Kisner: Wrist and Hand

You are evaluating a patient with rheumatoid arthritis of the hand and wrist. You notice several deformities, including hyperextension of the PIP joints and flexion of the DIP joints of digits 2, 3, and 4. This deformity is called: A) Swanneck deformity B) Heberden's deformity C) Boutonnière deformity D) Saddleback deformity

A) Swanneck deformity

Friction massage to adhesive scar tissue is best applied by which of the following methods? A) Tendon lengthened, massage perpendicular to tendon and longitudinally proximal and B) Tendon lengthened, massage parallel to tendon and longitudinally proximal and distal C) Tendon shortened, massage perpendicular to tendon and longitudinally proximal and D) Tendon shortened, massage parallel to tendon and longitudinally proximal and distal

A) Tendon lengthened, massage perpendicular to tendon and longitudinally proximal and

Each of the following descriptions of the flexor zones of the hand and forearm is correct except: A) Zone I is where the FDS tendon inserts; if the tendon avulses, the patient will be unable to flex the DIP joint B) Zone II, known as "noman's land," is where the extrinsic flexor (FDS and FDP) tendons lie in close proximity; rangelimiting adhesions that prevent tendon gliding are likely to develop in this area after injury and repair C) Zone III is in the palm of the hand; injury in this area can damage the lumbricales and interfere with MCP flexion D) Zone IV includes the carpal tunnel; extrinsic flexor tendons (FDS, FDP, and FPL) can adhere in the tunnel following inflammation

A) Zone I is where the FDS tendon inserts; if the tendon avulses, the patient will be unable to flex the DIP joint

Your patient has an extensor lag of the MCP joint. The exercise of choice to remediate this problem is: A) While stabilizing the IP joints of one finger in extension, passively extend the MCP joint of that finger B) Have the patient move actively from the straight fist position to the tabletop position of C) Have the patient move actively from the full fist position of the hand to the tabletop D) Have the patient move actively from the full fist position of the hand to the hook fist (claw hand) position

D) Have the patient move actively from the full fist position of the hand to the hook fist (claw hand) position

The type of grip in which muscles function primarily in an ISOM manner is which of the following? A) Combined grip B) Precision grip C) Power grip D) Hook grip

C) Power grip

One of the interventions appropriate during the protection phase of rehabilitation for tenosynovitis is crossfiber massage. If your target tendon is the extensor pollicis longus tendon, the best results are achieved by applying crossfiber massage to the sheath with the thumb in which of the following positions? A) Flexion B) Extension C) Halfway between full flexion and extension D) It does not matter

A) Flexion

Your patient has an "extensor lag" of the MCP joints. What does this suggest? A) It is possible to extend the MCP joint passively through the full range of extension, but full active MCP extension is not possible owing to weakness of the extensor digitorum B) Posterior (dorsal) sliding of the proximal phalanx on the head of the metacarpal is restricted C) Full passive MCP extension is not possible D) It is possible to extend the MCP joint passively through the full range of extension, but full active MCP extension is not possible owing to weakness of the lumbricales

A) It is possible to extend the MCP joint passively through the full range of extension, but full active MCP extension is not possible owing to weakness of the extensor digitorum

Which of the following is least appropriate after arthroplasty of the wrist? A) Manual stretching techniques to restore full ROM of the wrist during the final phase of rehabilitation B) Active wrist flexion/extension (greater emphasis on extension) and forearm pronation/supination (greater emphasis on supination) as soon as the immobilization device can be removed for exercise C) Lowintensity (about 1 lb) dynamic resistance exercises of the wrist and hand during the intermediate and late phases of rehabilitation D) Use of the hand for light functional activities at about 3 months postoperatively

A) Manual stretching techniques to restore full ROM of the wrist during the final phase of rehabilitation

Which of the following methods is the most effective when stretching to increase wrist extension? A) Palm on table with fingers flexed over the edge; patient moves forearm over stabilized hand B) Palm on table with fingers extended; patient moves forearm over stabilized hand C) Dorsum of hand on table with fingers flexed; patient moves forearm over stabilized hand D) Dorum of hand on table with fingers extended; patient moves forearm over stabilized hand

A) Palm on table with fingers flexed over the edge; patient moves forearm over stabilized hand

