Revision questions

Question 1

Methotrexate is used for the treatment of Rheumatoid Arthritis. Which of the following is true of its pharmacology?
a. It activates the immune system to inhibit the production of immune mediators
b. It is the primary treatment for Gouty Arthritis
c. It inhibits Xanthine Oxidase
d. It increases Adenosine levels
e. It is co-administered with IL-6 for greater effect.

Answer 1

d

Question 2

Which drug can be coadministered with methotrexate to treat rheumatoid arthritis?
A. Allopurinol
B. Hydroxychloroquine
C. Probenecid
D. Colchicine
E. Sulfinpyrazone

Answer 2

B. csDMARD

Question 3

2. In an injury to the upper roots of the brachial plexus, the resulting weakness will significantly affect:
   a) Elevation of the scapula
   b) Extension of the elbow
   c) Adduction of the thumb
   d) Abduction of the glenohumeral joint
   e) Extension at the interphalangeal joints

Answer 3

Injury to the upper roots of the brachial plexus (C5 and C6) usually results from an excessive increase in angle between the neck and the shoulder; this may happen when someone is thrown off from a motorcycle or a horse, landing on the shoulder in a way that separates the shoulder and neck or when excessive stretching of the neck occurs during delivery. As a result of the injury, paralysis (Erb’s Palsy) is observed mainly in the muscles of the shoulder and arm supplied by the spinal nerves C5 and C6.

Some of these muscles include the deltoid, supplied by the axillary nerve; biceps brachii and brachialis, supplied by the musculocutaneous nerve; and rotator cuff muscles, supplied by various nerves of the brachial plexus. Considering the action of the affected muscles, Erb’s palsy is likely to most significantly affect flexion of the forearm at the elbow joint, and abduction and rotation of the glenohumeral joint. As such, the usual clinical appearance of a patient suffering from Erb’s palsy is an upper limb with an adducted shoulder, medially rotated arm and extended elbow.

Question 4

4. Supination of the forearm:
   a) Involves the humeroulnar joint
   b) Is facilitated by both the radial and musculocutaneous nerves
   c) Requires the forearm to be extended
   d) Is primarily caused by the supinator
   e) Is impaired by injury to the lower roots of the brachial plexus

Answer 4

(b) The supination of the forearm is facilitated by two muscles: biceps brachii, innervated by the musculocutaneous nerve, and supinator, which is a deep muscle innervated by the radial nerve.

Question 5

7. It is possible to locate and identify the cephalic vein in the following places except:
   a) Lateral end of the dorsal venous arch
   b) Anatomical snuff box
   c) Medial aspect of the arm
   d) Deltopectoral groove
   e) In front of the elbow

Answer 5

(C) Medial Aspect of the Arm
The cephalic vein is one of the superficial veins of the upper limb, which means that it is in fact visible under the skin.
It originates from the lateral aspect of the dorsal venous arch (or network), running through the anatomical snuffbox and superiorly along the lateral aspect of the forearm. Anterior to the elbow, the cephalic vein communicates with the median cubital vein, which passes obliquely across the anterior aspect of elbow in the cubital fossa and subsequently joins the basilic vein. The basilic vein is also another superficial vein present in the upper limb but unlike the cephalic vein, runs primarily on the medial aspect of the upper limb.
The cephalic vein subsequently continues along the lateral aspect of the arm, superiorly towards the shoulder. It passes between the deltoid and the pectoralis major muscles along the deltopectoral groove and enters the clavipectoral triangle to join the terminal part of the axillary vein.

Question 6

In an obstruction to the 2nd part of the axillary artery, collateral circulation (to bypass the obstruction) to the arm may be established between the:
a) First and third parts of the axillary artery
b) Lateral thoracic and subscapular arteries
c) Subclavian artery and branches of the third part of the axillary artery
d) Scapular anastomosis and the brachial artery
e) Subclavian artery and the brachial artery

Answer 6

C

Question 7

The components not significantly involved in generating the biceps tendon reflex is:
a) Muscle spindles in the biceps tendon
b) Musculocutaneous nerve
c) Selected dorsal root ganglia
d) Axons of selected motor neurons in the spinal cord
e) Sarcoplasmic reticulum in the biceps muscle fibres

Answer 7

A. In a typical tendon reflex such as the biceps tendon reflex, the first step involves inducing a short lengthening of the muscle by lightly tapping on the tendon. The short lengthening of the muscle stimulates the muscle spindles in the BELLY of the muscle to send signals through the afferent sensory neurons, which have their cell bodies contained within the dorsal root ganglion. The signal is passed along the afferents into the dorsal horn of the spinal cord. Thereafter, the afferent sensory neurons then synapse with the efferent motor neurons, and the signal continues to travel along the axons of the motor neurons out through the ventral horn of the spinal cord. The signal eventually returns back to the muscle fibres by way of the relevant peripheral nerve (in the case of the biceps tendon reflex, the musculocutaneous nerve), triggering the contraction of the muscle.

Question 8

11. Injury to the lateral cord of brachial plexus is most likely to cause:
    a) Weakness of abduction
    b) Weakness of supination
    c) Wrist drop
    d) Numbness of little finger
    e) Difficulty in doing push-ups

Answer 8

(b) Weakness of supination is to be expected because the biceps brachii, a strong supinator of the forearm, is innervated by the musculocutaneous nerve, which is a branch of the lateral cord of the brachial plexus. Lesion of the lateral cord will effectively result in denervation of the biceps brachii muscle and cause weakness of supination, especially so when the elbow joint is flexed. *The supinator is however not affected because it is supplied by the radial nerve, which is a branch of the posterior cord.

