UPPER LIMB

UPPER LIMB – MCQ

QUESTIONS

PART 1

01) True or false regarding humerus

a) The area separating the head from the tubercles is the anatomical neck.
b) The lesser tubercle is an elevation on the anterior aspect of the upper end.
c) Lesser tubercle is anteriorly elevated upward.
d) Teres minor is inserted into the lateral lip of the inter – tubercular sulcus.
e) Fracture of the shaft of the humerus damages the radial nerve.

02) True or false regarding the arm

a) Cephalic vein lies in the medial side.
b) Muscles on the posterior side are supplied by posterior cord of brachial plexus.
c) The skin of the lateral part of the arm is supplied by C5 segment.
d) The skin of the medial side of the upper arm is supplied by T1 segment.

03) True of false regarding the upper limb

a) Rhomboids minor is supplied by dorsal scapular nerve.
b) Latissimus dorsi originates from lumbar fascia.
c) Rhomboids major involving in retraction of scapula.
d) Trapezeus is supplied by accessory nerve.
e) Serratus anterior involving in abduction.

04) True of false regarding the nerves of the arm

a) Medial epicondyle fracture can damage ulnar nerve.
b) Radial nerve does not supply muscles of the arm.
c) In the region of the upper limb accessory nerve associate with profunda brachi
artery.
d) Medial cutaneous nerve of arm arises from medial cord of brachial plexus.
e) Medial nerve supplies muscles of the arm.

05) True of false regarding the shoulder joint

a) The joint capsule is attached around the epiphyseal line of the humeral head.
b) Osteomyelitis of upper end of the humerus can involve the shoulder joint.
c) The stability of the shoulder joint is mainly due to glenoid labrum.
d) Supraspinatus initiates abduction of the humerus at shoulder joint.

06) True of false regarding the clavicle

a) It has a medullary cavity.
 b) It ossifies around fifth to sixth week in foetus.
c) Is developed by cartilage.
d) It’s lateral 1/3 is convex.
e) Infraspinatus is the medial rotater of humerus at the shoulder joint.

07) Which of these are correctly match regarding pectoralis major muscle
a) Has three heads.
b) Manubrium part of pectoralis major is inserted on lateral lip of intertubercular
sulcus.
c) Clavicular head form a rounded appearance in anterior axillary wall.
d) Sernocostal head of the pectoralis major is clinically tested by abducting arm 60
degrees and adduct against resistance.

08) True or false regarding pectoralis minor muscle

a) Pectoralis minor arises from 3rd and 5th costal cartilages.
b) The tendon is attached to the tip of the coracoid process.
c) It is an important land mark in the region.
d) Nerve supply is only by lateral pectoral nerve.
e) Contraction of the muscle cause abduction of the arm.

09) Regarding axilla

a) The apex of the axilla is directed towards the root of the neck.
b) Clavipectoral fascia help to make the anterior axillary fold.
c) Root of brachial plexus lie in axilla.
d) Posterior wall formed only by the subscapularis muscle.
e) Circumflex branches can get easily damaged during mastectomy.

10) Regarding axillary artery

a) Axillary artery is lateral to axillary vein.
b) It is covered throughout by the perctoralis major muscle.
c) It becomes brachial artery at the lower border of the teres minor.
d) It arises at the lateral border of the first rib.

11) Superior trunk of the brachial plexus

a) Is formed by C5, C6 roots.
b) Lies between scalenus medius and scalenus posterior.
c) Gives origin to subclavian nerve.
d) Gives origin to supra scapular nerve.
e) Gives origin to long thoracic nerve.

12) Axillary artery

 a) Begins at the outer border of the first rib.
b) It crosses median nerve in the arm.
c) Lies laterally to axillary vein.
d) Profunda brachii branch gives inferior to teres major.
e) End at the lower border of teres major.

13) The range of movement of the shoulder joint enhanced by,

a) Lax capsule.
b) Large humeral head in proportion to the glenoid cavity.
c) Rotation of the scapula on the chest wall.
d) Coracoacromial arch.
e) Acromioclavicular joint.

14) Regarding the movements of the shoulder joint, true/false,

a) Levator scapula.
b) Serratus anterior.
c) Rhomboid major.
d) Rhomboid minor.
e) Trapezius.

15) Regarding latissimus dorsi muscle

a) Forms the posterior fold of the axilla.
b) It supplies by the long thoracic nerve.
c) Assists in the extension of the shoulder.
d) It is tested clinically by shrugging the shoulder against resistance.
e) If paralyzed causes winged scapula.

16) Regarding the deep fascia of the upper limb

a) Clavipectoral fascia splits to enclose subclavius muscle.
b) Pectoralis minor enclosed by layers of fascia.
c) Brachialis and biceps are in the same compartment.
d) Coracobrachialis and triceps are in the same compartment.

17) Osteology of upper limb

a) The ulna grows towards the wrist.
b) Clavicle is ossified from two primary ossification centers.
c) The ossification of the capitates is the last among carpal bones.
18) If the radial nerve is cut at the axilla
a) Hand cannot be extended at the wrist.
b) There is a wide area of sensory loss over the back of the forearm.
c) The metacarpophalangeal joints cannot be extended.
 d) Flexed forearm cannot be pronated.

19) Brachial plexus lesion at the level of trunks cause paralysis in

a) Deltoid.
b) Latissimus dorsi.
c) Supra spinatus.
d) Rhomboid minor.
e) Serratus anterior.

20) True of false,

a) Biceps brachi is supplied by musculocutaneous nerve.
b) Scapula is a bone which fractures rarely.
c) Supraspinatus is supplied by axillary artery.
d) The brachial artery commences at the lateral border of the pectoralis minor.
e) Posterior group of axillary lymph nodes lie along the subscapular artery.

21) Regarding the shoulder joint

a) Abduction of the arm is initiated by the Deltoid muscle.
b) It is a Ball & Socket type of synovial joint.
c) Dislocation can lead to wasting of shoulder joint.
d) It is weakest on the inferior aspect.
e) Labrum glenoidale is the main stabilizing factor.

22) Posterior interosseous nerve

a) Has cutaneous branches for forearm.
b) It pierces the supinator muscle.
c) Supplies brachialis muscle.
d) Supplies the extensor muscles.
e) When damaged of its origin causes “Claw Hand”

23) Patient with a deep cut in the anterior aspect of the wrist
a) Radial artery should be examined for injury.
b) Cut end of the flexor digitorum superficialis need to be identified.
c) Parasthesia of palmer surface can occur.
d) Bleeding can be completely arrested by compressing radial artery proximally.
e) Proximal ends of cut tendons cannot be seen at the wound due to contraction of
their corresponding muscles.

24) Radial artery

a) Passes lateral to the Biceps tendon at cubital fossa.
b) Passes over the radial origin of flexor digitorum superficialis.
 c) Crosses the anatomical snuff box.
d) Lies medial to the radial nerve in middle 1/3 of forearm.
e) Is the commonest site for arterial canaliculation.

25) Regarding the spaces of the hand

a) Radial bursa is formed by the synovial sheath of the tendons of flexor pollicis
longus.
b) Infections in the pulp space lead to necrosis of distal phalanx.
c) Infections of the 5th finger tend to infections of the ulnar bursa.
d) Digital synovial sheath of the index finger contact with ulnar bursa.

PART 2

Mention T/F regarding following statements.