Which of the following is a true statement about MCP arthroplasty and postoperative management of the fingers? A) Repair of ruptured extrinsic finger flexor tendons often is coupled with MCP joint replacement arthroplasty for the patient with RA and chronic tenosynovitis B) After MCP arthroplasty and removal of the postoperative compression dressing, a dynamic splint with an outrigger is worn to maintain the MCP joints in full extension when the fingers are relaxed but to allow active MCP flexion within a limited range and unrestricted IP C) If a patient has an ulnar drift deformity of the fingers, dynamic splinting is contraindicated postoperatively D) Use of static splinting has been shown to be an ineffective alternative to dynamic splinting for improving ROM and function after MCP arthroplasty

B) After MCP arthroplasty and removal of the postoperative compression dressing, a dynamic splint with an outrigger is worn to maintain the MCP joints in full extension when the fingers are relaxed but to allow active MCP flexion within a limited range and unrestricted IP

A patient with RA of the hands and wrists is experiencing an acute flare of the disease. To protect the inflamed joints and minimize deforming forces on the hands and wrists, you should teach the patient to: A) Avoid all activities with the hands until there is no pain B) Avoid strong gripping motions that require wrist extension, radial deviation of the wrist, and ulnar deviation of the fingers C) Exercise the hands in functional ways such as wringing out a dish rag under warm water D) Stretch the extrinsic finger tendons across all the joints simultaneously to gain mobility and counter contractures

B) Avoid strong gripping motions that require wrist extension, radial deviation of the wrist, and ulnar deviation of the fingers

Your patient sustained a laceration of the palmar aspect of the fingers in zone II ("no- man's land") of the hand. The patient subsequently underwent a repair of the lacerated tissues. During the subacute (moderate protection) phase of healing, it is critical to: A) Keep the fingers immobile because there is poor circulation and therefore poor healing in this area B) Begin tendongliding exercises to minimize the formation of rangelimiting adhesions C) Initiate maximumlevel resistance exercises of the extrinsic flexors to regain normal strength of the injured muscletendon unit D) Limit exercise to passive ROM to protect the healing tendons

B) Begin tendongliding exercises to minimize the formation of rangelimiting adhesions

Which of the following methods is the correct way to teach a patient to stretch the lumbricals and interossei muscles? A) Extension of MCP joints, extension of IP joints B) Extension of MCP joints, flexion of IP joints C) Flexion of MCP joints, extension of IP joints D) Flexion of MCP joints, flexion of IP joints

B) Extension of MCP joints, flexion of IP joints

"Placeandhold" exercises are: A) A form of dynamic exercises in which the patient actively moves through a series of hand positions to prevent tendon adhesions B) Gentle musclesetting (isometric/static) exercises used during the early phase of rehabilitation after, for example, a tendon repair whereby an involved finger is placed passively in a particular position (by the therapist or by the patient using the sound hand); the patient then is asked to try actively to hold the position without assistance C) A form of isometric exercise in which the therapist places a finger in a particular position and then asks the patient to hold the position as manual resistance is applied to the contracting muscle D) A form of stretching exercise in which a patient is asked to perform an isometric contraction of a muscletendon unit against lowintensity resistance followed by relaxation and elongation of that muscle

B) Gentle musclesetting (isometric/static) exercises used during the early phase of rehabilitation after, for example, a tendon repair whereby an involved finger is placed passively in a particular position (by the therapist or by the patient using the sound hand); the patient then is asked to try actively to hold the position without assistance

Your patient has a 5year history of rheumatoid arthritis. There are no obvious deformities, but during this current exacerbation of the disease the wrist and MCP joints are swollen, red, tender, and warm. There is generally decreased ROM, pain during joint motion, and increased pain at the end of the available range of each joint. An appropriate shortterm goal and intervention is: A) Minimize deforming forces by maintaining ROM with gentle, passive stretching to the involved joints B) Maintain joint mobility and decrease pain by using grade I or II joint oscillation techniques C) Increase muscle length by using contract-relax (hold-relax) techniques D) Control pain by imposing continuous rest, using splints on the wrists and hands

B) Maintain joint mobility and decrease pain by using grade I or II joint oscillation techniques