Question 9

13. Abduction of the arm to the vertical position is not caused by:
    a) Levator scapulae
    b) Trapezius
    c) Deltoid
    d) Supraspinatus
    e) Serratus anterior

Answer 9

13. (A) Levator scapulae
    Abduction of the arm to the vertical position can be split in three segments:
    (a) Initial abduction of the arm (15°): Supraspinatus muscle carries out the initial abduction of the arm. Note that patients with a paralyzed supraspinatus tend to passively carry out the initial abduction by tilting their trunk to abduct their arms before the deltoid takes over. This is something noteworthy to keep at the back of the mind.
    (b) Abduction of the arm up to 120°: The deltoid muscle takes over as the primary abductor of the arm after the initial 15°, assisted by the supraspinatus. The scapulo-humeral mechanism comes into play: for every 3° of abduction of the arm, 2° abduction occurs in the glenohumeral joint while the other degree occurs by rotation of the scapula. The rotation of the scapula lateral to the spinal column is carried out by the descending fibres of the trapezius and the serratus anterior muscle.
    (c) Abduction of the arm up to 180° from 120°: At about 120° of abduction, the greater tubercle of the humerus comes into contact with the lateral edge of the acromion. Further abduction of the arm is carried out purely by the rotation of the scapula up till the vertical position.
    The levator scapulae elevates the scapula and does not participate in the overhead abduction of the arm.

Question 10

15. Axillary lymph nodes are least likely to receive lymph from:
    a) Side of the neck
    b) Breast
    c) Epigastrium
    d) Scapula region
    e) Hand

Answer 10

(A) Side of the neck
The axillary lymph nodes can be divided into five groups: humeral (lateral) lymph nodes, central lymph nodes, apical lymph nodes, subscapular (posterior) lymph nodes and pectoral (anterior) lymph nodes. Lymph is then directed towards the clavicular lymph nodes. The subclavian trunk then fuses with the jugular and bronchomediastinal trunk to form the right lymphatic duct. On the left, the subclavian trunk commonly joins the thoracic duct.
(a) Most of the superficial tissues of the neck are drained by lymphatic vessels that enter the superficial cervical lymph nodes. Lymph then continues to drain into the inferior deep cervical lymph nodes, which fuse to form the jugular lymphatic trunk. On the right side, jugular lymphatic trunk continues to join the right lymphatic duct while on the left, the trunk continues into the thoracic duct.
(b) The pectoral (anterior) axillary lymph nodes receive lymph from most of the breast, especially the superolateral aspect of the breast and the subareolar plexus. Lymph from the medial aspect of the breast drains towards the parasternal lymph nodes.
(c) Lymph from regions of the anterolateral abdominal wall superior to the transumbilical plane drain mainly to the axillary lymph nodes, though a few of the superficial lymphatic vessels may drain into the parasternal lymph nodes. *Lymph from the regions inferior to the transumbilical plane drain mainly to the superficial inguinal lymph nodes.
(d) The subscapular (posterior) nodes receive lymph from the posterior aspect of the thoracic wall and scapular region. These nodes lie along the posterior axillary fold and subscapular blood vessels.
(e) Lymph from the hand, in fact most of the upper limb, primarily drains towards the humeral (lateral) lymph nodes. These nodes receive nearly all the lymph from the upper limb, except that carried by the lymphatic vessels accompanying the cephalic vein, which primarily drains towards the apical axillary and infraclavicular nodes.

Question 11

Suprascapular nerve supplies the:
a) Subscapularis
b) Teres minor
c) Rhomboid Minor
d) Infraspinatus
e) Latissimus dorsi

Answer 11

D

Question 12

In a supracondylar fracture, which of the following structures is most likely to be injured:
a) Radial nerve
b) Median nerve
c) Ulnar nerve
d) Circumflex artery
e) Axillary nerve

Answer 12

(B) Median Nerve. A supracondylar fracture usually occurs from a fall on an outstretched hand with the elbow extended. The pull of the triceps brachii muscle on the distal fragment causes the posterior dislocation of the distal fragment. As a result, the proximal humeral fragment usually overrides the distal fragment.
The danger of a supracondylar fracture lies in the entrapment of the brachial artery and the median nerve (sometimes the radial nerve may be entrapped as well).
Entrapment of the brachial artery can potentially cut off blood supply to the muscles of the forearm (and hand) and if the entrapment persists for more than a few hours, permanent muscle damage (and even death) might likely occur. Systemic complications can also arise from hyperkalemia and release of myoglobin.
On the other hand, entrapment of the median nerve can cause loss of sensation over the palmar surface of radial 3½ digits, and loss of function of some of the short muscles of the hand (L.O.A.F.s) and the muscles in the flexor compartment of the forearm. So, careful management is required if a supracondylar fracture is suspected.

Question 13

In the upper extremity, a pulse may be palpated at all of the following locations except:
a) In the arm against the humerus just distal to the pectoralis minor
b) In the cubital fossa medial to the biceps brachii tendon
c) In the wrist at the radial side of the tendon of the flexor carpi radialis muscle
d) At the wrist at the radial side of the pisiform bone
e) In the hand between the tendons of the extensor pollicis brevis and abductor pollicis longus muscles

Answer 13

Question 14

Which of the following statements describing the pectoralis minor muscle is correct:
a) It attaches to the acromion process of the scapula
b) It crosses anterior to the cords of the brachial plexus
c) It is an adductor and medial rotator of the humerus
d) It is innervated by the middle subscapular (thoracodorsal) nerve
e) It originates deep to the axillary artery

