D. Brachioradialis
Explanation: ***Pronator quadratus*** - The **pronator quadratus** primarily functions in **pronation of the forearm** and has no role in elbow flexion. - It is innervated by the **anterior interosseous nerve**, a branch of the median nerve, and not involved with elbow flexion. *Flexor carpi ulnaris* - While its main actions are **wrist flexion** and **adduction**, it can contribute *weakly* to elbow flexion due to its origin partially spanning the elbow joint. - It is innervated by the **ulnar nerve**. *Flexor carpi radialis* - The **flexor carpi radialis** acts as a primary **flexor of the wrist** and also assists in **abduction of the wrist**. - It provides a *minor* contribution to elbow flexion because it crosses the elbow joint, and is innervated by the **median nerve**. *Brachioradialis* - The **brachioradialis** is a significant elbow flexor, particularly when the forearm is in a **mid-prone position**. - It is innervated by the **radial nerve**, which explains why elbow flexion is still possible despite musculocutaneous nerve damage.
Question 6: In combined tendon and nerve injuries, the preferred sequence of repair is:
- A. Tendons should be repaired before nerves
- B. Nerves should be repaired before tendons (Correct Answer)
- C. None of the above
- D. Tendons should not be repaired simultaneously with nerves
Explanation: ***Nerves should be repaired before tendons*** - Nerve repairs are **more delicate** and require precise microsurgical technique with minimal tension - Repairing nerves first allows optimal **anatomical positioning** and coaptation without interference from tendon manipulation - Tendon repair involves **greater tissue handling and tension**, which could disrupt a freshly repaired nerve if done first - This sequence is the **standard teaching** in hand surgery (Green's Operative Hand Surgery, Campbell's Operative Orthopaedics) - Once nerves are secured, tendons can be repaired with the necessary tensioning without risk to neural structures *Tendons should be repaired before nerves* - This would subject the **fragile nerve repair to mechanical stress** during subsequent tendon manipulation - Tendon repair requires **forceful suturing and tensioning** that could displace or damage a previously repaired nerve - This sequence makes nerve repair technically more difficult as tendons may obstruct access *Tendons should not be repaired simultaneously with nerves* - While the exact sequence matters, both structures are typically repaired **in the same surgical setting** - The statement is confusing as "simultaneously" could mean same surgery (which is done) versus same moment (which is avoided) - Modern practice favors complete repair in one operation when possible *None of the above* - There is a well-established preferred sequence in combined tendon and nerve injuries - The principle of nerve-before-tendon repair is supported by surgical literature and clinical practice
Question 7: A 30-year-old man involved in a fisticuff, injured his middle finger and noticed slight flexion of the distal interphalangeal (DIP) joint. X-rays were normal. The most appropriate management at this stage is:
- A. Ignore
- B. Splint the finger in hyperextension (Correct Answer)
- C. Surgical repair of the flexor tendon
- D. Buddy strapping
Explanation: ***Splint the finger in hyperextension*** - The description of slight flexion of the **distal interphalangeal (DIP) joint** with normal X-rays after an injury suggests a **mallet finger**. This occurs due to rupture of the terminal extensor tendon, allowing unopposed flexion of the DIP joint. - The standard conservative treatment for **mallet finger** is continuous splinting of the DIP joint in slight **hyperextension** for 6 to 8 weeks, leaving the proximal interphalangeal (PIP) joint free. *Ignore* - Ignoring the injury is inappropriate as **mallet finger** will lead to a **permanent deformity** (extensor lag) and functional impairment if left untreated. - Early intervention with proper splinting provides a high success rate for tendon healing and restoration of function. *Surgical repair of the flexor tendon* - Surgical repair is indicated when the injury involves a **complex fracture**, severe subluxation, or chronic untreated cases of mallet finger that have failed conservative management. - The injury here affects the **extensor tendon**, not the flexor tendon, thus flexor tendon repair would be incorrect. *Buddy strapping* - **Buddy strapping** involves taping the injured finger to an adjacent healthy finger. This technique is primarily used for **phalangeal fractures** or dislocations to provide support and restrict movement. - For **mallet finger**, it would not adequately immobilize the DIP joint in hyperextension, which is crucial for healing the ruptured extensor tendon.