Each of the following is an example of a precision pattern grip except: A) Pad to pad B) Pinch C) Tip to tip D) Pad to side

B) Pinch

You are working to strengthen the extensor carpi radialis muscle. The best technique would be which of the following? A) Resist on volar surface of 2nd and 3rd metacarpals B) Resist on dorsal surface of 2nd and 3rd metacarpals C) Resist on volar surface of 4th and 5th metacarpals D) Resist on dorsal surface of 4th and 5th metacarpals

B) Resist on dorsal surface of 2nd and 3rd metacarpals

All of the following can be impairments present with osteoarthritis in the hands except: A) Pain B) Systemic fatigue C) Joint swelling D) Subluxation of affected joints

B) Systemic fatigue

Which of the following hand positions for flexor tendon gliding exercises is also known as the intrinsic plus position? A) Straight fist B) Table top C) Full fist D) Hook fist

B) Table top

A laceration in "no man's land" is in which of the following anatomical zones of the volar surface of the distal upper extremity? A) Zone I B) Zone II C) Zone III D) Zone IV

B) Zone II

Which position of the wrist is preferable for a strong functional grasp? A) Neutral position B) 15° flexion C) 15° extension D) 30° extension

C) 15° extension

Which of the following is true statement about carpometacarpal (CMC) arthroplasty of the thumb and postoperative management? A) For a patient with erosion of the articular surfaces and subluxation of the CMC joint, joint replacement arthroplasty with prosthetic implants is a far more common procedure than trapezial resection/tendon interposition arthroplasty with ligament reconstruction B) A longer period of immobilization of the thumb is required after total joint arthroplasty with prosthetic implants than after trapezial resection/tendon interposition arthroplasty with ligament reconstruction C) After CMC arthroplasty the thumb is immobilized in abduction D) A priority in a postoperative exercise program is to gain active flexion combined with adduction of the thumb (sliding the thumb across the palm) as early as possible

C) After CMC arthroplasty the thumb is immobilized in abduction

Each of the following is true regarding management of the patient with rheumatoid arthritis of the hands except: A) PRE is contraindicated so long as there are signs of inflammation B) Principles of joint protection and energy conservation are integral components of patient education to reduce deforming forces on involved joints and reduce excessive fatigue C) Application of splints should be avoided in the rheumatoid hand because it promotes loss of joint mobility D) With MCP joint deformities, forceful pinch and grip exercises are contraindicated

C) Application of splints should be avoided in the rheumatoid hand because it promotes loss of joint mobility

Precautions after wrist arthroplasty include all of the following except: A) If an ambulation aid is required, use platform attachment initially B) Avoid weight bearing on operated hand during transfers initially C) Avoid functional activities that place loads on the wrist while the forearm is supinated D) Permanently refrain form highimpact recreational activities such as racquet sports

C) Avoid functional activities that place loads on the wrist while the forearm is supinated

Exercises that follow the progression of active isolated MCP extension, isolated PIP and DIP extension, and terminal range extension of IP joints describe which of the following? A) Tendongliding exercises B) Tendonblocking exercises C) Extensor lag exercises D) Place and hold exercises

C) Extensor lag exercises

Each of the following is correct about proximal interphalangeal arthroplasty, associated soft tissue reconstruction, and postoperative management except: A) Because correction of a boutonnière deformity during PIP arthroplasty involves a central slipsplitting approach, it is important to postpone resisted PIP extension exercises for at least 6 to 8 weeks B) When initiating ROM of the PIP joint after PIP arthroplasty, stabilize the MCP and DIP joints in neutral C) For functional grasp after PIP arthroplasty, more flexion of the PIP joints of the index and middle fingers is necessary than flexion of the ring and little fingers D) After PIP arthroplasty that included correction of a swanneck deformity, emphasize PIP flexion and DIP extension more so than PIP extension and DIP flexion

C) For functional grasp after PIP arthroplasty, more flexion of the PIP joints of the index and middle fingers is necessary than flexion of the ring and little fingers

Any of the following interventions are appropriate in the protection phase of recovery for a person with osteoarthritis of the hands except: A) Tendongliding exercises B) Gentle ISOM exercises C) Grade III mobilization techniques D) Active assistive ROM exercises