01) Breast is a modified sweat gland of apocrine which the capsule derived from
clavipectoral fascia.
02) Axillary lymph nodes accounts for 75% lymph drainage of upper limb.
03) Axiallry lymph nodes are five in number.
04) All the breast tissue lies superficial to the pectoralis major muscle.
05) Breast is ectodermal origin completely.
06) In fracture of clavicle is just above the coracoid process of scapula.
07) The median nerve is most vulnerable to damage in supracondylar fractures of humerus.
08) Posterior border of ulnar can be exposed surgically without danger.
09) Ulnar pulse is palpated medial to flexor carpi ulnaris tendon.
10) Brachial artery is the main artery of the upper limb.
11) Clavicle is used to bone marrow aspiration as it is subcutaneous.
12) Third part of the Subclavian artery and branches as well as trunks of brachial plexus
passes behind middle third of clavicle.
13) Both epicondyles of humerus are intracapsular.
14) Lower end of humerus is angulated 450 for ward to its shaft.
15) Pisiform is a sesamoid of flexor carpi ulnaris and of largest sesamoid.
16) Longest bursa of the body is found in respect to upper limb.
17) In supraspinatus tendinitis pain is felt as adduction is initiated.
18) With respect to pronation and supination, supination is more powerful because of
supinator.
19) When forearm is flexed there is tendency to supination too.
20) Above pect.minor muscle brachial plexus lies above and behind brachial artery.
21) Breast carcinoma can be dangerous as it communicates with Baston’s plexus.
22) Apex of axilla lies medial to first rib.
23) Acute pancreatitis may give rise to referred pain in both shoulder tips.
24) Apical lung tumors may give rise to sensory losses along medial side of arm.
25) Rotator cuff is formed by tendon of long muscles action on long joint.
26) Brachialis and flexor carpi ulnaris are muscles that enjoy double innervations.
27) Golf elbow condition results from tearing of common extensor origin.
28) Median cubital vein is usually preferred for injections as it is most superficial.
29) Carrying angle is important as arm comes in line with long axis of forearm in midprone
position where hand is most used.
30) Radial bursa and ulnar bursa does not communicate in 50% cases.
31) Pronator syndrome and carpal tunnel syndrome can be distinguished according to the
sensory loss of palm region.
32) Claw hand arising from ulnar nerve damage affect ring finger and little finger more than
index and middle.
33) Radial nerve damage in spiral groove leads to triceps paralysis.
34) Ulnar artery and nerve passed below flexor retinaculum.
35) Thenar space is the one contains thenar muscles.
36) Midpalmar space is continued with 2, 3, 4 lumbrical canals
37) 1st intercostals joint is a primary cartilaginous joint
38) Nipple and areolar are devoid of fat.

PART 3

01) The pulp of the finger

a) Has skin adhered to the terminal phalanx.
b) Receives a relatively poor blood supply.
c) Has no subcutaneous tissue.
d) Has a rich nerve supply.
e) Includes the nails and nail beds.

02) The elbow joint

a) Communicates with the superior radio-ulnar articulation.
b) Has a synovial membrane closely adhesive to the capsule.
c) Has a capsule fairly adherent to the articular bones.
d) Includes the articulation between radius, ulnar and humerus.
e) Is a Hinge joint but adduction and abduction occur.

03) Radio-ulnar joint

a) Head of the radius is easily dislocated downwards through the annular ligament in
an adult.
b) The fibrous capsule of the distal joint is weak.
 c) Most of the fibers of the interosseous membrane run downwards and medially
from radius to the ulnar head.
d) Fibers of the interosseuos membrane act partly as the joint capsule.

04) Radio-ulnar joint

a) Annular ligament and the radial notch of the ulnar articulate with the head of the
raidus.
b) Neck of the radius is strongly attached to the annular ligament.
c) Capsule of the distal radio-ulnar joint blends with the interosseous membrane.
d) Anconeous assists the pronation.
e) During pronation the distal end of the radius carries the hand and the articular disk
with it.

05) Regarding the wrist joint

a) On the carpal articular surface of the radius a ridge separates a lateral triangular
area.
b) Proximal articular surface of the Scaphoid faces more to the palmer surface.
c) The apex of the articular disc is attached to the medial border of inferior articular
surface of the radius.
d) The dorsal radio-carpal ligament is thinner and weaker than the palmer radio-
carpal ligament.
e) In the abducted hand, the head of the ulnar is separated from a triquetral by the
articular disc.

06) At the wrist

a) Flexion and extension occur at the radio carpal articulation alone.
b) The main movement of the inter-carpal joints is flexion and extension.
c) Adduction and abduction are associated with inter-carpal articulation.
d) The joint cavity may communicate with the inferior radio-ulnar joint.
e) There are no note-worthy intra articular structures.

07) At the wrist joint

a) The range of adduction is more than that of the abduction.
b) Range of medial rotation is more than the lateral rotation.
c) Lunate and Schaphoid articulate with the inferior articular surface of the radius
during flexion.
d) In adduction lunate passes radially.
e) In extension the movement is more at the wrist joint than at the inter-carpal joints.

08) In the wrist

 a) In the anatomical potisoin, scaphoid and lunate articulate with the raidus.
b) Range of extension is greater than flexion.
c) Lunate deviates to the medial side in adduction.
d) Has both medial and lateral rotation in equal range.

09) Regarding the wrist joint

a) Flexion is done by only ulnar and median nerves.
b) Extension is done by only the radial nerve.
c) Ulnar deviation is done by the ulnar and radial nerves.
d) Radial deviation is done only by the radial nerves.
e) Distal radio-ulnar joint is a part of it.

10) Regarding the wrist joint

a) Articulate
b) In the position of rest, scaphoid, lunate and triquetral bones articulate with the
distal end of the ulna.
c) Triangular articular disc separates the ulna from the joint.
d) Movements at the radio-carpal joints are accompanied by movements at the inter-
carpal joints.
e) In the radial nerve is damaged in the axilla, flexion at the wrist is weakened.

11) The radio-carpal joint

a) Joint can be marked by a superiorly convex line drawn in between the two styloid
processes of the ulna and radius.
b) Flexion at the wrist occurs at the radio carpal joint is greater than the movement
of the midcarpal joint.
c) Proximal joint surface is formed by the distal end of the radius and the articular
disc.
d) In adduction lunate touches the radius.
e) Pronation is more powerful than supination.

12) The metacarpophalangeal joint

a) Is a freely movable ellipsoid joint.
b) Permits active rotation.
c) Has a very thick palmer ligament.
d) Includes adduction and abduction in all its range of movement.
e) On the dorsum, fibrous capsule is replaced by the extensor tendon.

13) Regarding scapula

a) If serratus anterior is paralyzed, the lower angle of scapula is prominent.
b) Serratus anterior is attached to the medial margin of the scapula.
 c) Spine of the scapula is at the level of T3 vertebra.
d) Coracoid process can be palpated through the anterior fibers of deltoid.
e) When brachial artery is blocked in the arm, blood flows to the distal part through
the scapular anastomosis.

14) Regarding the scapula

a) Deep branch of the transverse cervical artery lies deep to the rhomboid muscle.
b) The circumflex scapular artery curve at the lateral side of the scapula.
c) The subscapular artery does not take part in the scapular anastomosis.
d) In coarctation of the aorta, the blood supply to lower parts of the body is stopped.
e) Ligation of the 3rd part of the subclavian artery cannot stop the blood supply to the
hand.

15) The scapula

a) Covers parts of the 2nd and 7th ribs.
b) Cannot move at the acromio-clavicular joint.
c) Has muscular attachment to skull, vertebrae and ribs.
d) Forms the boundary of the area of auscultation.
e) Suprascapular nerve enters the infraspinatus fossa through the spinoglenoid notch.

16) Regarding scapula

a) Articukar surface of clavicle is in the medial border of the acromian.
b) Gains attachment to the lower five digits of serratus anterior.
c) Trapezius and serratus anterior are lateral rotators of scapula.
d) Osscification completes at puberty.
e) Suprascapular nerve runs posterior to its spine to supply the infraspinatus muscle.

17) Regarding the scapula

a) When the arm is hanging by the side the coracoids process projects directly
forwards.
b) A bursa lies anterior to the neck of the scapula.
c) Coracoid process of the scapula ossifies separately and joins with the rest at 15
years.
d) Groove for the circumflex scapular artery lies between the attachment of teres
major and teres minor.

18) The scapula

a) Is raised upwards on the chest wall by the trapezius muscle.
b) Has a coracoids process projecting forward above the clavicle.
c) Is rotated on the chest wall by the pectoralis minor so that its inferior angle moves
laterally.
 d) Ossifies in membrane.
e) Has the teres minor muscle attached to its inferior angle.

19) The scapula

a) Has teres major muscle attached to its inferior angle.
b) Has the long head of the biceps brachii muscle attached to its infra glenoid
tubercle.
c) Is moved forward on the chest wall by serratus anterior muscle.
d) As it moved upwards on the chest wall is associated with an upward movement of
the medial end of the clavicle.
e) Has two centers of ossification in its coracoids process.

