Upper Limb

Question 1

At the superior surface of the shoulder, skin is innervated by what nerves?

Answer 1

Supraclavicular nn. (C4) that are branches of the cervical plexus

Question 2

From the proximal to distal surfaces of the lateral side of the arm, skin is innervated by what nerves?

Answer 2

C5 of the brachial plexus

Question 3

On the anterior side of the forearm from the proximal to distal surfaces of the lateral side, and on the posterior side, from the proximal end of the arm to the distal end of the forearm, including the pollex and index finger, skin is innervated by what nerve?

Answer 3

C6 of the brachial plexus

Question 4

From the proximal to distal surfaces of the middle forearm, including index, middle, and ring fingers, skin is innervated by what nerve?

Answer 4

C7 of the brachial plexus

Question 5

From the proximal to distal surfaces of the medial side of the forearm, skin is innervated by what nerve?

Answer 5

C8 of the brachial plexus

Question 6

From the proximal to distal surfaces of the medial side of the arm, skin is innervated by what nerve?

Answer 6

T1 of the brachial plexus

Question 7

At the upper medial surface of the arm (armpit), the skin is innervated by what nerve?

Answer 7

Iintercostobrachial nn. (T2,T3) that arrive from the intercostal segmental nn.

Question 8

The biceps reflex test tests what nerve?

Answer 8

C5

Question 9

The brachioradialis reflex test tests what nerve?

Answer 9

C6 mainly

Question 10

The triceps reflex test tests what nerve?

Answer 10

C7 mainly

Question 11

Extension of wrist associated with what nerve?

Answer 11

C6

Question 12

Flexion of wrist associated with what nerve?

Answer 12

C7

Question 13

Extension of fingers associated with what nerve?

Answer 13

C7

Question 14

Flexion of fingers associated with what nerve?

Answer 14

C8

Question 15

Adduction/Abduction of fingers associated with what nerve

Answer 15

T1

Question 16

A herniated disc between vertebrae C4 and C5 involves what nerve root? What motor, reflex, and sensory abilities will be affected?

Answer 16

Impinges C5 nerve root.
Motor of deltoid and biceps affected.
Reflex of biceps affected.
Sensation of dermatome lateral border of arm affected.

Question 17

When would you see Klumpke paralysis? What exercise would you ask patient to perform to determine this?

Answer 17

If ulnar nerve (C8,T1) was cut/had lesion as it runs over medial epicondyle, ulnar flexors would be lost, rendering patient unable to flex the metacarpophalangeal joints due to paralysis of interosseous and lumbricals mm.

Radial interphalangeal joints can still be flexed (innervated by median n.).
Ulnar digits cannot be flexed at all if the injury is at the forearm.
Muscles of mesothenar paralyzed if injury is at wrist/hand.
Ulnar digits can be flexed at PIP and DIP joints.

You would ask the patient to make a fist –claw hand

Question 18

Besides the characteristic claw hand, what else might you see in Klumpke paralysis?

Answer 18

Atrophy of the interossei would lead to hollowing of the interosseous spaces between digits 2,3,4,5 in the metacarpus.

Sensory abnormalities confined to the little finger.

Question 19

When would you see Froment’s sign? What exercise would you ask patient to perform to determine this?

Answer 19

Froment’s sign is a special test of the wrist. It tests for palsy of the ulnar nerve, specifically, the action of adductor pollicis.

To perform the test, you would ask patient to hold piece of paper in a pinch grip b/t thumb and forefinger. Thumb will not lay flat and when the examiner attempts to pull paper from grip, patient will have difficulty holding on to it.

Question 20

What postures does Klumpke palsy produce?

How does it manifest in the newborn period?

Answer 20

1. flexion and supination of the elbow, extension of the wrist, hyperextension of the metacarpophlangeal joints, and flexion of the interphalangeal joints with the “claw hand” posture.
2. Manifests in the newborn period as weakness restricted to or mainly involving the hand. Usually there is no reflex or spontaneous movements of the intrinsic hand muscles.

Question 21

Which nerves have been damaged in Erb-Duchenne palsy?

Answer 21

C5, C6
Usually suprascapular, musculocutaneous, and axillary nn.
This is a superior brachial plexus injury

Question 22

What symptoms would you expect to see in Erb-Duchenne palsy?

Answer 22

“Waiter’s tip position”
Arm is :
- adducted due to deltoid and supraspinatus weakness
- internally rotated due to teres minor and infraspinatus wakness
- extended due to biceps and brachioradialis weakness
- pronated due to supinator and brachioradialis weakness
And the wrist is flexed due to extensor carpi radialis longus and brevis weakness

Question 23

What may cause Erb-Duchenne palsy in infants?

Answer 23

The most common cause of Erb’s palsy is dystocia, an abnormal or difficult childbirth or labor.

• it can occur if the infant’s head and neck are pulled toward the side at the same time as the shoulders pass through the birth canal.
• can also be caused by excessive pulling on the shoulders during a cephalic presentation (head first delivery), or by pressure on the raised arms during a breech (feet first) delivery

Question 24

Paralysis of the deep branch of the radial nerve would lead to what symptoms? What exercise would you use to test for this?

