(MCQs) with explanations for a PhD-level orthopedic exam on tendon and hand deformities.
Case 1: Trapeziometacarpal (TMC) Osteoarthritis
Case Scenario:
A 65-year-old female presents with pain at the base of her thumb, which worsens during activities requiring a pinch grip, such as opening jars. On examination, there is tenderness over the first carpometacarpal joint, and the grind test is positive.
What is the most likely diagnosis?
a) Scaphoid fracture
b) De Quervain’s tenosynovitis
c) Trapeziometacarpal (TMC) osteoarthritis
d) Rheumatoid arthritis
e) Intersection syndrome
Answer:
c) Trapeziometacarpal (TMC) osteoarthritis
Explanation:
TMC osteoarthritis commonly affects postmenopausal women and presents with pain at the base of the thumb, particularly during pinch grip. The grind test (axial compression with rotation of the thumb metacarpal) is often positive.
Case 2: Stability of the TMC Joint
Case Scenario:
A 58-year-old woman with TMC osteoarthritis undergoes a clinical examination. The physician notes that the primary stabilizing ligament of the joint is intact.
Which ligament provides primary stability to the TMC joint?
a) Dorsal ligament
b) Lateral ligament
c) Beak ligament
d) Ulnar collateral ligament
e) Transverse carpal ligament
Answer:
c) Beak ligament
Explanation:
The beak ligament (anterior oblique ligament) is the primary stabilizer of the TMC joint. It prevents excessive dorsoradial subluxation. Its degeneration is a key factor in TMC osteoarthritis.
Case 3: Conservative Management of TMC OA
Case Scenario:
A 62-year-old male with early-stage TMC osteoarthritis is advised on initial treatment options.
What is the first-line conservative treatment?
a) Joint fusion
b) NSAIDs and splinting
c) Tendon repair
d) Excision arthroplasty
e) Corticosteroid injection
Answer:
b) NSAIDs and splinting
Explanation:
Conservative management includes NSAIDs for pain relief and splinting to reduce joint stress. Corticosteroid injections are an option but are not first-line. Surgery is reserved for severe cases.
Case 4: Surgical Complications of TMC OA
Case Scenario:
A 67-year-old woman undergoes trapeziectomy with ligament reconstruction for advanced TMC OA. Postoperatively, she develops a complication.
What is the most common surgical complication?
a) Hematoma
b) Radial nerve palsy
c) Fracture of the trapezium
d) Infection
e) Joint instability
Answer:
d) Infection
Explanation:
Infections are a recognized complication of TMC OA surgery, though rare. Other complications include joint instability and persistent pain.
Case 5: Dupuytren’s Disease
Case Scenario:
A 55-year-old man presents with progressive flexion contractures of the ring and little fingers. There are firm, non-tender nodules in the palm. The patient has a history of chronic alcoholism and diabetes.
What is the most likely diagnosis?
a) Rheumatoid arthritis
b) Trigger finger
c) Dupuytren’s disease
d) Tenosynovitis
e) Psoriatic arthritis
Answer:
c) Dupuytren’s disease
Explanation:
Dupuytren’s disease is a fibroproliferative disorder of the palmar fascia leading to flexion contractures. Risk factors include alcoholism, diabetes, and genetics.
Case 6: Risk Factors for Dupuytren’s Disease
Case Scenario:
A 60-year-old man with progressive palmar contractures is concerned about potential risk factors.
Which of the following is NOT a risk factor for Dupuytren’s disease?
a) Diabetes Mellitus
b) Alcoholism
c) Rheumatoid arthritis
d) HIV
e) Family history
Answer:
c) Rheumatoid arthritis
Explanation:
Dupuytren’s disease is associated with genetic predisposition, diabetes, alcohol use, and certain viral infections. It is not associated with rheumatoid arthritis.
Case 7: Boutonniere Deformity
Case Scenario:
A 45-year-old male presents after a sports injury with a flexed PIP joint and hyperextended DIP joint. The injury involved a forceful blow to the dorsum of the finger.
What is the likely diagnosis?
a) Mallet finger
b) Swan neck deformity
c) Boutonniere deformity
d) Trigger finger
e) Jersey finger
Answer:
c) Boutonniere deformity
Explanation:
Boutonniere deformity is caused by rupture of the central slip of the extensor tendon, leading to PIP flexion and DIP hyperextension. It is commonly seen in rheumatoid arthritis or traumatic injuries.
Case 8: Management of Severe Dupuytren’s Disease
Case Scenario:
A 70-year-old male has severe Dupuytren’s contractures affecting daily activities. The fingers are in fixed flexion, and non-surgical options have failed.
What is the preferred surgical treatment?
a) NSAIDs
b) Limited palmar fasciectomy
c) Tendon release surgery
d) Joint replacement
e) Collagenase injection
Answer:
b) Limited palmar fasciectomy
Explanation:
For advanced Dupuytren’s contractures, limited palmar fasciectomy is the gold standard. Collagenase injections can be used for early-stage disease.
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