20) The clavicle

a) Always has an epiphysis at its medial end.
b) Has the apex of the lungs behind its medial one third.
c) Develops by endochondral ossification.
d) Is crossed posteriorly by the supraclavicular nerve.
e) Has attached to the pectoralis minor muscle.

21) Regarding the clavicle

a) Bony prominence over the shoulder is formed by lateral end of the bone.
b) The cord of the brachial plexus lie behind the middle of the clavicle.
c) The sternoclavicular joint is a secondary cartilaginous joint.
d) Ossifies in membrane.
e) When fractured the lateral part is elevated by the trapezius.

22. Lower end of the humerus

a) Has part of the supinator muscle attached to it.
b) Has the ulnar nerve running posterior to the lateral part.
c) Usually has its four epiphysis fused by 8 years.
d) Fused with the shaft before the upper end fuses with the shaft.
e) Has part of pronator teres muscle to it.

23) The shaft of the humerus

a) Has the lateral head of the triceps muscle attached to it on its upper posterior part.
b) Has a nutrient foramen directed upwards.
c) Has the radial nerve posterior to it.
d) Has the brachialis muscle attached to its anterior surface.
e) In adults contain red bone marrow.

24) Nerves directly related to humerus

 a) The radial nerve.
b) The axilary nerve.
c) The median nerve.
d) Then ulnar nerve.
e) The musculocutaneous nerve.

25) The upper end of the humerus

a) Has the subscapularis muscle attached to the greater tubercle.
b) Has the teres major muscle attached to the floor of the intertubercular sulcus.
c) Has 4 epiphysis which are fused separated with the shaft.
d) Has capsular ligament of the glenohumeral joint attached to the wall of the
anatomical neck.
e) Is the growing end of the humerus.

26) Regarding the radius

a) The brachialis muscle is attached to the tubercle.
b) Trapezium is in contact with the lateral part of the inferior articular surface.
c) Has flexor digitorum profundus muscle attached to it.
d) Annular ligament surrounds the neck.
e) Extensor pollicis longus is attached to it.

27) Regarding the radius

a) Annular ligament surrounds the neck.
b) Lateral part of the anterior articualr surface is connected with trapezium.
c) Growing end is upper end.
d) Tuberosity gives attachment to biceps tendon.
e) Anterior surface gives attachment to flexor digitorum profundus.

28) True or false

a) The tuberosity of the radius can be felt on the posterior surface of the forearm.
b) Biceps muscle is attached to the anterior surface of the coronoid process of the
ulna.
c) The lower part of the radius is the growing end.
d) The ulnar head of pronator teres is attached to the medial margin of the coronoid
process.

29) True or false

a) Extensor carpi ulnaris tendon lies in the groove at the posterior surface of the
lower end of ulna.
b) The joint between the upper part of the ulna and the radius is a hinge joint.
c) Brachialis is attached to the coronoid process of ulna.
 d) Supinator is attached to the crest below the radial notch.
e) The ossification center of the styloid process of the radius fuses with the
secondary center of the lower end at the 18th year.

30) True or false

a) Cutaneous innervations of the upper limb is only by the anterior primary rami of
the spinal nerves.
b) The extension of the elbow joint is concerned with the C5 central rami.
c) Lateral cutaneous nerve of the forearm is a branch of musculocutaneous nerve.
d) Elbow joint receives its nerve supply from musculocutaneous nerve through its
branch to brachialis.
e) Anterior branch of the medial cutaneous nerve of the forearm may lie over the
median cubital vein.

31) True or false

a) The flexion of the scapula is only concerned with median and ulnar nerves.
b) Retraction of the scapula is brought about by levator scapulae.
c) Inferior dislocation of the shoulder is the commonest type.
d) Cut injury at the anatomical snuff box can result in loss sensation in the lateral
side of the dorsum of the hand.
e) The extensor carpi radialis muscle is supplied by deep branch of the radial nerve.

32) True or false

a) The clavicle is the first bone to ossify in the body.
b) Three carpal bones can be seen in a radiograph of a three year old child.
c) Clavicle has three primary ossification centers.
d) Pisiform bone gives origin to the abductor digiti minimi.
e) Tendon of the Palmaris longus goes deep to the flexor retinaculum.

33) True or false

a) Second thoracic nerve doesn’t supply the skin of the upper limb.
b) The lateral cutaneous nerve of the forearm supplied the proximal part of the
thenar eminence.
c) Supraclavicular nerve supplies upto the sterna angle.
d) Axillary nerve is medial to the long head of the triceps muscle.
e) Axillary nerve appears posteriorly in triangular area.

34) True or false

a) Brachial artery can be compressed against the humerus in its entire course in arm.
b) Radial artery enters the palm between the two flexor adductor pollicis.
c) The ulnar nerve accompanies the ulnar artery under the flexor retinaculum.
d) The nutrient branch of the brachial artery to the humerus is an end artery.
e) Deep palmar arch lies between flexor tendons and carpal bones.
 UPPER LIMB – MCQ
ANSWERS

PART 1

01) a) T Surgical neck is between the shaft and the head.

b) T Greater tubercle is an elevation that forms the upper part of the head.

c) T

d) F Teres minor is inserted in lowest impression of the greater tubercle. Pectoralis

major is inserted into the lateral lip of the intertubercular sulcus.

e) T Radial nerve lies in the radial groove of the posterior aspect of the shaft.

02) a) F Cephalic vein lies in the lateral side. Basilic vein lies in the medial side.

b) T Radial nerve, which is branch of the posterior cord, supplies the triceps.

c) T This area is supplied by the upper lateral cutaneous nerve of arm which is a
branch of the axillary nerve and the lower lateral cutaneous nerve of arm which
is a branch of the radial nerve.

d) It is supplied by the T2 segment. T1 supplies medial side of the forearm.

03) a) T Dorsal scapular nerve supplies Rhomboids major, minor and levator scapulae.

b) T Latissimus dorsi origins fom spinous processes of lower six thoracic vertebra,
thoracolumbar fascia, iliac crest, and inferior three or four ribs. It inserts
into floor
of the bicipital groove.

c) T Retraction is by middle part of the Trapezius, Rhomboids major &minor and

latissimus dorsi. Protraction is by Serratus anterior, Pect. Minor and major.

d) T Spinal root of the accessory nerve supplies trapezius and sternocleidomastoid.

e) T Supraspinatus initiates abduction. Deltoid abducts up to 900 and serrus anterior

and trapezuis involve in overhead abduction.
04) a) T It lies behind the medial epichondyle.

b) F It supplies the Triceps muscles in the posterior compartment of arm.

c) F Radial nerve accompanies profunda brachii artery.

d) T

e) F Median nerve doesn’t give muscular branches in the arm. It supplies the anterior
compartment of the forearm and palmer aspect of hand.

05) a) T Joint capsule lacks and is attached around the epiphyseal line of both the glenoid
and the humeral head.

b) T Joint capsule extends down on diaphysis on the medial aspect of the

neck of humerus, so that an osteomyelitis of the upper end of the humeral shaft
may involve in the joint by direct spread.

c) F Glenoid labrum deepens the glenoid fossa and helps to stabilize the joint. But the
main stabilizing factor is the tone of the rotator cuff muscles around the joint.

d) T Supraspinatus initiates the abduction up to 150.

06) a) F Clavicle has no medullary cavity.

b) T It is the first bone to ossify in foetus.

c) F Although clavicle is a long bone it develops in membrane, not in cartilage.

d) F Its lateral 1/3 is concave anteriorly. Its medial 2/3s is convex anteriorly.

e) F Infraspinatus is a lateral rotator of the shoulder joint. Subscapularis, Teres major

and pect. major are medial rotators.

07) a) T Pect. Major has sternocostal, Clavicular and Abdominal heads.

b) T Middle fibers arising from the manubrium contributes to form the posterior
lamina of the ptec.major bilaminar tendon. It is finally inserted on lateral lip of
bicipital groove.

c) F Fibers from the sternum and aponeurosis of external oblique muscle are twisted
 around the lower border of the rest of the muscle. These twisted fibers form the
anterior axillary fold.

d) T Sternoclavicular head can be tested by adducting the arm after it is raised slightly
below the horizontal level. Clavicular head is tested by adducting the arm after it
is raised above the horizontal level.