Answer 24

In the case of a complete lesion, the hand cannot be extended – “Wrist drop”

In the case of a partial lesion, you can test for paralysis by extending the metacarpophylangeal joints against resistance. When normal, tendons become prominent on the dorsum of the hand.

Question 25

What nerve has become paralyzed if patient is asked to make a fist and shows “ape hand”?

Where is the nerve damaged if the radial forearm flexors are also paralyzed? Where is it damaged if they are not paralyzed so that digits can still be flexed?

Answer 25

Median nerve

The lesion would be at the forearm (ulnar flexors, which are innervated by the ulnar nerve are unaffected)

The lesion would be at the wrist/hand (as in carpal tunnel syndrome or other wrist injury)

Question 26

If the hand cannot be extended, there is “wrist drop”, or the tendons do not become prominent on the dorsum of the hand when patient is attempting to extend against resistance, what nerve is most likely damaged?

Answer 26

Deep branch of the radial n.

Question 27

What symptoms are present with the paralysis of the median nerve?

Answer 27

Hand of benediction

At forearm:

• patient unable to flex the radial digits due to the paralysis of the radial forearm muscles
• Thenar muscles are paralysed, opposition and reposition of the thumb does not work = “ape hand”

At wrist/hand:

• “ape hand” b/c of thenar paralysis
• forearm flexors work, so digits can be flexed

Question 28

What signs are characteristic of the hand of benediction?

Answer 28

When patient tries to make a fist, they can flex only the ulnar fingers. There may be associated sensory disturbances, particularly in the autonomous area of the nerve (tips of digits 1,2,3, and half of 4)

Question 29

If patient is asked to lean against wall with arms outstretched, and scapula shows “winging”, what nerve is likely damaged? What muscle is being paralyzed?

Answer 29

Long thoracic nerve (C5,6,7)

Serratus anterior m. is paralyzed

Question 30

What is the cutaneous innervation of half of digit 4 and all of digit 5 including dorsum and palm of hand (ant and post sides of hand)?

Answer 30

Ulnar n.

Question 31

What is the cutaneous innervation of:
anterior side - digits 1,2,3, half of 4, and palm
posterior side - only digits 2,3, and half of 4

Answer 31

median n.

Question 32

What is the cutaneous innervation of

posterior side - digit 1 and half of the dorsum of hand

Answer 32

radial n.

Question 33

What occurs in carpal tunnel syndrome?

Answer 33

inflammatory processes of the carpal tunnel put pressure on the median nerve resulting in paralysis

Question 34

What symptoms are seen in Tinel’s sign? What sort of action is done to test for this?

Answer 34

Lightly percuss over the nerve to elicit a sensation of tingling or “pins and needles” in the distribution of the nerve in order to detect whether or not nerve is irritated.

In carpal tunnel syndrome where the median nerve is compressed at the wrist, Tinel’s sign is often “positive” causing tingling in the thumb, index, middle finger and the radial half of the fourth digit

Question 35

What is carpal tunnel syndrome?

Answer 35

Inflammatory processes of the carpal tunnel put pressure on the median n. resulting in paralysis

Question 36

What is Dupuytren’s contracture?

Answer 36

Pathological thickening and contraction of the palmar aponeurosis due to mechanical microtraumas. (seen in carpenters) Fingers are permanently in flexion

Question 37

Which is the most frequently injured carpal bone? What is this injury related to and how is it treated?

Answer 37

Scaphoid is the most frequently broken carpal. The palmar carpal branch of the radial artery supplies it from the radial end but the ulnar end of the bone is poorly supplied by arterial blood. As a result, it may take several months to heal. Avascular necrosis could occur in the proximal fragment and it is sometimes necessary to fuse the carpal bones surgically.

Question 38

What occurs in an avulsion fracture of the distal phalanx?

Answer 38

An avulsion is an injury in which a body structure is forcibly detached from its normal point of insertion by trauma - can result in permanently flexed distal phalanx

Question 39

What types of dislocation can happen to the radial head?

Answer 39

1. Subclinical subluxation - radial tuberosity of radius misaligned with radial fossa on the ulna but not unattached from anular ligament
2. Subluxation - head of humerus detaches from anular ligament and moves inferiorly
3. Dislocation - head of humerus detaches from anular ligament and moves laterally

Question 40

What occurs in a Colles fracture?

Answer 40

This is a fracture of the distal radius in the forearm with dorsal (posterior) displacement of the wrist and hand. The fracture is sometimes referred to as a “dinner fork” or “bayonet” deformity due to the shape of the resultant forearm.

Question 41

What occurs in an avulsion fracture of the humerus?

Answer 41

Muscles inserting on the greater tubercle pull the tubercle away from the head. Subscapularis muscle remains attached to the humerus, pulling the limb into medial rotation.

Question 42

What occurs in an avulsion fracture of the medial epicondyle?

Answer 42

Flexors pull away from the medial epicondyle, ulnar collateral ligament stays attached

Question 43

How do the synovial sheaths on the palmar side of the digits 1 and 5 contribute to the spread of inflammatory processes?

Answer 43

The synovial sheaths of the 1st and 5th digits extends to the antebrachium.

Question 44

What is De Quervain tendosynovitis?

Answer 44

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