Question 8: No man's land in palm corresponds to -
- A. Zone I
- B. Zone IV
- C. Zone II (Correct Answer)
- D. Zone III
Explanation: ***Zone II*** - **Zone II** of the flexor tendons, extending from the distal palmar crease to the mid portion of the middle phalanx, is known as "no man's land" due to the historical difficulty in achieving good outcomes after tendon repair. - This zone houses both the **flexor digitorum superficialis** and **flexor digitorum profundus** tendons within a single fibro-osseous sheath, making repairs complex and prone to adhesions. *Zone I* - **Zone I** extends from the insertion of the **flexor digitorum profundus** (distal to the middle phalanx) to the midportion of the middle phalanx [1]. - Injuries in this zone typically involve only the **profundus tendon**, allowing for more straightforward repair due to lack of the superficialis tendon. *Zone IV* - **Zone IV** constitutes the carpal tunnel, where nine flexor tendons and the median nerve pass through a confined space. - While injuries here can be severe due to potential nerve involvement, they are not typically referred to as "no man's land" in the context of tendon repair due to better outcomes historically compared to Zone II. *Zone III* - **Zone III** extends from the distal end of the carpal tunnel to the beginning of the A1 pulley (distal palmar crease). - This zone is predominantly in the palm and offers more space for tendon repair, leading to better outcomes than Zone II, as the tendons diverge here and are not yet constrained within a common sheath.
Question 9: A 45-year-old man visits the outpatient clinic after a digit of his left hand was injured when a door was slammed on his hand. A superficial cut on his middle finger has been sutured, but functional deficits are observed in the finger: The proximal interphalangeal joint is pulled into constant flexion, whereas the distal interphalangeal joint is held in a position of hyperextension. What is the most likely diagnosis?
- A. Boutonniere deformity (Correct Answer)
- B. Mallet finger
- C. Dupuytren's contracture
- D. Swan-neck deformity
Explanation: ***Boutonniere deformity*** - This deformity is characterized by **flexion of the proximal interphalangeal (PIP) joint** and **hyperextension of the distal interphalangeal (DIP) joint**, a classic presentation resulting from damage to the central slip of the extensor tendon. - The injury to the finger from the door slam likely caused trauma to the **extensor mechanism**, leading to this specific joint posture. *Mallet finger* - This condition involves an inability to **extend the distal interphalangeal (DIP) joint**, resulting in a constant flexed posture of the DIP joint. - It usually occurs due to a rupture or avulsion of the **extensor tendon at its insertion on the distal phalanx**, which is different from the described PIP flexion and DIP hyperextension. *Dupuytren's contracture* - This involves a progressive **fibrosis of the palmar fascia**, leading to fixed flexion deformities primarily in the metacarpophalangeal (MCP) and PIP joints. - It most commonly affects the **ring and little fingers** and is generally an idiopathic or inherited condition, not typically caused by acute trauma like a door slam. *Swan-neck deformity* - This deformity presents with **hyperextension of the PIP joint** and **flexion of the DIP joint**, which is the inverse of the described clinical picture. - It is often seen in conditions like **rheumatoid arthritis** or following trauma that disrupts the flexor tendons.
Question 10: Flexor Digitorum Profundus tendon avulsion injury leads to -
- A. Jersey Finger (Correct Answer)
- B. Extensor tendon injury
- C. Ulnar collateral ligament injury
- D. Central slip injury
Explanation: ***Jersey Finger*** - **Jersey finger** is a common name for an avulsion injury of the **flexor digitorum profundus (FDP) tendon** from its insertion on the distal phalanx. - This injury typically occurs when the finger is forcibly extended while the FDP tendon is contracting, often seen in sports where a player grabs an opponent's jersey. *Extensor tendon injury* - An **extensor tendon injury** involves the tendons on the dorsal side of the hand, responsible for extending the fingers. - This is distinct from a **flexor tendon injury**, which involves tendons on the palmar side. *Ulnar collateral ligament injury* - An **ulnar collateral ligament (UCL) injury** most commonly affects the thumb's metacarpophalangeal (MCP) joint, often called **"skier's thumb"**. - This injury involves damage to the ligament supporting the joint, not an avulsion of a flexor tendon. *Central slip injury* - A **central slip injury** affects the middle slip of the extensor digitorum communis tendon over the proximal interphalangeal (PIP) joint. - Untreated, it can lead to a **Boutonnière deformity**, which is characterized by PIP joint flexion and distal interphalangeal (DIP) joint hyperextension.
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