08) a) T Arises from the 3rd, 4th, 5th ribs.

b) T

c) T Axillary artery is divided into 1st, 2nd and 3rd parts by the pect.minor muscle.

d) F Innervation is only by medial pectoral. Pect. Major is supplied by both medial and
lateral pectoral nerves.
e) F Functions are; Protraciton of the scapula, Depresses the point of the shoulder,
Helps in forced inspiration.

09) a) T

b) T Below the pect. minor, clavipectoral fascia continues as the suspensory ligament
and forms the anterior axillary wall. It helps to keep the axillary fascia pulled up.

c) F Cords of the brachial plexus are in the axilla. Roots lie between the anterior and
middle scalene muscles.

d) F It is formed by subscapularis above and teres major and latissimus dorsi below.

e) F Circumflex arteries anatmose around the surgical neck and can be damaged in
shoulder dislocation.

10) a) T

b) F

c) F Becomes the brachial artery below the teres major muscle.

d) T Subclavian artery becomes the axillary artery at the outer border of the first rib.

11) a) T
 b) F It lies between scalenus anterior and medius.

c) T

d) T

e) F Long thoracic nerve is given by roots C5, C6, C7

12) a) T

b) F Median nerve crosses the brachial artery from lateral to medial in the mid arm

c) T

d) F Profunda artery is given by the brachial artery.

e) T

13) a) T

b) T Humeral head is a one third of s sphere. The ratio between the glenoid fossa and
the head is 1:4

c) T The range of movements is further increased by concurrent movements of the

shoulder girdle.

d) F Coracoacromial arch stabilizes the joint so that the range of movement is reduced

e) F

14) a) F

b) T Needed for the overhead abduction of the shoulder joint.

c) F

d) F

e) T Needed for the overhead abduction.

15) a) T Posterior wall of the axilla is formed by latissimus dorsi and teres major below
 and subscapularis above.

b) F It is supplied by thoracodorsal nerve. Long thoracic nerve supplies serratus

anterior.

c) T Latissimus dorsi adducts, extends, and medially rotates the arm in shoulder joint.

d) F That is to test serratus anterior.

e) F It is by paralysis of serratus anterior.

16) a) T Clavipectoral fascia encloses both subclavius & pectoralis minor muscles.

b) T Clavipectoral fascia splits into 2 layers & encloses the pectoralis muscle.

c) T Both muscles are in the anterior compartment. But they are separated by the
transverse septum which is an extension of deep fascia.

d) F Triceps ~ Posterior compartment

Coracobrachialis ~ anterior compartment

17) a) F Ulnar grows towards the elbow.

b) T It has two primary & one secondary ossification.

c) F Capitate ossifies first, Pisiform is the last bone to ossify.

18) a) T Radial nerve supplies the extensor muscles of the forearm. paralysis of these
muscles causes Wrist Drop.

b) T Posterior cutaneous nerve of the forearm is a branch of the radial nerve.

c) T Paralysis of extensor digitorum causes this.

d) F Pronator Quadratus is the main pronator. Its nerve supply is intact.

19) a) T In Erb’s paralysis there is damage to the upper trunk. It causes paralysis in
Deltoid, biceps, brachialis & brachioradialis.

b) T
 c) T Suprascapular nerve is the branch of the upper trunk.

d) F Rhomboids minor is supplied by the dorsal scapular nerve which is a branch of

C5 nerve root.

e) F Serratus anterior is supplied by the long thoracic nerve. which is a branch of

C5,C6,C7 nerve roots.

20) a) T

b) T It is protected well by muscles.

c) F

d) F It commences at the lower border of the teres major.

e) T

21) a) F Abduction is initiated by the Supraspinatus. Deltoid abducts the arm between 15
to 90 degrees. 90 to 180 degrees abduction is done by serratus anterior &
Trapezius.

b) T

c) T Inferior dislocation damages the axillary nerve. As it supplies the Deltoid, there is
the wasting of this muscle. Then the smooth contour of shoulder joint disappears.

d) T There are no muscles in the inferior aspect.

e) F Rotator cuff muscles are the main stabilizing factor.

22) a) F

b) F It lies within the supinator muscle.

c) F Musculocutaneous nerve & main trunk of the radial nerve supply brachialis
muscle.

d) T
 e) F

23) a) F It turns backwards into the anatomical snuff box before the wrist joint.

b) T

c) T Cutaneous nerve to the palm is damaged.

d) F It is done by compressing the ulnar artery.

24) a) F Radial nerve lies lateral to the biceps tendon.

b) T

c) T

d) T

e) T

25) a) T

b) T The blood vessels to the shaft of the distal phalanx traverse the pulp space & may
become thrombosed in a severe pulp infection resulting necrosis of distal phalanx.

c) T The synovial sheath of the 5th finger continues as the ulnar bursa.

d) F

PART 2

01) F Capsule is formed by the pectoral fascia.

02)
03) F There are 20-30 Axillary lymph nodes which are arranged in five groups.

04) F Axillary tail pierces the deep fascia and lies in the Axilla.

05) F Stroma is mesodermal in origin.

06) T It is the weakest point in the clavicle; it is the junction between medial 2/3s and
lateral 1/3.
07) T

08) T It is entirely subcutaneous and crossed by no named nerves or vessels.

09) F Artery lies lateral to the tendon

10) T

11)

12) F They pass behind the medial third of the shaft.

13) F Both epichondyles are extra-capsular.

14) T

15) F Largest sesamoid bone is the patella. Pisiform is a sesamoid bone which develops
Within the tendon of the flexor carpi ulnaris.

16) T Subacromian bursa continues as the Subdeltoid bursa as the largest bursa of the
Body.

17) F Supraspinatus initiates abduction. In supraspinatus tendinitis painful arc of

Shoulder abduction is between 60-1200.

18) F Supination is more powerful because of the action of Biceps brachii muscle.

19) T Contraction of Biceps brachii is a weak flexor and a powerful supinator of the
Elbow joint.

20) T

21)
22) F Apex of the axilla is bounded by the lateral border of the 1st rib.

23)

24)

25) F Rotator cuff is formed by the tendons of the short muscles; namely Supraspinatus,
Infraspinatus, Teres minor and Subscapularis

26) F Brachialis has a dual nerve supply (musculocutaneous – motor, radial –

Proprioception). Flexor Carpi ulnaris is innervated by ulnar nerve.

27) F Golf elbow results from tearing of common flexor origin. Tearing of common
extensor origin gives rise to Tennis elbow.

28) T

29) T

30) T In 50% cases do communicate causing spread of infections between each other.

31)

32) T In claw hand, there is hyperextension of metacarpophalangeal joints & flexion of

interphalangeal joints due to damage of intrinsic muscles which are supplied by
ulnar nerve. Lateral two lumbricals are supplied by median nerve & medial two
are supplied by ulnar nerve.
So it affects ring & little fingers more than index & middle.

33) T Radial nerve gives a branch to the Triceps in the spiral groove of the humerus.

34) F Both pass above the flexor retinaculum.

35) F Thenar space lies superficial to the 2nd & 3rd metacarpals & adductor pollicis
muscle.

36) T The Midpalmer space lies behind the flexor tendons & in front of the 3rd,4th & 5th
metacarpals.

37) T Costosternal joints; 1st ~Primary cartilaginous joints. 2nd to 7th ~synovial joints.
 38) T Also devoid of hair.

UPPER LIMB – MCQ

ANSWERS

01) a) T Pulp spaces are at the tip of the fingers. They contain subcutaneous fat arranged in
tight compartments formed by fibrous septa which passes from skin to periosteum
of terminal phalanx.

b) F Has a rich blood supply from digital phalanx

 c) F

d) T

e) F

02) a) T

b) T Elbow joint is a synovial joint. Every synovial joint has a synovial membrane
closely related to joint capsule.

c) T

d) T

e) F Flexion and extension are the only movements.

03) a) F It occurs in children.

b) T It is weak in upper part.

c) T

d) T It blends with the joint capsule of distal radioulnar joint.

