Upper Limb A

Question 1

A man has an incision sited than runs 8cm from the deltopectoral groove to the midline. Which of the following is not at risk of injury? A. Cephalic vein B. Shoulder joint capsule C. Axillary artery D. Pectoralis major E. Trunk of the bra

Answer 1

This region will typically lie medial to the joint capsule. The diagram below illustrates the plane that this would transect and as it can be appreciated the other structures are all at risk of injury

Question 2

Question 7-9 of 328 Theme: Nerve InjuryA. Median nerveB. Ulnar nerveC. Radial nerveD. Musculocutaneous nerveE. Axillary nerveF. Anterior interosseous nerveG. Posterior interosseous nerveFor each scenario please select the mos

Answer 2

7. A 19 year old student is admitted to A&E after falling off a wall. He is unable to flex his index finger. An x-ray confirms a supracondylar fracture.You answered Radial nerveThe correct answer is Median nerveThis median nerve is at risk during a supracondylar fracture.8. A well toned weight lifter attends clinic reporting weakness of his left arm. There is weakness of flexion and supination of the forearm.You answered Ulnar nerveThe correct answer is Musculocutaneous nerveMucocutaneous nerve compression due to entrapment of the nerve between biceps and brachialis. Elbow flexion and supination of the arm are affected. This is a rare isolated injury.9. An 18 year old girl sustains an Holstein-Lewis fracture. Which nerve is at risk?Radial nerveProximal lesions affect the triceps. Also paralysis of wrist extensors and forearm supinators occur. Reduced sensation of dorsoradial aspect of hand and dorsal 31/2 fingers. Holstein-Lewis fractures are fractures of the distal humerus with radial nerve entrapment.

Question 3

Question 10 of 328 A 35 year old farm labourer is injures the posterior aspect of his hand with a mechanical scythe. He severs some of his extensor tendons in this injury. How many tunnels lie in the extensor retinaculum that transmit the tendon

Answer 3

SIXThere are six tunnels, each lined by its own synovial sheath.

Question 4

Question 23 of 328 A 68 year old man falls onto an outstretched hand. Following the accident he is examined in the emergency department. On palpating his anatomical snuffbox there is tenderness noted in the base. What is the most likely injury i

Answer 4

Scaphoid fractureA fall onto an outstretched hand is a common mechanism of injury for a scaphoid fracture. This should be suspected clinically if there is tenderness in the base of the anatomical snuffbox. A tendon rupture would not result in bony tenderness.

Question 5

Question 25 of 328 Which of the following structures passes through the quadrangular space near the humeral head? A. Axillary artery B. Radial nerve C. Axillary nerve D. Median nerve E. Transverse scapular artery

Answer 5

Axillary nerveThe quadrangular space is bordered by the humerus laterally, subscapularis superiorly, teres major inferiorly and the long head of triceps medially. It lies lateral to the triangular space. It transmits the axillary nerve and posterior circumflex humeral artery.

Question 6

Question 28 of 328 The following structures are closely related to the brachiocephalic artery except: A. Trachea posteriorly B. Right brachiocephalic vein C. Inferior thyroid vein D. Right recurrent laryngeal nerve E. None of th

Answer 6

Right recurrent laryngeal nerveThere is no brachiocephalic artery on the left, however the left brachiocephalic vein lies anteriorly to the roots of all the 3 great arteries (including the brachiocephalic artery). The right recurrent laryngeal nerve has no relation to the brachiocephalic artery.

Question 7

Question 29 of 328 Which of the following structures separates the ulnar artery from the median nerve? A. Brachioradialis B. Pronator teres C. Tendon of biceps brachii D. Flexor carpi ulnaris E. Brachialis

Answer 7

Pronator teresIt lies deep to pronator teres and this separates it from the median nerve

Question 8

Question 31 of 328 A 32 year old motorcyclist is involved in a road traffic accident. His humerus is fractured and severely displaced. At the time of surgical repair the surgeon notes that the radial nerve has been injured. Which of the followin

Answer 8

None of the aboveMuscles supplied by the radial nerveBESTBrachioradialisExtensorsSupinatorTricepsThe radial nerve supplies the extensor muscles, abductor pollicis longus and extensor pollicis brevis (the latter two being innervated by the posterior interosseous branch of the radial nerve).

Question 9

Question 33 of 328 Which muscle is responsible for causing flexion of the interphalangeal joint of the thumb? A. Flexor pollicis longus B. Flexor pollicis brevis C. Flexor digitorum superficialis D. Flexor digitorum profundus E.

