Upper Limb Practice Questions

Q: A 45-year-old woman presents with neck pain. An MRI reveals a herniated disk in the cervical region. Physical examination demonstrates weakness in wrist extension and paresthesia on the back of her arm and forearm. Which of the following spinal nerves is most likely injured?

C7. ### Explanation The patient presents with symptoms characteristic of **C7 radiculopathy**, which is the most common cervical disc herniation. [1] **1. Why C7 is Correct:** * **Motor Deficit:** The C7 nerve root supplies the **Triceps** (elbow extension) and the **Extensors of the wrist**. Weakness in wrist extension (specifically via the extensor carpi radialis brevis and extensor digitorum) is a classic sign of C7 involvement. * **Sensory Deficit:** The C7 dermatome covers the **middle finger** and the **posterior aspect of the arm and forearm**. Paresthesia in these regions strongly points toward C7. * **Reflex:** Although not mentioned, a diminished **triceps reflex** would further confirm C7 injury. **2. Why Other Options are Incorrect:** * **C5:** Injury typically results in weakness of shoulder abduction (Deltoid) and elbow flexion (Biceps). The sensory loss occurs over the lateral aspect of the upper arm (regimental badge area). * **C6:** This nerve root controls elbow flexion (Biceps) and wrist extension (Extensor carpi radialis longus). While C6 also involves wrist extension, the sensory loss is localized to the **lateral forearm and thumb**, not the back of the arm/forearm. * **C8:** Injury leads to weakness in **finger flexors** (grip strength) and intrinsic hand muscles. Sensory loss occurs on the medial side of the hand and the little finger. **3. Clinical Pearls for NEET-PG:** * **Rule of N+1:** In the cervical spine, the nerve root exits **above** the numerically corresponding vertebra (e.g., the C7 nerve exits between C6 and C7). Therefore, a C6-C7 disc herniation compresses the **C7 nerve root**. * **Most Common Site:** C6-C7 (affecting C7) is the most frequent site of cervical disc prolapse, followed by C5-C6 (affecting C6). [1] * **Key Landmark:** C7 sensory distribution is the "Middle Finger." Remember: **C6 (Thumb), C7 (Middle), C8 (Pinky).**

Q: The capitate bone articulates with all of the following EXCEPT:

Trapezium. The **capitate** is the largest carpal bone and occupies a central position in the wrist. To answer this question, one must visualize the carpal rows and the specific articulations of the capitate. ### **Explanation of the Correct Answer** **C. Trapezium:** The capitate does **not** articulate with the trapezium. The trapezium is located in the distal carpal row on the most lateral (radial) side. It articulates with the scaphoid proximally, the trapezoid medially, and the 1st and 2nd metacarpals distally. The capitate is separated from the trapezium by the **trapezoid** bone. ### **Analysis of Incorrect Options** * **A. Second Metacarpal:** The capitate has a large distal surface that articulates primarily with the **3rd metacarpal**, but it also has small facets for the **2nd and 4th metacarpals**. * **B. Lunate:** The rounded "head" of the capitate fits into the concavity formed by the lunate and scaphoid. The lunate sits directly proximal to the capitate. * **D. Scaphoid:** The capitate articulates with the scaphoid on its lateral (radial) aspect, specifically at the proximal-lateral quadrant of the capitate's head. ### **High-Yield NEET-PG Pearls** * **Articulations:** The capitate articulates with **7 bones**: Scaphoid, Lunate (proximal); Hamate (medial); Trapezoid (lateral); and 2nd, 3rd, and 4th Metacarpals (distal). * **Center of Rotation:** The capitate is considered the center of the wrist's movements; the axis for radial/ulnar deviation and flexion/extension passes through its head. * **Ossification:** The capitate is the **first** carpal bone to ossify (usually by 1–3 months of age). * **Clinical:** In perilunate dislocations, the capitate is typically displaced posteriorly relative to the lunate.

Q: Compression of a nerve within the carpal tunnel produces inability to?