04) a) F Annular ligament encircles the head of the radius. Radial notch of the ulnar
articulates with the head of the radius.

b) F

c) T

d) T

e) T

05) a) T

b) F It faces more to the distal surfaces.

c) T
 d) T

e)

06) a) F It also occurs in joints between carpal bones.

b) F The main movement is the glinding movement.

c) T

d) F The articular disc of the distal radioulnar joint separates it from the wrist joint.

e) F There are articular discs within the joints.

07) a) T Abduction is limited by the styloid process of the radius.

b) T

c) T

d)

e) T Flexion occurs mainly at the mid carpal joints.

08) a) T

b) F Range of flexion is greater than extension.

c)

d) F

09) a) T

b) T

c) T It is done by both flexor & extensor muscles.

d) F Flexor muscles are also involved.

 e) F

10) a)

b) F They articulate with distal end of the radius & articular disc of inferior radioulnar
joint.

c) T

d) T

e) F It causes weakness in extension. (wrist drop)

11) a) T

b) F

c) T

d)

e) F Supination is more powerful than pronation because it is an anti-gravity

movement.
Pronators ~ pronator quadratus , pronator teres

12) a) F It is a synovial joint.

b) T

c) T

d) F

e) T Transverse bands of the extensor expansions join the dorsal surface.

13) a) T Medial border and inferior angle become prominent.(winging of scapula)

b) T

c) T
 d) T

e) F Scapula anastomosis occurs between axillary artery and subclavian artery. It

cannot supply blood to the distal part of the arm.

14) a) T It travels in the medial border of the scapula.

b) T

c) F Circumflex scapular artery is a branch of subscapular artery.

d) F It only reduces.

e) T Then the blood supply to the hand is given by the scapular anastomosis.

15) a) T

b) F Acromioclavicular joint is a synovial plane joint which has a gliding movement

when the scapula rotates.

c) T It has attachments through trapezius, lattisimus dorsi, levator scapulae, rhomboids

minor major.

d) T Borders of auscultatory triangle.

Medial border- trapezius
Lateral border- Medial border of scapula.
Inferior border- Latissimus dorsi.

e) T Suprascapular vessels also travel through this.

16) a) T Acromioclavicular joint is between the acromian of the scapula & the lateral end
of the clavicle.

b) T 1st digit ~ root of the spine.

2nd & 3rd digits ~ medial border.
Last 5 digits ~ Inferior angle.

c) T

d) F Ossification completes at 25th year.

e) F It runs around the lateral border of the scapular spine.

17) a) T

b) T
 c) T

d) T This artery lies in the upper triangular space.

Boundaries.
Medial ~ teres minor.
Lateral ~ Long head of the triceps.
Inferior ~ Teres major.

18) a) T Upper fibers of the trpezius elevate scapula.

b) F Coracoid process lies below the clavicle.

c) F

d) F Has an endochondral ossification.

e) F Is attached to the inferior angle.

19) a) T

b) F Long head of biceps is attached to the supraglenoid tubercle.

Long head of triceps is attached to the infraraglenoid tubercle.

c) T

d) F It is associated with downwards movements of the medial end of the clavicle.

e) T 1st secondary center~ Middle of coracoid process.

Subcoracoid center~ Root of the coracoid process.

20) a) T

b) T Apex of the lungs lies behind the medial 1/3 of the clavicle & extends 2.5cm
above the clavicle.

c) F Develops in membrane.

d) F Supraclavicular nerves ( medial, intermediate, lateral) are the cutaneous supply to

the skin from the clavicle to the 2nd rib.

e) F Has an attachment to the pectoralis major muscle.

21) a) F Bony prominence over the shoulder is made by the greater tubercle.

b) F The divisions of the brachial plexus lies behind the clavicle.

 c) F It is a synovial joint.

d) T

e) F The medial part is elevated by trapezius.

22) a) T Supinator muscle

Origin- Distal border of lateral epicondyle of humerus.
Lateral ligament of elbaw joint.
Annular ligament of the radius.
Supinator crest of the ulnar.
Insertion- Lateral surface of the radius, between anterior & posterior oblique
lines.

b) F Ulnar nerve lies posterior to the medial epicondyle.

c) F Upper end has 2 epiphysis which fuse together in 6th year.

Lower end has 2 epiphysis which fuse together in 15th year.

d) T Upper end fuses with the shaft at 20th year.

Lower end fuses with the shaft at 15th year.

e) T

23) a) T Medial head of triceps~ Posterior surface of the shaft of the humerus below the
radial groove.

b) F It is directed downwards.

c) T Radial nerve lies in the radial groove in the posterior surface of the shaft of the
humerus.

d) T

e) F Born marrow is found in the two ends of long bones

24) a) T Lies in the radial groove.

b) T Winds around the surgical neck.

c) F

d) T Lies behind medial epicondyle.

 e) F

25) a) F Subscapularis is attached to lesser tubercle. Supraspinatus, infraspinatus & teres

minor are attached to the greater tubercle.

b) F Floor of the intertubercular sulcus ~ Latissimus dorsi

Lateral lip ~ Pectoralis major
Medial lip ~ Teres major

c) F Has 2 epiphysis which fuse together & then fuse with the shaft.

d) F Inferiorly it extends up to the surgical neck.

e) T

26) a) F Brachialis
Origin ~ Lower half of the front of the humerus.
Medial & lateral intermuscular septa.
Insertion ~ Coronoid process & ulnar tuberosity.

b) F Radius articulates with scaphoid, lunate & triquetral bones.

c) F Flexor digitorum profundus.

origin ~ anterior surface of shaft of the ulna.
Insertion ~ base of the distal phalanx of medial 4 fingers in palmar surface.

d) F It surrounds the head.

e) F Extensor pollicis longus originates from posterior surface of the shaft of the ulna
& inserts into base of the distal phalanx of thumb.
27) a) F

b) F

c) F Growing end is lower end.

d) T Biceps brachii
Origin ~ Long head ~ supraglenoid tubercle.
Short head ~ tip of the coracoid process.
Insertion ~ tuberosity of radius.
 Bisipital aponeurosis.

e) F

28) a) F

b) F

c) T

d) T Pronator teres
Origin ~ humeral head ~ medial epicondyle of humerus.
ulnar head ~ medial border of coronoid process of ulna.
Insertion ~ laterl aspect of shaft of radius.

29) a) T

b) F It is a pivot type of synovial joint.

c) T

d) T

e)

30) a) T Cutaneous innervation of the upper limb.

Branches of brachial plexus
Cervical plexus
2nd intercostal nerve.

b) F Extension of the elbow is done by the triceps muscle it is supplied by the radial
nerve which arises from anterior rami of C5,C6, C7, C8 & T1.

c) F It is the continuation of the musculocutaneous nerve.

d) T

e) T Medial cutaneous nerve of forearm divides into anterior & posterior branches.
Anterior branch lies over median cubital vein. Posterior branch accompanies the
basilic vein.
31) a) F Flexion of the shoulder joint is done by
Pectoralis major~ lateral& medial pectoral nerves.
Coracobrachialis~ musculocutaneous nerve.
Deltoid~ axillary nerve.

b) F Retraction is done by rhomboid major & minor. Levator scapulae elevates

scapula.

c) T Inferiorly there are no muscles & the capsule is weak.

d) T A branch of the radial nerve which supplies the skin over the lateral side of the
thumb can be damaged.

e) F Extensor carpi radialis longus~ radial nerve.

Extensor carpi radialis brevis~ deep branch of the radial nerve.

32) a) T

b) F 4 bones can be seen.

Capitate & hamate appear in first year.
Pisiform appears in first to second years.
Triquetral appears in third year.

c) F

d) T

e) F It goes above the flexor retinaculum.

33) a) F Supplies the floor of the axilla & upper part of the medial surface of the arm.

b) T

c) T

d) F Axillary nerve lies lateraltotriceps muscle in the quadrangular space.

e) F It passes posteriorly through the quadrangular space.

34) a) F
 b) T

c) F They both pass above the flexor retinaculum.

d) T

e) F It lies deep to long flexor tendons & on the bases of metacarpals.

UPPER LIMB – SEQ

QUESTIONS

November 2005

3) A motorcyclist sustains a dislocation of his right shoulder in a road accident. The house
officer in the surgical ward is concerned about the possibility of damage to the neurovascular
supply.