Answer 9

Flexor pollicis longusThere are 8 muscles:1. Two flexors (flexor pollicis brevis and flexor pollicis longus)2. Two extensors (extensor pollicis brevis and longus)3. Two abductors (abductor pollicis brevis and longus)4. One adductor (adductor pollicis)5. One muscle that opposes the thumb by rotating the CMC joint (opponens pollicis).Flexor and extensor longus insert on the distal phalanx moving both the MCP and IP joints.

Question 10

Question 39 of 328 An 18 year old man is stabbed in the axilla during a fight. His axillary artery is lacerated and repaired. However, the surgeon neglects to repair an associated injury to the upper trunk of the brachial plexus. Which of the fol

Answer 10

The palmar interossei are supplied by the ulnar nerve. Which lies inferiorly and is therefore less likely to be injured.

Question 11

Question 40 of 328 A 23 year old man is involved in a fight, during the dispute he sustains a laceration to the posterior aspect of his right arm, approximately 2cm proximal to the olecranon process. On assessment in the emergency department he

Answer 11

TricepsThe triceps muscle extends the elbow joint. The other muscles listed all produce flexion of the elbow joint.

Question 12

Question 45 of 328 Which of the following muscles does not attach to the radius? A. Pronator quadratus B. Biceps C. Brachioradialis D. Supinator E. Brachialis

Answer 12

The brachialis muscle inserts into the ulna. The other muscles are all inserted onto the radius.

Question 13

Question 48 of 328 Which of the following is not an intrinsic muscle of the hand? A. Opponens pollicis B. Palmaris longus C. Flexor pollicis brevis D. Flexor digiti minimi brevis E. Opponens digiti minimi

Answer 13

Palmaris LongusMnemonic for intrinsic hand muscles’A OF A OF A’A bductor pollicis brevisO pponens pollicisF lexor pollicis brevisA dductor pollicis (thenar muscles)O pponens digiti minimiF lexor digiti minimi brevisA bductor digiti minimi (hypothenar muscles)Palmaris longus originates in the forearm.

Question 14

Question 51 of 328 A 28 year old man lacerates the posterolateral aspect of his wrist with a knife in an attempted suicide. On arrival in the emergency department the wound is inspected and found to be located over the lateral aspect of the extensor

Answer 14

Superficial branch of the radial nerveThe superficial branch of the radial nerve passes superior to the extensor retinaculum in the position of this laceration and is at greatest risk of injury. The dorsal branch of the ulnar nerve and artery also pass superior to the extensor retinaculum n but are located medially

Question 15

Question 54 of 328 Transection of the radial nerve at the level of the axilla will result in all of the following except: A. Loss of elbow extension. B. Loss of extension of the interphalangeal joints. C. Loss of metacarpophalangeal e

Answer 15

Loss of extension of the interphalangeal jointsThese may still extend by virtue of retained lumbrical muscle function

Question 16

Question 61 of 328 Which of the following muscles does not adduct the shoulder? A. Teres major B. Pectoralis major C. Coracobrachialis D. Supraspinatus E. Latissimus dorsi

Answer 16

Supraspinatus is an abductor of the shoulder

Question 17

Question 69 of 328 Which of the following structures is not closely related to the brachial artery? A. Ulnar nerve B. Median nerve C. Cephalic vein D. Long head of triceps E. Median cubital vein

Answer 17

The cephalic vein lies superficially and on the contralateral side of the arm to the brachial artery. The relation of the ulnar nerves and others are demonstrated in the image below:

Question 18

Question 70 of 328 The following statements relating to the musculocutaneous nerve are true except? A. It arises from the lateral cord of the brachial plexus B. It provides cutaneous innervation to the lateral side of the forearm C. If dam

Answer 18

If damaged then extension of the elbow joint will be impairedIt supplies biceps, brachialis and coracobrachialis so if damaged then elbow flexion will be impaired.

Question 19

Question 71 of 328 Which ligament keeps the head of the radius connected to the radial notch of the ulna? A. Annular (orbicular) ligament B. Quadrate ligament C. Radial collateral ligament of the elbow D. Ulnar collateral ligament

Answer 19

The annular ligament connects the radial head to the radial notch of the ulna. This is illustrated below:

Question 20

Question 72 of 328 A 38 year old man presents to the clinic with shoulder weakness. On examination he has an inability to initiate shoulder abduction. Which of the nerves listed below is least likely to be functioning normally? A. Suprascapular

Answer 20

Suprascapular nerve

Question 21

Question 74 of 328 Which of the following is not a branch of the subclavian artery? A. Superior thyroid artery B. Vertebral artery C. Thyrocervical trunk D. Internal thoracic artery E. Dorsal scapular artery

Answer 21

Superior thyroid arteryMnemonic for the branches of the subclavian artery: VIT C & DV ertebral arteryI nternal thoracicT hyrocervical trunkC ostalcervical trunkD orsal scapularSuperior thyroid artery is a branch of the external carotid artery.

