Question 36#

In obstetrical brachial plexus palsy:

A. The incidence has declined over the last 50 years due to more intensive obstetric intervention

A differential diagnosis includes shoulder injury, cervical cord lesions and arthrogryphosis. The incidence of brachial plexus palsy in the UK is 0.42/1000 live births. This is very similar to the rates described almost 50 years ago, and is despite advances in obstetric care. A possible explanation for this is the increase in birth weight that has been observed over this time. The main associated factors are shoulder dystocia (65%),  assisted delivery (ventouse or forceps - 36%), and high birth weight. The incidence of breech delivery in obstetrical brachial plexus palsy is the same as that of the normal population. The most important differential diagnosis is that of shoulder injury. Lack of movement can mimic brachial plexus palsy, but passive range of movement is also affected. Much rarer differentials include cervical cord lesions and arthrogryphosis.

Question 37#

Arthritis can be treated by all except:

A. Joint excision

Joint mobilisation under anaesthesia. This statement is incorrect; joint mobilization is not an accepted treatment for arthritis.

Question 38#

In De Quervain’s tenosynovitis (tenovaginitis) all are true except:

A. Can be assessed by Finkelstein’s test

Multiple slips of both abductor pollicis longus (APL) and extensor pollicis brevis (EPB) can be present. This is incorrect; while multiple slips of APL are common, EPB is normally a single tendon or can be absent in around 5% of cases. Another common anatomical variation is septation of the first dorsal compartment into two distinct tunnels. Finkelstein’s test was first described by Eichoff, but was first reported in the American literature by Harry Finkelstein in 1930 1. To perform the test, the thumb is placed in a closed fist and the hand is ulnar deviated. If sharp pain occurs along the distal radius, DeQuervain’s tenosynovitis is likely. 

References:

1. Finkelstein H. Stenosing tendovaginitis at the radial styloid process. J Bone Joint Surg 1930; 12: 509-40.

Question 39#

In Dupuytren’s disease:

A. Splinting may prevent progression of the contracture

Needle fasciotomy is as successful in correcting MCP joint contracture as fasciectomy. However, the recurrence rates are probably higher. Nevertheless, this is balanced by the lower risk of surgery and simplicity of an office procedure, as well as repeatability.

Question 40#

Regarding tumours in the hand:

A. Hildreth’s test differentiates glomus tumours from other vascular tumours

Giant cell tumours of tendon sheath recur commonly and are usually benign. Melorheostosis is a rare and progressive disorder characterised by hyperostosis (thickening) of the cortical bone. Melorheostosis affects both bone and soft tissue growth and development. Giant cell tumours of tendon sheath are most likely to recur if disease is left behind and this is more likely where it arises from joints. Despite the high recurrence rate of giant cell tumours, they remain benign in the majority. Acral melanoma occurs on the hand, and is especially common in black skin.