Answer 14

(B) It crosses anterior to the cords of the brachial plexus.
(a) The pectoralis minor muscle originates (proximal attachment) from the 3rd to 5th ribs near their costal cartilages, while the muscle inserts (distal attachment) at the medial border and superior surface of the coracoid process of the scapula.
(b) In fact, it crosses anterior to most of the neurovascular structures passing from the trunk into the upper limb, such as the brachial plexus, axillary artery and axillary vein. The neurovascular structures which run anterior to the pectoralis minor muscle are the thoraco-acromial artery and the cephalic vein (one of the superficial veins of the upper limb).
(c) It stabilizes the scapula by drawing it inferiorly and anteriorly against the thoracic wall. Note that the pectoralis minor muscle does not carry out adduction and medial rotation of the humerus because it is attached proximally to the ribs and distally to the scapula, and not the humerus.
(d) It is innervated by the medial pectoral nerve. The medial pectoral nerve also supplies the sternocostal part of the pectoralis major muscle. On the other hand, the thoracodorsal nerve innervates the latissimus dorsi muscle.
(e) It passes anterior to the axillary artery. In fact, the pectoralis minor muscle is used as a form of landmark to demarcate the first part of the axillary artery (proximal to the muscle), the second part (deep to the muscle), and the third part (distal to the muscle).

Question 15

The ulnar nerve innervates which of the following muscles of the thumb:
a) Abductor pollicis brevis
b) Abductor pollicis longus
c) Deep head of the flexor pollicis brevis
d) Opponens pollicis

Answer 15

C

Question 16

27. Which of the following muscles originates from the medial epicondyle of the humerus:
    a) Brachioradialis
    b) Extensor carpi ulnaris
    c) Flexor carpi radialis
    d) Flexor pollicis longus
    e) Supinator

Answer 16

C.
The muscle which originates from the medial epicondyle of the humerus is the flexor carpi radialis muscle. Here, the concept to keep in mind is that the medial epicondyle serves as a common flexor origin, where many of the flexors in the forearm originate from. This includes palmaris longus, the humeral head of flexor carpi ulnaris and the humeral head of pronator teres, other than FCR.
On the other hand, the lateral epicondyle serves as a common extensor origin, where many of the extensors in the forearm originate from. Some of the muscles include extensor carpi ulnaris, extensor digitorum, extensor digiti minimi and extensor carpi radialis brevis.

Question 17

28. All of the following statements concerning the veins of the cubital region are true except:
    a) At the level of the midaxilla, the basilic vein is joined by the cephalic vein to form the axillary vein
    b) The basilic vein runs along the medial aspect of the forearm
    c) The cephalic vein originates on the radial side of the dorsum of the hand
    d) The median cubital vein links the cephalic and basilic veins in the cubital fossa
    e) The median cubital vein is separated from the brachial artery by the bicipital aponeurosis

Answer 17

Question 18

The distal attachment (insertion) of the triceps brachii muscle is:
a) Coronoid process of the ulna
b) Olencranon process of the ulna
c) Styloid process of the ulna
d) Radial notch of ulnar
e) Ulnar tuberosity

Answer 18

(B) Olecranon process of the ulna
The triceps brachii muscle is the main extensor of the elbow joint, innervated by the radial nerve (one of the terminal branches of the posterior cord of the brachial plexus) and supplied by the profunda brachii artery. Its name is derived as such because it has three heads:
(a) Long head of the triceps: Originates from the infraglenoid tubercle of the scapula
(b) Medial head of the triceps: Originates from the posterior surface of the humerus, inferior to the radial groove
(c) Lateral head of the triceps: Originates also from the posterior surface of the humerus, superior to the radial groove
The three heads share a common distal attachment: the olecranon process of the ulna and the fascia of the forearm.

Question 19

30. Most of the muscles that act on the shoulder girdle and upper limb joints are supplied by branches of the brachial plexus. Which of the following is not:
    a) Trapezius
    b) Teres minor
    c) Latissimus dorsi
    d) Rhomboid major
    e) Levator scapulae

Answer 19

A

Question 20

31. Increasing muscle mass and tone is the aim of many people who work out at the gym. This is done by contracting the muscle against resistance. If you want to increase the muscle mass of the latissimus dorsi muscle, which of the following actions would you be most likely to perform:
    a) Depression of the scapula
    b) Abduction of the arm
    c) Extension of the arm
    d) Flexion of the arm
    e) Lateral rotation of the arm

Answer 20

31. (C) Extension of the arm
    The latissimus dorsi muscle originates from the inferior 3 or 4 ribs, the inferior angle of the scapula and the spinous processes of T7 to T12 vertebra and the posterior 1/3 of the iliac crest. It attaches onto the floor of the intertubercular groove of the humerus. Take note that the fibres wind medial to the humerus towards its insertion. With that in mind, one can imagine as the muscle contracts, it will extend, adduct and internally rotate the arm. These are the larger motions carried out by the latissimus dorsi muscle.
    *Considering that it also originates from the inferior angle of the scapula, it can also, to a lesser degree, depress the scapula. However, if one wants to work the muscle, a larger motion like extension of the arm would definitely be preferable.

Question 21

The true statement about the posterior compartment of the arm is:
a) It receives its motor supply from the median nerve
b) It contains the profunda brachii artery and radial nerve
c) It contains a single elbow flexor
d) Its major artery is the brachial artery
e) It contains the ulnar nerve in its distal part

Answer 21

B

Question 22

Label A to E

Answer 22

A: Greater tubercle of the humerus
B: Head of the humerus
C: Coracoid process
D: Acromion of the scapula
E: Lesser tubercle of the humerus

Question 23

A structure found in the deltopectoral groove is the:
a) Cephalic vein
b) Basilic vein
c) Brachial vein
d) Radial vein
e) Musculocutaneous nerve

Answer 23

A. It passes between the deltoid and the pectoralis major muscles along the deltopectoral groove and enters the clavipectoral triangle to join the terminal part of the axillary vein.

Question 24

In the cubital fossa, the median cubital vein is frequently used for venipuncture. This vein is separated from the underlying neurovascular structures by the:
a) Investing fascia of the brachialis muscle
b) Crural fascia
c) Bicipital aponeurosis
d) Anconeus muscle
e) Tendon of the biceps brachialis muscle

Answer 24

(C) Bicipital aponeurosis.