3.1 State the most likely position of the right upper limb after the dislocation. (20 marks)
3.2 Enumerate the neurovascular structures which could have been damaged in this patient.
(20 marks)
3.3. State the possible complication which could arise as a result of damage to the above
structures. (20 marks)
3.4. List the other structures which could get damaged in this injury. (20 marks)
3.5. Briefly describe why the shoulder joint is very vulnerable for dislocation (20 marks)

November 2006

03) A 49 year old woman presents to her family doctor with pain & numbness in her hands.
On examination the doctor notices bilateral thenar wasting & weakness of thumb abductors. He
confirms the diagnosis of carpal tunnel syndrome by requesting nerve conduction studies.

3.1) Briefly describe the anatomy of the carpal tunnel. (25 marks)
3.2) Using your knowledge in anatomy explain the basis of the pain, numbness &
thenar wasting in this patient. (25 marks)
3.3) Draw a clearly labeled diagram of a coronal section through the carpal
tunnel. (25
marks)
3.4) Write notes on the surface anatomy of the flexor retinaculum. (25 marks)

March 2007

Write short notes.

I. Pulp space
II. Avascular necrosis of schapoid

5.2) An elderly obese women complained of pins and needles sensation in the index and
middle fingers of the right hand. Examination of her hand revealed that her thenar eminence was
wasted.

5.2.1) State the boundaries of the carpal tunnel (10 marks)

5.2.2) State the contents of the carpal tunnel (10 marks)
5.2.3) State the anatomical basis of her complaint and the examination findings
(30 marks)

March 2008

02) A thirty year old female presented to rheumatology clinic with right shoulder pain of 3
months duration. The pain worsens on abduction and internal rotation of the shoulder.
2.1 State the muscles and their nerve supply which are involved in abduction and internal
rotation. (40 marks)
2.2 State two bursae related to the shoulder joint and briefly describe their anatomy.
(20 marks)
2.3 List two important structures that get damaged during dislocation of the shoulder joint.
(10 marks)
2.4 List the important supports of the shoulder joint. (30 marks)

January 2009

2.1) A soldier sustains a gunshot injury in the posterior compartment of the arm. The bullet
has penetrated the mid arm at the level of the attachment of the coracobrachialis muscle to the
shaft of the humerus.

2.1.1 Draw a clearly labeled diagram of a transverse section of the arm at this level.
(20 marks)
2.1.2 List the anatomical structures which could be damaged at this level
(15 marks)
2.1.3 On recovery, the patient suffers from wrist drop and weakness in extension at the wrist.
Using your knowledge in Anatomy, describe the anatomical basis of this.
(30 marks)
2.2

2.2.1 Briefly describe the movements of the shoulder joint. (20 marks)
2.2.2 Describe the anatomical supports of the shoulder joint. (20 marks)

May 2010

4.1 A patient presented at the surgical clinic with contracture deformities of the muscles of
the forearm. He has sustained a supracondylar fracture of the humerus which had been corrected
using a plaster cast two weeks earlier.

Briefly describe the anatomical basis of the ischaemic contracture deformity in this
patient. (20 marks)
 UPPER LIMB – SEQ
ANSWERS

November 2005

3)

3.1
 Shoulder joint has a wide range of movement (ROM)
 ROM α 1
Stability
 Therefore stability is relatively low.
 Stability is maintained by the rotator cuff.
 It lacks inferiorly.
  Therefore Humeral head is least supported inferiorly.
 So It is mostly dislocated antero-inferiorly.
 (But if direct force is applied to the joint anteriorly, posterior dislocation too is possible)
 When the head of the humerus is violently abducted,
- Head slips from the glenoid fossa
- And lies below the subglenoid tubercle
- This is called the subglenoid position
- This is partly because of the effect of gravity due to the weight of arm
 Then the head of humerus is drawn medially by the shoulder adductors, namely;
- Pectoralis major
- Latissimus dorsi
 Also it is pulled upwards by the flexors of the shoulder, namely;
- Pectoralis major
- Anterior fibers of the Deltoid
- Biceps brachii
- Coracobrachialis
 The head of the humerus lies below the coracoids process of scapula.
 This position is Subcoracoid position.
 Therefore after the dislocation head of the humerus lies in the Subglenoid, Subcoracoid
position.
 As a result,
- Greater tubercle is no longer the most prominent bony prominence.
- It is replaced by a the acromion process of scapula.
- Bulge of Deltoid after grater tubercle is lost.
- Characteristic flattening of this muscle occurs.

3.2

1. Axillary nerve Can be damaged as they lies in the

2. Posterior humeral circumflex artery quadrangular space, below the joint.
3. Posterior humeral circumflex vein
4. Radial nerve Can be damaged as they run along
5. Profunda brachii artery of the brachial artery the radial groove of the humerus
6. Profunda brachii vein

3.3

Damage to axillary nerve

 A branch of the posterior cord of brachial plexus.
 Is in close relationship with the medial side of the surgical neck of humerus
  Divides into anterior and posterior branches.
 Anterior branch supplies the Deltoid muscle.
 Damage to axillary nerve impairs the function of deltoid muscle, namely;
- Flexion
- Extension
- Medial rotation
- Lateral rotation
- Abduction
of the arm in the shoulder joint.
 Also it supplies to the skin over the deltoid muscle.
 Therefore damage to the anterior branch result in loss of sensation over this area.
 Posterior branch supplies the teres minor muscle
 Damage to axillary nerve impairs the function of teres minor muscle; namely;
- Lateral rotation of arm in shoulder joint
- Acting as a rotator cuff muscle by maintaining its tone.
 Also the posterior branch gives the upper lateral cutaneous neve of arm.
 So damage can lead to loss of sensation over the lower lateral part of the deltoid.

Damage to posterior circumflex humeral artery and vein

 Posterior circumflex humeral artery is a branch of the third part of the subclavian artery.
 It follows the axillary nerve to the quadrangular space & anastomose with anterior
circumflex humeral artery around the surgical neck of the humerus.
 If this vessel is damaged, the blood supply to the shoulder joint will be reduced.
 But, it will not lead to any necrosis, as there is rich anastomosis around the joint.
 The posterior circumflex humeral vein follows the artery & drain in the axillary vein.
 When damaged the venous drainage around the area is impaired.
 But not lost due to anastomosis.

Damage to the radial nerve.

 The radial C5,C6 nerve of the posterior cord.

 Root value- C7,C8 & T1.
 In the humerus it run in the spiral groove.
 Here it gives muscular branches to the medial and lateral heads of the triceps brachii
muscle.
 So if damage it will prevent extension of the forearm.
 Also radial gives the lover lateral cutaneous nerve of the arm.
 Damage to this lead to loss of sensation of the skin over the antero lateral part of the
lower half of the arm.
 It also gives posterior cutaneous nerve of forearm, so damage to this leads to loss of
sensation of the skin over the middle of back of forearm up to the wrist.
 If damaged completely, the supply to extensor compartment too will be damaged.
  This will lead to wrist drop.
 Also it will lead to loss of sensation over an area of the dorsum& proximal phalanges of
lateral 3& ½ fingers

Damage to profunda brachii artery

 The profunda brachii artery is a branch of the brachial artery.
 It accompanies the radial nerve in the spiral groove.
 When damaged,the blood supply to triceps & shoulder joint will be impaired.
 Profunda brachii vein follows the artery.

 Therefore in an inferior dislocation of shoulder joint these complications can occur

according to the damage to the respective damage.

3.4
Bony structures
 Humeral head
 Anatomical neck of humerus
 Glenoid fossa
 Glenoid labrum

Muscles
Rotator cuff muscles
 Supraspinatus
 Infraspinatus
 Subscapularis
 Teres minor

 Tendon of long head of Biceps brachii

 Tendon of long head of Triceps brachii

Ligaments
 Three glenohumeral ligaments
 Transverse humeral ligament
 Coracohumeral ligament
 Coracoacromion ligament
 The joint capsule

Synovial membrane of the joint

 Subscapularis bursa
 Subacromion bursa

3.5
  Shoulder joint is a very mobile joint & it allows a wide range of movements.
 It is a synovial , Ball & Socket joint.
 The movements it allows are flexion, extension, abduction, adduction, medial & lateral
rotation & circumduction.
 The wide range of movement is achieved at the cost of stability.
 Stability of the joint α 1/mobility of the joint.
 Therefore comparing to its counterpart in the lower limb which is the hip joint,the
shoulder joint permits more mobility.
 But,more vulnerable for dislocation.