Question 22

Question 83 of 328 A baby is found to have a Klumpke’s palsy post delivery. Which of the following is most likely to be present? A. Loss of flexors of the wrist B. Weak elbow flexion C. Pronation of the forearm D. Adducted shoulder E

Answer 22

Loss of flexors of the wristFeatures of Klumpkes Paralysis Claw hand (MCP joints extended and IP joints flexed) Loss of sensation over medial aspect of forearm and hand Horner’s syndrome Loss of flexors of the wristA C8, T1 root lesion is called Klumpke’s paralysis and is caused by delivery with the arm extended.

Question 23

Question 91 of 328 With respect to the basilic vein, which statement is false? A. Its deep anatomical location makes it unsuitable for use as an arteriovenous access site in fistula surgery B. It originates from the dorsal venous network on t

Answer 23

Its deep anatomical location makes it unsuitable for use as an arteriovenous access site in fistula surgeryIt is used in arteriovenous fistula surgery during a procedure known as a basilic vein transposition.

Question 24

Question 94 of 328 A 78 year old man is lifting a heavy object when a feels a pain in his forearm and is unable to continue. He has a swelling over his upper forearm. An MRI scan shows a small cuff of tendon still attached to the radial tuberosity co

Answer 24

Biceps brachiiBiceps inserts into the radial tuberosity. Distal injuries of this muscle are rare but are reported and are clinically more important than more proximal ruptures.

Question 25

Question 97 of 328 Which of the following is a branch of the third part of the axillary artery? A. Superior thoracic B. Lateral thoracic C. Dorsal scapular D. Thoracoacromial E. Posterior circumflex humeral

Answer 25

Posterior circumflex humeralThe other branches include: Subscapular Anterior circumflex humeral

Question 26

Question 101-103 of 328 Theme: Nerve lesionsA. IntercostobrachialB. MedianC. AxillaryD. RadialE. UlnarF. MusculocutaneousG. Brachial plexus upper cordH. Brachial plexus lower cordPlease select the most likely nerve injury for th

Answer 26

Question 101-103 of 328 Theme: Nerve lesionsA. IntercostobrachialB. MedianC. AxillaryD. RadialE. UlnarF. MusculocutaneousG. Brachial plexus upper cordH. Brachial plexus lower cordPlease select the most likely nerve injury for the scenarios given. Each option may be used once, more than once or not at all.101. A 23 year old rugby player sustains a Smiths Fracture. On examination opposition of the thumb is markedly weakened.You answered RadialThe correct answer is MedianThis high velocity injury can often produce significant angulation and displacement. Both of these may impair the function of the median nerve with loss of function of the muscles of the thenar eminence102. A 45 year old lady recovering from a mastectomy and axillary node clearance notices that sensation in her armpit is impaired.You answered RadialThe correct answer is IntercostobrachialThe intercostobrachial nerves are frequently injured during axillary dissection. These nerves traverse the axilla and supply cutaneous sensation.103. An 8 year old boy falls onto an outstretched hand and sustains a supracondylar fracture. In addition to a weak radial pulse the child is noted to have loss of pronation of the affected hand.You answered UlnarThe correct answer is MedianThis is a common injury in children. In this case the angulation and displacement have resulted in median nerve injury.

Question 27

Question 119 of 328 In Froment’s test which muscle function is tested? A. Flexor pollicis longus B. Adductor pollicis longus C. Abductor pollicis brevis D. Adductor pollicis E. Opponens pollicis

Answer 27

Adductor pollicis

Question 28

Question 121-123 of 328 Theme: Cutaneous innervationA. Ulnar nerveB. Fifth cervical spinal segmentC. Radial nerveD. Musculocutaneous nerveE. Median nerveF. None of thesePlease select the source of innervation for the region describe

Answer 28

Question 121-123 of 328 Theme: Cutaneous innervationA. Ulnar nerveB. Fifth cervical spinal segmentC. Radial nerveD. Musculocutaneous nerveE. Median nerveF. None of thesePlease select the source of innervation for the region described. Each option may be used once, more than once or not at all.121. The skin on the palmar aspect of the thumbYou answered Radial nerveThe correct answer is Median nerveThe median nerve supplies cutaneous sensation to this region.See diagram below122. The nail bed of the index fingerYou answered Musculocutaneous nerveThe correct answer is Median nerve123. The skin overlying the medial aspect of the palmYou answered Fifth cervical spinal segmentThe correct answer is Ulnar nerveThis area is innervated by the ulnar nerve.