Question 25

A 52-year-old man was brought to the emergency room after being found in the park where he had apparently lain overnight after a fall. He complained of severe pain in the left arm. Physical examination suggested a broken humerus, which was confirmed radiologically. The patient was able to extend the forearm at the elbow, but supination appeared somewhat weak; the hand grasp was weak when compared with the uninjured arm. Neurologic examination revealed an inability to extend the wrist (“wrist drop”). Since these findings pointing to apparent nerve damage, the patient was scheduled for a surgical reduction of the fracture.

The observations that extension at the elbow appeared normal, but supination of the forearm weak, warrants localization of the injured nerve to the:
a) Posterior division of the brachial plexus
b) Posterior cord of the brachial plexus in the axilla
c) Radial nerve at the distal third of the humerus
d) Radial nerve in the vicinity of the head of the radius
e) Radial nerve in the mid-forearm

Answer 25

C

Question 26

43. The thumb action that is totally affected by radial nerve trauma is:
    a) Abduction
    b) Adduction
    c) Extension
    d) Flexion
    e) Opposition

Answer 26

c) Extension
Explanation
The radial nerve is responsible for innervating the extensor muscles of the forearm, which are crucial for extending the wrist and fingers, including the thumb. When the radial nerve is injured, it leads to a condition known as “wrist drop,” where the individual cannot extend the wrist or fingers effectively. This includes the inability to extend the thumb, as the extensor pollicis longus and extensor pollicis brevis muscles, which facilitate thumb extension, are innervated by the radial nerve.
Other thumb actions, such as abduction (a), adduction (b), flexion (d), and opposition (e), are primarily controlled by other nerves, including the median and ulnar nerves, and therefore are not completely affected by radial nerve trauma.

Question 27

Which of the following muscles is innervated by the ulnar nerve:
a) Flexor pollicis longus
b) Extensor pollicis longus
c) Abductor pollicis brevis
d) Adductor pollicis
e) Opponens pollicis

Answer 27

(D) Adductor Pollicis
Recall that all the muscles of the anterior compartment of the forearm are innervated by the median nerve except the ulnar half of the flexor digitorum profundus and flexor carpi ulnaris while all the short intrinsic muscles of the hand are supplied by branches of the ulnar nerve except the L.O.A.F.s muscles.
*L.O.A.F.s is the mnemonic for 1st and 2nd lumbricals (L), opponens pollicis (O), abductor pollicis brevis (A), and the superficial head of the flexor pollicis brevis (F.s).
Hence, the only muscle innervated by the ulnar nerve amongst the options is the adductor pollicis.

Question 28

47. If you slide a piece of paper between a patient’s fingers, then ask the patient to hold onto the paper when you try to pull it from the fingers, and the patient is unable to perform this action, which nerve is suspected to be non-functional:
    a) Radial nerve
    b) Median recurrent nerve
    c) Ulnar nerve
    d) Deep radial nerve
    e) Superficial radial nerve

Answer 28

(C) Ulnar nerve
The adduction of the fingers is mediated by the palmar interossei muscles (P.A.D), and these muscles are innervated by the ulnar nerve. Recall that all short intrinsic muscles of the hand are innervated by the ulnar nerve other than the L.O.A.F.s muscles. If the patient is unable to perform this action, then the suspicion would be that the integrity of the ulnar nerve has been compromised, resulting in paralysis of the palmar interossei muscles.

Question 29

Which of the following muscles does not rotate the arm medially (or internally):
a) Subscapularis
b) Supraspinatus
c) Latissimus dorsi
d) Pectoralis major
e) Anterior fibres of deltoid

Answer 29

A

Question 30

54. Which of the following muscles is a lateral rotator of the arm:
    a) Infraspinatus
    b) Subscapularis
    c) Latissimus dorsi
    d) Teres major
    e) Anterior fibres of deltoid

Answer 30

A

Question 31

Which of these muscles of the forearm has a double innervation:
a) Flexor digitorum profundus
b) Flexor digitorum superficialis
c) Pronator teres
d) Flexor pollicis longus
e) Pronator quadratus

Answer 31

(A) Flexor Digitorum Profundus
The flexor digitorum profundus muscle receives dual nerve supply from both the median nerve and the ulnar nerve. The lateral half of the flexor digitorum profundus is innervated by the median nerve, while the medial half of the muscle is innervated by the ulnar nerve. Therefore, palsy of either nerve will present with different deformities.
*Short notes on the other muscles:
* Flexor pollicis longus, flexor digitorum profundus, pronator teres and pronator quadratus are all innervated by the median nerve

Question 32

57. The muscle that forms the bulk of the anterior axillary fold is the:
    a) Latissimus dorsi
    b) Pectoralis major
    c) Subscapularis
    d) Teres minor
    e) Teres major

Answer 32

B

Question 33

58. The infraglenoid tubercle serves as an attachment for the:
    a) Long head of biceps
    b) Long head of triceps
    c) Medial head of triceps
    d) Coracobrachialis
    e) Subscapularis

Answer 33

B.

Question 34

Muscles of the hypothenar eminence are innervated by the:
a) Median nerve
b) Ulnar nerve
c) Radial nerve
d) Median and radial nerves
e) Median and ulnar nerves

Answer 34

B) Ulnar Nerve
Recall that:
The ulnar nerve supplies all the short intrinsic muscles of the hand other than the L.O.A.F.s muscles which are supplied by the median nerve; while the median nerve supplies all the muscles in the anterior compartment of the forearm other than the ulnar half of the flexor digitorum profundus and flexor carpi ulnaris, which are supplied by the ulnar nerve.
With that in mind, muscles of the hypothenar eminence – opponens digiti minimi, abductor digiti minimi, flexor digiti minimi – are all supplied by the ulnar nerve.