 The bony attachments of the joint are relatively unstable.

 The humeral head is a 2/5 of a sphere & it articulates with the shallow, pear shaped
glenoid cavity of the scapula.
 Though the glenoid fossa is deepened by a fibrocartilagenous rim called the glenoid
labrum, still a greater part of the humeral head doesn’t articulate with the glenoid fossa.
 The main stabilizing factor of the shoulder joint is the tone of the rotator cuff muscles.
 These muscles surround the joint anteriorly, posteriorly & superiorly. But lacks
inferiorly.
 Therefore the shoulder joint is least supported in its inferior part.
 Because of this it is more prone to be dislocated anteroinferiorly.

 The fibrous joint capsule of the joint attaches outside the articular surfaces.
 This capsule is thin & lacks specially inferiorly.
 This is to increase the range of movements.
 But because of this it makes the joint more vulnerable to dislocation.

 There are several ligaments in the shoulder joint.

- Three glenohumeral ligaments anteriorly,
- the transverse humeral ligament across the tuberosities of the humerus.
- Coracohumeral ligament.
- Coracoacromian ligament acts as an accessory ligament.
 These ligaments don’t support the joint inferiorly. Therefore making it vulnerable for
dislocation.

November 2006

3.1)
 Carpal tunnel is a ossiofacial tunnel that connects the distal end of the forearm & the
hand.
 It is made by the carpus & flexor retinaculum & it contains many structures.
 The bony frame work of the tunnel is made by the carpus.
 The carpus is concave on its anterior surface & forms a bony gutter.
  The lateral wall of the tunnel is made by the scaphoid ( proximally) & the
trapezium( distally).
 The medial wall is made by the triquetral with the pisiform on it( proximally) & the
hamate ( distally).
 The floor is made by the rest of the carpal bones, proximally by the lunate & distally by
trapezoid & capitate.
 The roof of the tunnel is made by the flexor retinaculum.
 It is attached medially to the pisiform bone & hook of hamate, laterally to the scaphoid &
the crest of the trapezium.
 There are several structures passing through the tunnel( under the flexor retinaculum)
from forearm to hand.
 Some structures pass superficially to the flexor retinaculum.
 4 tendons of flexor digitorum superficialis arranged in 2 rows- anterior & posterior.
 Those to the middle & ring fingers lying in front of those to the index & little fingers. At
the lower border of flexor retinaculum 4 tendons diverge & come & arranged in to a same
plane.
 4 tendons of flexor digitorum profundus are on the same plane & lies behind the
superficialis tendon.
 All 8 tendons of flexor digitorum superficialis & flexor digitorum profundus are contain
in 1 synovial sheath, the ulnar bursae.
 The tendon of the flexor carpi radialis passes under the flexor retinaculum, contained in a
separate compartment which is form by fibrous septum given by the retinaculum. It lies
in the plane of flexor digitorum superficialis.
 The tendon of flexor pollicis longus runs deep to the flexor retinaculum in its own
synovial sheath.
 Median nerve passes in the tunnel( deep to the retinaculum) in a restricted space between
flexor digitorum superficialis & the flexor carpi radialis.
 The structures passing superficial to the flexor retinaculum are flexor carpi ulnaris
tendon, ulnar nerve, ulnar artery, palmaris longus tendon, palmar cutaneous nerve of
ulnar nerve & median nerve.

3.2)
 As described above the median nerve is contain in a restricted space in the carpal tunnel.
 Here it can be compressed due to various reasons.
Eg: Bony pathology like ~ Dislocation of lunate.
Old fracture of wrist.
Osteoarthritis of carpal bones.
Soft tissue pathology like ~ Inflammation of synovial sheath.
Obesity
Acromegally
 Because of the compression, the structures supplied by the median nerve lose their nerve
supply.
 This leads to sensory & motor impairment in the hand.
  Median nerve is a mixed nerve.
 It gives motor supply to the muscles in the thenar eminence. They include
I. abductor pollicis brevis
II. flexor pollicis brevis
III. opponens pollicis & also to the 1st 2 lumbricals.
 Paralysis of this small muscles give rise to the weakness of thumb abductors.
 Impaired motor activity of the thenar muscles leads to the wasting of muscles.
 Median nerve also gives cutaneous branches to the palm. It gives digital cutaneous supply
to the lateral 3 &1/2 fingers, that is the thumb, index finger, middle finger & lateral half
of ring finger.
 It also supplies adjoining skin of the palm & inter phalangeal clefts.
 On the dorsum of hand it supplies the distal 2 phalanx of the lateral 3& ½ digits.
 When the cutaneous nerve supply is impaired pain & numbness can be felt in the lateral
part of the hand.
 As the median supplies the 1st 2 lumbricals the function of these muscle too can be
impaired.

3.3)

* Harold Ellis – 11th edition Page-175 , fig.126

3.4)
 Flexor retinaculum is a thickening of deep fascia at the wrist.
 It stretches acrosses the concave carpus & turns it in to the carpal tunnel.
 The flexor retinaculum keeps the tendons of long flexor muscle in position @ wrist.
 It is attached ,
Medially- to the pisiform bone proximally & to the hook of hamate distally.
Laterally – to the tubercle of scaphoid proximally & crest of trapezium distally.
Superiorly- to the skin & superficial
Inferiorly- to the palmar apponeurosis.
 It gives 2 slips to the trapezium, deep & superficial & make a separate compartment for
the tendon of flexor carpi radialis.
 Structures passing superficial to the tendon (medial to lateral),
- flexor carpi ulnaris tendon
- ulnar nerve
- ulnar artery
- palmar cutaneous branch of ulnar nerve
- palmaris longus tendon
- palmar cutaneous branch of median nerve
 Structures passing deep to it ( medial to lateral),
 - flexor digitorum superficialis & flexor digitorum profundus tendons
(posteriorly).
- Median nerve
- Flexor pollicis longus tendon,
- Flexor carpi radialis tendon.

March 2007

Pulp space
 In the hand, tips of the fingers and thumb contain subcutaneous fat.
 This fat is divided into tight compartments formed by fibrous septa.
 These are called pulp spaces.
 Fibrous septa pass from the skin down to the periosteum of terminal phalanx.
 Infection of this space is known as “whitlow”.
 As fibrous septa tightly bind these compartments, there is little space for expansion of
inflamed and oedematous tissue, thus causing severe pain.
 Blood vessels to the shaft of the distal phalanx transverse this space.
 Therefore can be thrombosed in severe pulp infection resulting less blood supply to the
distal phalanx.
 This can lead to necrosis of diaphysis of the bone.
 Base of the distal phalanx receive blood supply more proximally (branch of digital artery
in middle segement of finger.) and therefore survives.
 At each of skin crease skin is tightly bound to flexor sheath.
 So pulp over each phalanx is in a separate compartment.
 Infections may track from one space to another along neurovascular digital bundle.

*Diagram: Ellis 9th edition - Figure 145 page 216

Avascular necrosis of schapoid

 Fracture of the schapoid is quite common.
 Normally schapoid has two nutrient arteries.
- One enters from the palmer surface of the tubercle.
- One enters from dorsal surface of the body.
 Bone fractures through the waist at right angles to its long axis.
 Fracture is caused by fall on the outstretched hand or on the tips of the fingers.
 This may lead to non union & avascular necrosis of the body of the bone.
 Occasionally, both vessels enter through the tubercle or through the distal half of the
bone.
  In such cases the distal fragment may lose its blood supply.
 This leads to avascular necrosis of that segment of the Schapoid.