C) Grade III mobilization techniques

Each of the following is true about lesions of the extensor tendons of the wrist and hand except: A) A mallet finger is a lesion of the extensor mechanism of the DIP joint and is managed nonoperatively with splinting in full extension B) A lesion of the central tendon (central slip) of the extensor hood and, if untreated, results in a PIP flexion contracture and boutonnière deformity over time C) If a tendon lesion occurs in zone V, PIP and DIP extension is disrupted, but MCP extension remains intact D) A laceration of the extensor tendons in zone VII can cause a wrist flexion deformity and requires surgery to repair the lesion

C) If a tendon lesion occurs in zone V, PIP and DIP extension is disrupted, but MCP extension remains intact

Which of the following is true about regimens that employ customized splinting and early controlled motion after flexor tendon repair in zones I, II, or III? A) May involve the use of a dorsal tenodesis splint that allows full active extension of the wrist and MCP joints B) May involve the use of a dynamic dorsal blocking splint with elastic bands attached providing full passive extension of the fingers and allowing limited active flexion of the fingers C) May involve the use of a dynamic dorsal blocking splint with elastic bands attached, allowing limited active finger extension and providing passive finger flexion D) May involve the use of a volar tenodesis splint that allows full ROM of the wrist while maintaining the fingers in full extension

C) May involve the use of a dynamic dorsal blocking splint with elastic bands attached, allowing limited active finger extension and providing passive finger flexion

What is the biomechanical cause of a Boutonnière deformity? A) Overstretching of the volar plate (palmar plate) and bowstringing of the lateral bands of the extensor hood mechanism B) Volar displacement of the extensor carpi ulnaris tendon causing a flexion force at the wrist joint C) Rupture of the central band (central slip) of the extensor hood mechanism causing the lateral bands to slip in a volar direction at the PIP joint D) Overstretching or rupture of the collateral ligaments of the MCP joints

C) Rupture of the central band (central slip) of the extensor hood mechanism causing the lateral bands to slip in a volar direction at the PIP joint

Each of the following is true about flexor tendongliding exercises except: A) Maintain or develop freegliding between the FDS and FDP tendons B) To perform these exercises the patient actively moves his fingers into five different positions C) To perform these exercises the therapist passively moves the patient's fingers into five different positions in a particular sequence D) Maintain or develop freegliding between the FDS and FDP tendons and adjacent bones

C) To perform these exercises the therapist passively moves the patient's fingers into five different positions in a particular sequence

Each of the following is true about the use of early controlled motion after tendon repair in the hand and forearm except: A) When ROM exercises are initiated, they are performed within a protected range to minimize the risk of excessive stress on the repair site and gapping of the repaired tendon ends B) Has been shown to increase the tensile strength of the scar at the repair site more effectively than the use of prolonged immobilization after a surgical repair C) Is thought to improve synovial fluid diffusion, thereby improving tendon nutrition and promoting tendon healing D) Is used more often after extensor tendon repair than after flexor tendon repair

D) Is used more often after extensor tendon repair than after flexor tendon repair

During the subacute stage of soft tissue healing after injury and repair of the flexor tendons of the hand or forearm, each of the following is an important intervention except: A) Scar management with pressure on the scar B) Tendon gliding exercises C) Gentle prolonged stretch D) Progressive resistance exercise

D) Progressive resistance exercise

Which of the following is a relative or absolute contraindication for wrist arthroplasty despite debilitating pain in the wrist region and diminished hand and upper extremity function from advanced arthritis? A) Significant, arthritisrelated, ipsilateral limitation of motion of joints proximal and distal of the wrist B) Subluxation or dislocation of the radiocarpal joint C) Previous, arthritisrelated arthrodesis of the opposite wrist where arthrodesis of both wrists would potentially reduce, rather than improve, function D) The need to perform highload, highimpact occupational tasks postoperatively

D) The need to perform highload, highimpact occupational tasks postoperatively

The concept of passive insufficiency guides you to avoid which of the following combinations of movement with a repaired flexor tendon? A) Wrist flexion, finger flexion B) Wrist flexion, finger extension C) Wrist extension, finger flexion D) Wrist extension, finger extension

D) Wrist extension, finger extension