Question 35

Which nerve is probably damaged if a patient cannot abduct the arm beyond 25 degrees:
a) Axillary nerve
b) Radial nerve
c) Musculocutaneous nerve
d) Median nerve
e) Ulnar nerve

Answer 35

(A) Axillary Nerve
Abduction of the arm up to the first 30 degrees is first initiated by the supraspinatus muscle, which is innervated by the suprascapular nerve. Subsequently, abduction is primarily carried out by the deltoid muscle at the glenohumeral joint, assisted by the supraspinatus muscle. The deltoid muscle, innervated by the axillary nerve, can abduct the arm up to 120 degrees. In raising the arm overhead, scapulothoracic movement is also necessary. This mechanism is known as the scapulohumeral rhythm. For every three degrees of arm abduction, 2 degrees of abduction is carried out at the glenohumeral joint, while the remaining degree is carried out by the lateral rotation of the scapula. Lateral rotation of the scapula is mediated by the serratus anterior muscle and the trapezius muscle.
So, various lesions may present with different deformities and behaviors.
* Lesion of the suprascapular nerve causes paralysis of the supraspinatus muscle; patients with this lesion will not be able to initiate abduction and hence rely on gravity to carry out this initial abduction by leaning towards the affected side.
* Lesion of the axillary nerve causes paralysis of the deltoid muscle; patients with this lesion cannot abduct their arm beyond 30 degrees.
* Lesion of the long thoracic nerve causes paralysis of the serratus anterior muscle; patients with this lesion cannot completely abduct their arm vertically overhead due to the impaired scapulothoracic movement. The patient will at most be able to abduct the arm slightly above the horizontal.

Question 36

Name all the nerves

Answer 36

(A) Musculocutaneous Nerve – Terminal branch of the lateral cord. The musculocutaneous nerve supplies all the muscles of the anterior (flexor) compartment of the arm, including brachialis, coracobrachialis and biceps brachii.
(B) Radial Nerve – Terminal branch of the posterior cord. The radial nerve supplies most (in fact all) of the extensors of the upper limbs, which are found in the posterior compartment of the arm and forearm. Some examples include triceps brachii, extensor digitorum, extensor carpi ulnaris and extensors carpi radialis longus and brevis.
(C) Median Nerve – Terminal branch of the medial and lateral cords of the brachial plexus (this forms the characteristic M shape which identifies the plexus in a cadaveric examination). The median nerve supplies all the muscles in the anterior compartment of the forearm except flexor carpi ulnaris and the ulnar half of flexor digitorum profundus.
(D) Ulnar Nerve – Terminal branch of the medial cord. The ulnar nerve supplies all the short intrinsic muscles of the hand except the L.O.A.F.s muscles supplied by the median nerve; flexor carpi ulnaris and the ulnar half of flexor digitorum profundus.
(E) Axillary Nerve – Terminal branch of the posterior cord. The axillary nerve supplies muscles proximal to the trunk of the body such as the deltoid and teres minor muscles

Question 37

The middle trunk of the brachial plexus is formed by anterior rami of which spinal cord segments:
a) C7
b) C6 and C7
c) C6
d) C5 and C6
e) C7 and T1

Answer 37

C

Question 38

Loss of pronation of the hand suggests a lesion of the:
a) Median nerve
b) Radial nerve
c) Ulnar nerve
d) Intercostobrachial nerve
e) Musculocutaneous nerve

Answer 38

(A) Median Nerve
Pronation of the hand around the radio-ulnar joint is primarily carried out by the two pronator muscles in the forearm, namely pronator teres and pronator quadratus. Both muscles are innervated by the median nerve, and hence a median nerve lesion would result in paralysis of the muscles, and the consequent inability to pronate the forearm.

Question 39

If a tumor grows into the quadrangular space of the axillary region, which structures would be in danger:
a) Anterior humeral circumflex artery and axillary nerve
b) Posterior humeral circumflex artery and radial nerve
c) Posterior humeral circumflex artery and axillary nerve
d) Radial nerve and profunda brachii arter

Answer 39

C

Question 40

A branch of the axillary artery is the:
a) Costocervical arterial branch
b) Vertebral arterial branch
c) Dorsal scapular arterial branch
d) Suprascapular arterial branch
e) Subscapular arterial branch

Answer 40

E.
1) First Part – Superior thoracic artery
2) Second Part – Lateral thoracic artery and Thoraco-acromial artery
3) Third Part – Subscapular artery, Anterior and Posterior humeral circumflex arteries

Question 41

At the front of the elbow, which of the following lies superficial to the bicipital aponeurosis:
a) Median cubital vein
b) Brachial artery
c) Median nerve
d) Ulnar nerve
e) Cephalic vein

Answer 41

A

Question 42

The lateral boundary of the cubital fossa is formed by the:
a) Flexor carpi radialis muscle
b) Tendon of the biceps muscle
c) Brachialis muscle
d) Brachioradialis muscle
e) Pronator teres muscle

Answer 42

D

Question 43

Which artery accompanies the radial nerve to supply the posterior compartment of the arm:
a) Axillary artery
b) Brachial artery
c) Ulnar artery
d) Profunda brachii
e) Radial artery

Answer 43

(D) Profunda brachii
The profunda brachii artery (also known as the deep artery of the arm) runs between the long and medial heads of the triceps brachii muscle and accompanies the radial nerve in the radial groove. It descends further to participate in periarticular arterial anastomosis around the elbow joint. The profunda brachii artery is the deep arterial branch of the brachial artery near its origin as the brachial artery continues from the axillary artery.

