Zone 1 Flexor Tendon Injuries - Pre-test

1. Two weeks earlier, an 18 year-old football lineman injured his ring finger with a deformity seen in Figure 1. There is palmar tenderness at the PIP joint and decreased PIP range of motion. What is the most effective treatment for this problem at this time? 

A. Allow the athlete to compete until season’s end and then reconstruct the deformity 
B. Resection of the tendon in the palm
C. Free graft from the palm to the distal phalanx 
D. DIP fusion at 25 degrees of flexion
E. Primary repair of the avulsed tendon 


2. A college student presents 4 weeks after sustaining an injury to the ring finger of the dominant hand while playing flag football. Ultrasound assessment of the digit reveals that the distal stump of the flexor tendon is located at the level of the PIP joint. Inspection of the DIP joint demonstrates mild hyperextension. The recommended treatment is:

A. DIP joint arthrodesis
B. Direct repair of the flexor digitorum profundus
C. Single stage tendon graft reconstruction
D. Two stage flexor tendon reconstruction
E. Non-operative management


3. A 17 year-old male football player presents with a swollen, tender ring  finger and inability to flex the distal interphalangeal joint (DIP) joint of his dominant hand. The injury occurred from a missed tackle 5 weeks earlier. Physical examination reveals tenderness over the middle phalanx. He can actively flex the PIP joint without pain. Radiographs are normal. Appropriate management of the injury is:

A. Reinsertion of the avulsed FDP tendon into the distal phalanx
B. Primary tendon grafting and pulley reconstruction
C. Two-stage FDP tendon reconstruction with silicone rod insertion and delayed grafting
D. Conversion to a one-tendon finger 
E. Fusion of the DIP joint in slight flexion

4. A 43 year-old attorney presents with the following injury two days after trying to restrain his dog by grabbing the dog’s collar. What type of zone 1 flexor digitorum profundus avulsion is this?

A. Type I
B. Type II
C. Type III
D. Type IV
E. Type V


5. An 18yo female trips on the steps and catches the hand rail with only the small fingertip. She presents to your clinic the next day with the swollen, painful finger seen in Figures 1 and 2. The most appropriate treatment is: 

A. Splint and rehabilitation.
B. Open reduction, internal fixation within 6 weeks.
C. Open reduction, internal fixation and tendon repair within 6 weeks.
D. Tendon repair within 2 weeks.
E. Open reduction, internal fixation and tendon repair within 4-7 days.


6. In flexor profundus injuries retracted to the level of the proximal interphalangeal (PIP), tendon vascularity is maintained by which of the following structures?

A. Vinculum longus profundus
B. Vinculum brevis profundus
C. Intraosseous vessels from distal phalanx
D. Extraosseous vessels from distal phalanx
E. Vascular leash from the A5 pulley

7. Which of the following is the most common reason for the infrequent use of intrasynovial tendon graft in hand tendon reconstruction as compared to extrasynovial tendon graft?

A. Increased tendon adhesions
B. Healing with lack of gliding surface
C. Poor early functional result
D. Poor late functional result
E. Limited availability

8. A laceration of a ring finger flexor digitorum profundus tendon occurs distal to the insertion of the superficialis tendon. Primary repair was achieved, but required debridement of 1.5 cm of the damaged tendon ends. Four months later, the most likely clinical consequence is:

A. Bowstringing of the tendon in the ring finger.
B. Inability to fully flex the ring finger.
C. Inability to fully flex the long finger.
D. Boutonniere deformity of the adjacent long and small fingers.
E. Paradoxical extension of the long and small fingers.

9. Outcome studies comparing flexor tendon rehabilitation protocols reveal:

A. Better results with passive motion protocols
B. Better results with six weeks of immobilization
C. Decreased rupture rates with place and hold techniques
D. Improved results with use of a certified hand therapist
E. Superior total active motion with a home exercise program only

10. A patient sustains a traumatic, ring finger flexor digitorum profundus tendon rupture (jersey finger) diagnosed by physical examination and confirmed by MRI. He elects no surgical treatment initially. Three months later, he notes that when he attempts to flex the finger, it involuntarily extends at the proximal interphalangeal joint. The most likely cause of this phenomenon is:

A. Change in distal insertion of the profundus tendon
B. An extrinsic extensor tendon contracture
C. An intrinsic contracture of the third palmar interosseous muscle
D. A pseudoboutonniere deformity
E. A swan neck deformity

11. A patient presents with loss of grip one year following repair of a zone I flexor tendon laceration. With active digital flexion, the distal and proximal interphalangeal joints extend. Which of the following procedures is most likely to address this issue?

A. Terminal extensor tendon tenotomy
B. Oblique retinacular ligament reconstruction
C. Distal instrinsic release
D. Lumbrical release
E. Ring FDS transfer

12. In a two-stage flexor tendon reconstruction using the Paneva-Holevich technique (which creates an FDS pedicle graft where in the first stage, the FDS and FPD proximal ends are looped and sutured together in the palm), the main disadvantage is:

A. The tendon graft is extrasynovial
B. Tensioning of the graft is done at the distal end
C. A lumbrical plus finger commonly results
D. Rupture at the proximal end of the graft
E. The graft diameter may not match the diameter of the silicone rod

13. Which of the following donor tendons used for flexor tendon reconstruction has been reported by basic science investigators to show better survival without peritendinous adhesions when transplanted to the digital synovial sheath?

A. Palmaris Longus
B. Plantaris
C. Extensor Digitorum Longus (2nd toe)
D. Flexor Digitorum Longus (2nd Toe)
E. Extensor Indicis Proprius