Question 29

Question 144 of 328 Which of the following muscles is supplied by the musculocutaneous nerve? A. Brachialis B. Latissimus dorsi C. Flexor carpi ulnaris D. Teres minor E. Triceps

Answer 29

BrachialisMnemonicMuscles innervated by the musculocutaneous nerve BBC:Biceps brachiiBrachialisCoracobrachialis

Question 30

Question 147 of 328 A 17 year old male presents to the clinic. He complains of difficulty using his left hand. It has been a persistent problem since he sustained a distal humerus fracture as a child. On examination there is diminished sensation over

Answer 30

Ulnar nerveTheme from April 2012 ExamThis sensory deficit pattern is most consistent with ulnar nerve injury.

Question 31

Question 153 of 328 Which of the following nerves innervates the long head of the biceps femoris muscle? A. Inferior gluteal nerve B. Tibial nerve C. Superior gluteal nerve D. Common peroneal nerve E. Obturator nerve

Answer 31

Tibial nerveThe short head of biceps femoris, which may occasionally be absent, is innervated by the common peroneal component of the sciatic nerve. The long head is innervated by the tibial nerve.

Question 32

Question 162 of 328 Which of the following carpal bones is a sesamoid bone in the tendon of flexor carpi ulnaris? A. Triquetrum B. Lunate C. Pisiform D. Scaphoid E. Capitate

Answer 32

PisiformThis small bone has a single articular facet. It projects from the triquetral bone at the ulnar aspect of the wrist where most regard it as a sesamoid bine lying within the tendon of flexor carpi ulnaris.

Question 33

Question 163 of 328 A 70 year old man falls and fractures his scaphoid bone. The fracture is displaced and the decision is made to insert a screw to fix the fracture. Which of the following structures lies directly medial to the scaphoid? A.

Answer 33

LunateThe lunate lies medially in the anatomical plane. Fractures of the scaphoid that are associated with high velocity injuries may cause associated lunate dislocation.

Question 34

Question 165 of 328 A 73 year old lady is hit by a car. She suffers a complex fracture of the distal aspect of her humerus with associated injury to the radial nerve. Which of the following movements will be most impaired as a result? A. Elbow e

Answer 34

Wrist extensionThe triceps will not be affected so elbow extension will be preserved. Loss of wrist extension will be the most obvious effect.

Question 35

Question 170 of 328 An 18 year old man develops a severe spreading sepsis of the hand. The palm is explored surgically and the flexor digiti minimi brevis muscle is mobilised to facilitate drainage of the infection. Which of the following structures

Answer 35

Median nerveThe flexor digiti minimi brevis originates from the Hamate, on its undersurface lie the ulnar contribution to the superficial palmar arterial arch and digital nerves derived from the ulnar nerve. The median nerve overlies the flexor tendons.

Question 36

Question 172 of 328 A 22 year old man develops an infection in the pulp of his little finger. What is the most proximal site to which this infection may migrate? A. The metacarpophalangeal joint B. The distal interphalangeal joint C. The p

Answer 36

Proximal to the flexor retinaculumThe 5th tendon sheath extends from the little finger to the proximal aspect of the carpal tunnel. This carries a significant risk of allowing infections to migrate proximally.

Question 37

Question 173 of 328 Which of the following muscles is not innervated by the deep branch of the ulnar nerve? A. Adductor pollicis B. Hypothenar muscles C. All the interosseous muscles D. Opponens pollicis E. Third and fourth lumbr

Answer 37

. Opponens pollicis

Question 38

Question 176 of 328 During an arch aortogram the brachiocephalic artery is entered with an angiography catheter. The radiologist continues to advance the catheter. Into which of the following vessels is it likely to enter? A. Left subclavian

Answer 38

Right subclavian artery The axillary artery is a branch of the subclavian artery and although developmental anomalies may occur they are rare. The catheter may also enter the right carotid. There is no brachiocephalic artery on the left side.

Question 39

Question 177 of 328 Which of the following structures lie between the lateral and medial heads of the triceps muscle? A. Radial nerve B. Median nerve C. Ulnar nerve D. Axillary nerve E. Medial cutaneous nerve of the forearm

Answer 39

The radial nerve runs in its groove on between the two heads. The ulnar nerve lies anterior to the medial head. The axillary nerve passes through the quadrangular space. This lies superior to lateral head of the triceps muscle and thus the lateral border of the quadrangular space is the humerus. Therefore the correct answer is the radial nerve.

Question 40

Question 178 of 328 Into which of the following structures does the superior part of the fibrous capsule of the shoulder joint insert? A. The surgical neck of the humerus B. The body of the humerus C. The bicipital groove D. Immediately

Answer 40

The anatomical neck of the humerusThe shoulder joint is a shallow joint, hence its great mobility. However, this comes at the expense of stability. The fibrous capsule attaches to the anatomical neck superiorly and the surgical neck inferiorly