Question 44

76. All of these arteries may contribute to the anastomoses around the scapula except the:
    a) Subscapular
    b) Transverse cervical
    c) Suprascapular
    d) Intercostal
    e) Lateral thoracic

Answer 44

E

Question 45

The superficial vein that runs up the ulnar side of the upper limb is the:
a) Radial vein
b) Median forearm vein
c) Axillary vein
d) Cephalic vein
e) Basilic vein

Answer 45

E.

Question 46

When taking the blood pressure, the stethoscope is usually placed on which artery:
a) Ulnar artery
b) Profunda brachii
c) Axillary artery
d) Brachial artery
e) Radial artery

Answer 46

D

Question 47

The deep palmar arterial arch is formed primarily by the:
a) Deep radial artery
b) Superficial radial artery
c) Ulnar artery
d) Anterior interosseous artery
e) Posterior interosseous artery

Answer 47

A

Question 48

Abduction of the thumb is when it is moved:
a) Laterally from the palm
b) At right angles to the palmar surface
c) Along side the index finger
d) Straight across the palm
e) None of the above

Answer 48

B

Question 49

Which of the following statements is true for the pectoralis major muscle:
a) It arises from the humerus
b) It inserts into the bony ribs
c) It abducts the arm
d) It is innervated by the median nerve
e) There is no true statement

Answer 49

E) There is no true statement.
Correcting the statements with regards to the pectoralis major muscle,
“The pectoralis muscle arises from the anterior surface of the medial half of the clavicle, the superior six coastal cartilages, the anterior surface of the sternum and the aponeurosis of the external oblique muscle, and inserts into the lateral lip of the bicipital groove of the humerus. It is a strong flexor, medial rotator and adductor of the glenohumeral joint. It derives its nervous supply from the lateral and medial dorsal nerves, both branches of the brachial plexus.”
Hence, there is no true statement.

Question 50

The nerve most likely to be traumatized wit ha fracture of the surgical neck of the humerus is the:
a) Median nerve
b) Axillary nerve
c) Radial nerve
d) Ulnar nerve
e) Profunda brachii

Answer 50

B. Recall that an important landmark which transmits the axillary nerve (and the posterior humeral circumflex artery) is the quadrangular space of the axilla. The quadrangular space of the axilla is bounded:
* Superiorly by the teres minor and subscapularis muscles
* Inferiorly by the teres major muscle
* Laterally by the surgical neck of the humerus
* Medially by the tendon of the long head of the triceps brachii

Question 51

With an injury to the right upper trunk of the brachial plexus (Erb Duchenne paralysis), the patient’s right upper extremity would be:
a) Abducted
b) Extended
c) Medially rotated
d) Laterally rotated
e) Flexed

Answer 51

C

Question 52

At the wrist, the long slender tendon of which muscle serves as a guide to the median nerve, which is deep and lateral to it:
a) Flexor carpi radialis
b) Flexor carpi ulnaris
c) Flexor digitorum superficialis
d) Palmaris longus
e) Flexor digitorum profundus

Answer 52

D. The palmaris longus is a vestigial muscle which originates from the medial epicondyle, often referred to as the common flexor origin, and inserts into the distal half of flexor retinaculum and the palmar aponeurosis. It assists in flexion of the wrist, together with the flexor carpi ulnaris and radialis. Though it is absent in a significant proportion of the population, it does not significantly affect flexion of the wrist.
The median nerve is indeed found deep and lateral to the tendon of the palmaris longus. And this allows the surgeon to easily locate the median nerve by identifying the tendon of the palmaris longus. However, that said, often surgeons also mistakenly harvest the median nerve for a tendon graft instead of the tendon of the palmaris longus.

Question 53

The only rotator cuff muscle that does not contribute to the rotation of the arm is the:
a) Teres minor
b) Infraspinatus
c) Supraspinatus
d) Subscapularis

Answer 53

C

Question 54

The dermatome of the thumb is innervated by nervous elements arising from which spinal cord segment:
a) C5
b) C6
c) C7
d) C8
e) T1

Answer 54

B

Question 55

A large muscle that arises from two head flexes and medially rotates the arm. It is innervated by nerves arising from different cords of the brachial plexus. This is the:
a) Latissimus dorsi
b) Trapezius
c) Deltoid
d) Subscapularis
e) Pectoralis major

Answer 55

E

Question 56

Loss of opposition of the thumb is a symptom associated with lesion of which nerve:
a) Radial nerve
b) Ulnar nerve
c) Musculocutaneous nerve
d) Median nerve
e) Posterior interosseous nerve

Answer 56

93. (D) Median Nerve
    Recall that the first and second lumbricals, opponens pollicis, abductor pollicis brevis, and the superficial head of the flexor pollicis brevis muscles are innervated by the median nerve. All the other short intrinsic muscles of the hand, including the adductor pollicis muscle, are innervated by the ulnar nerve. With this in mind, loss of opposition of the thumb is a symptom associated with lesion of the median nerve, which results in the paralysis of the opponens pollicis muscle.
    *The loss of opposition is a symptom characteristic of median nerve compression in carpal tunnel syndrome.