*Diagram: Ellis 9th edition - Figure 127 page 189

5.2)

5.2.1)
Lateral wall: Scaphoid – proximally
Trapezium – distally
Medial Wall : Triquetral and pisiform –proximally
Hamate – distally
Floor : Lunate – proximally
Trapezoid and capitate – distally
Roof : Flexor retinaculum

5.2.2)
Tendons
- Flexor digitorum superficialis tendons and deep to them tendons of flexor digitorum
profundus in their synovial sheath (ulnar bursa)
- Flexor carpi radialis tendon in the radial bursa
- Flexor pollicis longus tendon
Nerves
- Median nerve

5.2.3)
* Refer Question 3.2 – November 2006

March 2008

2.1
Abduction
 Is initiated by supraspinatus.
 Abducts up to 150.
 Supplied by suprascapular nerve, which is a branch of upper trunk of the brachial plexus.
 Then lateral fibers of the Deltoid abducts up to 900.
 It is supplied by the axillary nerve, a branch of the posterior cord of brachial plexus.
 Overhead abduction is by trapezius and serratus anterior.
  Trapezius is supplied by spinal root of accessory nerve and Cervical nerves C3, C4.
 Serratus anterior is supplied by the long thoracic nerve.
 A branch of the roots C5, C6, C7 of brachial plexus.
 Abduction of arm is associated with rotation scapula and reciprocal movement of
sternoclavicular joint.

Internal rotation
 Is mainly by pectoralis major muscle.
 Supplied by medial pectoral nerve and lateral pectoral nerve.
 These are branches of medial and lateral cords of brachial plexus respectively.
 Another internal rotator is latissimus dorsi.
 Supplied by thoracodorsal nerve, a branch of the posterior cord of brachial plexus.
 Medial fibers of the deltoid
 Supplied by the Axillary nerve.
 Subscapularis muscle.
 Supplied by upper and lower subscapular nerves, which are branches of the posterior cord
of the brachial plexus.
 Teres major muscle
 Supplied by the lower subscapular nerve.

2.2
 Bursae are fluid filled synovial sacs.
 They reduce the friction when muscles move against bony surfaces.

Subscapular bursa
 Sunscapularis is a rotator cuff muscle.
 It origins from the subscapular fossa of the scapula.
 Its tendon is attached to the lesser tubercle of humerus.
 Tendon is lined by the synovial membrane of the joint, forming a bursa behind it; the
subscapular bursa.
 The joint capsule of the shoulder joint contains an aperture for this bursa.
Subacromian bursa
 Is formed by the joint synovial membrane encapsulating the tendon of the supraspinatus
muscle.
 Supraspinatus is insterted on to the greater tubercle.
 Subacromian bursa passes deep to the deltoid muscle
 And continue as the subdeltoid bursa.
 These two together form the longest bursa of the body.
  Inflammation of these bursae can lead to bursitis, causing severe pain.

2.3

1. Axillary nerve 2. Posterior humeral circumflex artery.

2.4

Bony contour
 Humeral head – 1/3 of a sphere. Covered with hyaline cartilage
 Glenoid cavity of the scapula
 Glenoid labrum (fibrocartilaginous ring deepening the glenoid cavity)

Muscles
Rotator cuff muscles: Long muscles
 Supraspinatus - Tendon of long head of biceps
 Infraspinatus - Tendon of long head of triceps
 Teres minor - More distally, the Deltoid
 Subscapularis

Ligaments
 Joint capsule – Lacks inferiorly
 Three glenohumeral ligaments
 Transverse humeral ligament
 Coracohumeral ligament
 Coracoclavicular ligament, Coracoacromian ligament – Accessory ligaments.

Synovial sheath.
 Synovial membrane lining the joint capsule
 Bursae
 Subacromial (subdeltoid) bursa
 Subscapularis bursa
 Infraspinatus bursa.
 Several other bursa related to the coracobrachialis, teres major, long head of the
triceps, latissimus dorsi, and the coracoid process.

January 2009

2.1
2.1.1. Chaurasia - 5th edition figure 8.20 page 96

2.2.2
Skin
Superficial fascia
Deep fascia
Triceps : Medial head
Lateral head
Long head
Radial nerve
Radial collateral vessels
Ulnar nerve
Superior ulnar collateral vessels

2.2.3
 Extensor muscles are supplied by the radial nerve.
 It is the main branch of the posterior cord.
 Root values C5, C6, C7, C8, T1
 In the axilla, it lies 1st behind the axillary artery.
 Then it passes backwards between the long and medial heads of triceps to lie in the spiral
groove.
 Spiral groove is bounded superiorly by the lateral head of triceps and inferiorly by the
medial head of the triceps.
 Profunda brachii artery accompanies the radial nerve in the spiral groove.
 At lower 1/3 of the humerus, radial nerve pierces the lateral intramuscular septum and
enters into the anterior compartment of the arm between brachialis and brachioradialis.
 At the level of the lateral epicondyle, it gives the posterior interosseous nerve.
 It winds around the radius within the supinator muscle.
 And goes into the posterior compartment of forearm.
 Supply the extensor muscles of forearm together with supinator and abductor pollicis
longus.
 Then the radial nerve continues as the superficial radial nerve.
 It lies deep to the brachioradialis.
 Above the wrist, nerve passes posteriorly beneath the tendon of brachioradialis.
 Gives cutaneous supply to posterior aspect of lateral 31/2 fingers.
 Main trunk of radial nerve innervates triceps, anconeus, brachioradialis &extensor carpi
radialis longus.
 Also it gives supply to brachialis.
  Due to the gun shot injury, the radial nerve lies in the posterior compartment of arm get
damaged.
 So the extensors get paralyzed due to impaired nerve supply.
 Wrist drop and weakness of extension occurs.

2.2

2.2.1
 Shoulder joint has a wide range of mobility.
 This is due to the laxity of the fibrous capsule disproportionate size of the articular
surfaces of the joint. (size of the glenoid fossa : head of the humerus is 1:4)
 Range of movement is increased by the movements of the shoulder girdle.
 There is a wide range of movements
- Flexion, extension, Abduction, Adduction, circumduction.
During flexion
- arm moves forwards and medially.
- Done by clavicular head of the pectoralis major, anterior fibers of the deltoid.
- Assisted by coracobrachialis and short head of biceps.
During extension
- Arm moves backward and laterally.
- Main muscles: Posterior fibers of deltoid, latissimus dorsi
- Assisted by Teres major, long head of triceps, Sternocostal head of pec. Major
During abduction and adduction
- Takes place at right angle to the plain of flexion and extension.
- In abduction
- Initiated by : * Suprapinatus → 0 - 150
* Deltoid → 15 - 900
* Serratus anterior and trapezius → Overhead abduction
Rotation of scapula also helps in this.
- In adduction
Main muscles : Pec. Major, Latissimus dorsi, Short head of biceps, long head
of biceps
Assisted by : Teres major, coracobrachialis
 During medial rotation and lateral rotation are best seen with mid flexed elbow
Medial rotation : Head moves medially
- Mainly by: pec. Major, anterior fibers of deltoid, latissimus dorsi, teres minor
- Assisted by : Subscapularis
Lateral rotation: Head moves laterally
- Mainly by : Posterior fibers of deltoid, teres minor, infraspinatus.
2.2.2
* Refer the answer to Question 2.4 – March 2008

May 2010

4.1.
 Supracondylar fracture occurs when the subject falls on the outstretched hand with the
elbow partially flexed.
 Several neurovascular structures can be damaged.
- Ulnar nerve – medially
- Median nerve – medially
- Radial nerve – Laterally
- Brachial artery – Anteriorly
 Brachial artery can be damaged either by
- The proximal bony fragment.
- Swelling of the soft tissue around the site of fracture.
 This leads to spasm of local segment of the brachial artery.
 Reduces blood supply to both flexor and extensor compartments of the forearm.
 This result in ischemia and subsequent fibrosis of both compartments and causes
contraction.
 This is Volkman’s contracture.
 Flexor group is bulkier than the extensor group.
 So its contraction is greater so the wrist therefore is flexed.
 The tendons of the long extensors of the fingers (extensor digitorum longus and brevis
muscle) insert into the proximal phalanges.
 Therefore, their contraction leads to extension of the metacarpophalangeal joint.
 The tendons of the long flexors of the fingers (flexor digitorum supreficialis and flexor
digitorum profundus) are attached to the middle finger.
 Therefore, interphalangeal joints are flexed.
 Flexed wrist, flexed interphalangeal joints and extended metacarpophalangeal joints
cause the contracture deformity of the hand.
 Another possibility to cause the pressure on the brachial artery is the over tight cast of
this patient.