Question 57

95. All of the following bony landmarks are visible on a skeleton when viewed directly from behind (posterior view), except the:
    a) Medial epicondyle
    b) Greater tubercle
    c) Spiral groove
    d) Lesser tubercle
    e) Olecranon process

Answer 57

D

Question 58

Inability to flex the distal phalanx of the middle finger indicates injury to which of these muscles:
a) Lumbrical
b) Dorsal interosseous
c) Flexor digitorum superficialis
d) Flexor digitorum profundus
e) Palmar interosseous

Answer 58

Question 59

The muscle attached to the whole length of the scapular spine is the:
a) Trapezius
b) Serratus anterior
c) Rhomboid major
d) Levator Scapulae
e) Infraspinatus

Answer 59

A

Question 60

All of the following muscles attach to the medial border of the scapula, except the:
a) Levator scapulae
b) Rhomboid major
c) Teres major
d) Serratus anterior
e) Rhomboid minor

Answer 60

C

Question 61

100. Which nerve-artery pair do not run together:
     a) Radial nerve, profundus brachii artery
     b) Axillary nerve, posterior humeral circumflex artery
     c) Ulnar nerve, superior ulnar collateral artery
     d) Median nerve, posterior interosseus artery
     e) Anterior interosseous nerve, anterior interosseous artery

Answer 61

Question 62

The following are TRUE about osteoarthritis, EXCEPT:
A. The primary pathology is centred in the synovium
B. The articular cartilage is thinned and damaged
C. Subchondral cyst is a complication
D. It may be associated with synovial inflammation
E. The disease often affects the hip and knee joints

Answer 62

A. Incorrect. This pathology is for Rheumatoid Arthrities, not OA.

Question 63

A 42-year-old man presented with extensive soft tissue infection of the arm
with areas of necrosis. Gram stain shows Gram-positive cocci in chains.
Which antibiotic is MOST suitable?
A. Penicillin
B. Gentamicin
C. Ciprofloxacin
D. Metronidazole
E. Cloxacillin

Answer 63

A. Strep species

Question 64

A 55-year-old general manager was diagnosed with gouty arthritis. Which of
the following drugs is LEAST appropriate for treatment of his condition?
A. Colchicine
B. Tofacitinib
C. Allopurinol
D. Celecoxib
E. Probenecid

Answer 64

B. Used for RA

Question 65

Patient presents with left shoulder pain and numbness, and weakened left brachioradialis and biceps reflexes. Where is the lesion?
A. Muscle
B. Radialnerve
C. Cerebrum
D. Cervicalcord
E. C5 root

Answer 65

E

Question 66

Patient presents with loin pain. A blood culture was taken. Which of the following statements is the MOST accurate regarding blood culture collection?
A. Disinfectskinwith70%alcohol
B. Minimumvolumeof5mLisrequired
C. Palpatetheveinagainifunsureafterdisinfection
D. Onlyaerobiccultureneeded

Answer 66

A

Question 67

Which of the following drugs is least appropriate to control pain in osteoarthritis in a 74 year old woman with history of myocardial infarction?

a) Ibuprofen
b) Naproxen
c) Aspirin
d) Paracetamol
e) Etoricoxib

Answer 67

E. Etoricoxib is a selective COX-2 inhibitor and as the name suggests, inhibits the enzyme COX-2 to a greater extent than COX-1. Because of this selective inhibition, the arachidonic acid is shunted towards COX-1 pathway, paradoxically increasing thromboxane levels which is known to increase platelet aggregation and promote vasoconstriction. Therefore, patients on these medications are actually at an increased risk of thrombosis and thrombotic events such as stroke and myocardial infarcts. Hence, it is the least appropriate drug among those listed.

Question 68

Bones can fracture or be displaced from their normal anatomical position at any of several locations. Each of these injuries may traumatize a nerve passing close to the bone in question at that location. Match the nerve most likely to be injured with the problem: Mid-shaft humeral fracture
a) Radial nerve
b) Axillary nerve
c) Ulnar nerve
d) Median nerve
e) Medial brachial cutaneous nerve

Answer 68

A. A mid-shaft humeral fracture may compromise the integrity of the radial groove or sulcus which is found on the posterior aspect of the humerus. The radial groove transmits both the radial nerve and the profunda brachii artery so should the groove be compromised, it is highly likely that there will be a lesion of the radial nerve and injury to the profunda brachii artery.

Question 69

Bones can fracture or be displaced from their normal anatomical position at any of several locations. Each of these injuries may traumatize a nerve passing close to the bone in question at that location. Match the nerve most likely to be injured with the problem: Anterior dislocation of the lunate
a) Radial nerve
b) Axillary nerve
c) Ulnar nerve
d) Median nerve
e) Medial brachial cutaneous nerve

Answer 69

D. The important concept to keep in mind here is that the median nerve traverses the carpal tunnel. In the anatomical position, the carpal tunnel is bounded anteriorly by the flexor retinaculum, which attaches onto the tubercles of the scaphoid and trapezium laterally as well as the pisiform bone and the hook of hamate medially; posteriorly by the carpal bones: three (scaphoid, lunate, triquetrum) on the proximal row and four (trapezium, trapezoid, capitate, hamate) on the distal row. It is also important to keep in mind that together with the median nerve, nine other structures traverse the carpal tunnel:
* Tendons of the flexor digitorum superficialis (4)
* Tendons of the flexor digitorum profundus (4)
* Tendon of the flexor pollicis longus

Question 70

The four chief bony attachments of the flexor retinaculum are:
a) Hamate, pisiform, trapezium, scaphoid
b) Hamate, capitate, trapezoid, scaphoid
c) Lunate, hamate, capitate, scaphoid
d) Lunate, pisiform, trapezoid, hamate
e) Trapezium, trapezoid, capitate, hamate

Answer 70

A

Question 71

Answer 71

C.

Question 72

Ans the following:

Answer 72

Question 73

A 51-year-old woman was prescribed methotrexate for her rheumatoid arthritis. However, the drug did not reach therapeutic effect. Which drug can be combined to give a better therapeutic efficacy?
A. Hyaluronic acid
B. Colchicine
C. Probenecid
D. Celecoxib
E. Hydroxychloroquine

Answer 73

E. The approach to rheumatoid arthritis therapy is:
1. Early diagnosis and treatment
2. Use of synthetic disease modifying Anti-rheumatic Drugs (sDMARDs) alone or in combination
3. Add on biological DMARDs

Options A, B, C are not used in rheumatoid arthritis. Celecoxib functions as an anti-inflammatory as well as a pain relief, however, the main concern here is that methotrexate did not reach its therapeutic effect. This calls for another DMARD to be used in combination with methotrexate. Hydroxychloroquine, although an anti-malarial agent, functions extremely well in combination with methotrexate. Option E is therefore the best option.

Question 74

Which of these conditions show the least degree of inflammation?
A) Osteoarthritis
B) Rheumatoid arthritis
C) Gouty arthropathy
D) Septic arthritis
E) Ankylosing spondylitis

Answer 74

A. OA is known for being a non-inflammatory form of arthritis

Question 75

Patient presented with long standing chronic lower back pain and stiffness. Pain worsens on rest but improves with activity. X-ray spine shows squaring and fusion of vertebral bodies producing bamboo like appearance. Which of the following is most likely true?
A) Malignant tumour should be suspected
B) Patient possesses HLA-A0207 antigen.
C) Increased rheumatoid factors in serum
D) Patient is likely to be an elderly
E) Sacroiliac joint most likely affected in such cases.

Answer 75

E. Factual - this patient presents with typical symptoms of Ankylosing Spondylitis (a type of seronegative arthritis) and one of the features of this is a propensity to affect the vertebral column and sacroiliac joint.

Question 76

Which one of the following do biological DMARDs target to treat RA?
A) Jak3
B) CD3
C) IL-2 receptor
D) IL-6 receptor
E) T cell receptor

Answer 76

D

Question 77

Which of the following nerves are most involved in raising the arm to vertical position?
a. Long thoracic
b. Musculocutaneous
c. Subscapular
d. Radial
e. Inferior trunk of the Brachial plexus

Answer 77

A. In raising the arm to the vertical position, anterolateral movement + lateral rotation of the scapula is necessary to overcome the greater tuberosity of the humerus being impeded by the lateral edge of the acromion (eg. in abduction of the arm without movement of the scapula). Hence, serratus anterior innervated by long thoracic nerve is necessary to achieve complete vertical positioning of arm

Question 78

Which action not true of hand lumbricals
a. Extension of proximal IP joint
b. Medial lumbricals innervated by ulnar nerve
c. Extension of distal IP joint
d. Flexion of MCP joint
e. Abduction of MCP joint

Answer 78

E.
a, c ,d - Lumbricals produce flexion at the MCP joint and extension at the interphalangeal (IP) joints of each digit.
b - medial lumbricals innervated by ulnar nerve, lateral lumbricals innervated by median nerve
e - abduction of MCP is by dorsal interossei

Question 79

A patient presents with numbness and tingling in the thumb after a car accident. The doctor suspects an injury to the radial nerve.

Which bone is most closely related to the radial nerve?

A) Humerus (upper arm bone)
B) Radius (forearm bone)
C) Carpals (wrist bones)
D) Metacarpals (hand bones)

Answer 79

B

Question 80

A patient presents with a weakened grip after a fall. The doctor suspects an injury to the median nerve.

Which muscle is most closely related to the median nerve?

A) Flexor digitorum profundus
B) Extensor pollicis brevis
C) Flexor pollicis longus
D) Abductor pollicis longus

Answer 80

A

Question 81

A 45-year-old male presents with right shoulder pain that started gradually over the last three months. He describes the pain as dull and aching, worsening with overhead activities. On physical examination, there is tenderness over the acromioclavicular (AC) joint and pain with cross-body adduction of the arm. There is no significant muscle weakness or atrophy.

Question:
What is the most likely diagnosis?

*	A) Rotator cuff tear
*	B) Subacromial bursitis
*	C) Adhesive capsulitis
*	D) Acromioclavicular joint arthritis

Answer 81

D. It is not infm

Question 82

A 50-year-old man complains of progressive stiffness and pain in his right shoulder for the past six months. He denies any trauma. The pain is present at night, and he has difficulty reaching behind his back. Examination reveals a global decrease in both active and passive range of motion.

Question:
What is the most likely diagnosis?

*	A) Rotator cuff tear
*	B) Adhesive capsulitis
*	C) Osteoarthritis of the shoulder
*	D) Subacromial impingement

Answer 82

B

Question 83

A 40-year-old mechanic presents with pain and clicking in the elbow. The pain is deep and localized over the lateral side, especially when he turns a wrench. Physical examination reveals tenderness over the radial head and pain with forearm pronation and supination.

Question:
What is the most likely diagnosis?

*	A) Lateral epicondylitis
*	B) Medial epicondylitis
*	C) Radial head fracture
*	D) Posterior interosseous nerve syndrome

Answer 83

Answer: C) Radial head fracture

Question 84

A 28-year-old construction worker presents with wrist pain and swelling after falling from a height and landing on his outstretched hand. He has limited wrist motion and tenderness over the dorsal wrist. X-rays show a lunate that appears more volar than expected.

Question:
What is the most likely diagnosis?

*	A) Scaphoid fracture
*	B) Lunate dislocation
*	C) Distal radius fracture
*	D) Triquetral fracture

Answer 84

B

Question 85

A 30-year-old woman with rheumatoid arthritis who is currently on methotrexate wishes to switch medications due to plans for pregnancy. She reports well-controlled symptoms and no history of significant flares.

Question:
Which medication would be the safest to continue during pregnancy?

*	A) Leflunomide
*	B) Hydroxychloroquine
*	C) Sulfasalazine
*	D) TNF inhibitors

Answer 85

B

Question 86

A 40-year-old man with rheumatoid arthritis and well-controlled disease on methotrexate is found to have new-onset hypertension during a routine visit. His blood pressure is 150/95 mmHg. He has no other significant medical history.

Question:
Which medication is most likely contributing to his hypertension?

*	A) Methotrexate
*	B) Prednisone
*	C) Hydroxychloroquine
*	D) Adalimumab

Answer 86

Answer: B) Prednisone