Oppose the thumb. **Explanation:** The **Median Nerve** is the structure compressed in **Carpal Tunnel Syndrome (CTS)** [1]. After passing through the carpal tunnel, it gives off a **recurrent branch** (the "million-dollar nerve") that supplies the muscles of the **thenar eminence**. **1. Why "Oppose the thumb" is correct:** The thenar muscles include the *Abductor Pollicis Brevis*, *Flexor Pollicis Brevis*, and **Opponens Pollicis**. Opposition is a complex movement initiated by the Opponens Pollicis. In CTS, denervation of this muscle leads to an inability to touch the tip of the thumb to the tips of the other fingers. **2. Why the other options are incorrect:** * **A. Abduct the thumb:** While the *Abductor Pollicis Brevis* (Median nerve) is affected, thumb abduction is also performed by the *Abductor Pollicis Longus*, which is supplied by the **Posterior Interosseous Nerve** (Radial nerve). Thus, abduction is weakened but not completely lost. * **B. Adduct the thumb:** This is performed by the *Adductor Pollicis*, which is supplied by the **Deep branch of the Ulnar Nerve**. It remains functional in CTS. * **C. Flex the distal phalanx:** This is the function of the *Flexor Pollicis Longus*. This muscle is supplied by the **Anterior Interosseous Nerve** in the forearm, *before* the median nerve enters the carpal tunnel [1]. **High-Yield Clinical Pearls for NEET-PG:** * **Ape Thumb Deformity:** Long-standing CTS leads to thenar atrophy, causing the thumb to fall into the same plane as the fingers. * **Sensory Sparing:** The **Palmar Cutaneous Branch** of the median nerve arises proximal to the carpal tunnel; therefore, sensation over the central palm is **preserved** in CTS [1]. * **Tests:** Phalen’s test and Tinel’s sign are classic clinical provocations for diagnosis.

Q: Identify the ligament:

Coraco-acromial ligament. ***Coraco-acromial ligament*** - Forms the **coraco-acromial arch** by connecting the **coracoid process** of the scapula to the **acromion**, creating a protective roof over the humeral head. - Clinically important in **shoulder impingement syndrome** as it can compress the **supraspinatus tendon** and **subacromial bursa** during overhead movements. *Acromio-clavicular ligament* - Connects the **lateral end of the clavicle** to the **acromion process** of the scapula, stabilizing the AC joint. - Does not form an arch structure and is located more laterally than the coraco-acromial ligament. *Coraco-humeral ligament* - Extends from the **coracoid process** of the scapula to the **greater tubercle** of the humerus, strengthening the shoulder joint capsule. - Functions to limit **external rotation** and **inferior translation** of the humeral head, not forming a protective arch. *Sterno-clavicular ligament* - Reinforces the **sternoclavicular joint** by connecting the **sternum** to the **medial end of the clavicle**. - Located at the **medial aspect** of the shoulder girdle, far from the subacromial space and coraco-acromial arch.

Q: Which of the following statements best describes the pectoral girdle and shoulder?

The clavicle starts ossifying in the fetus.. **Explanation:** **1. Why Option A is Correct:** The clavicle is a unique bone in the human body. It is the **first bone to begin ossification** in the fetus (around the 5th to 6th week of intrauterine life). Notably, it is the only long bone that undergoes **intramembranous ossification**, although its ends later ossify via endochondral ossification. **2. Why the Other Options are Incorrect:** * **Option B:** The clavicle most commonly fractures at the **junction of the lateral one-third and medial two-thirds**. This is the weakest point of the bone because it is where the curvature changes and the cross-section transitions from cylindrical to flattened. * **Option C:** The **subscapularis bursa** (located between the subscapularis tendon and the neck of the scapula) **always communicates** with the synovial cavity of the shoulder joint. This serves to reduce friction during rotation. * **Option D:** Under normal anatomical conditions, the **subacromial bursa does not communicate** with the shoulder joint capsule. They are separated by the rotator cuff tendons (specifically the supraspinatus). Communication between the two is a clinical sign of a full-thickness rotator cuff tear. **Clinical Pearls for NEET-PG:** * **Clavicle:** It is the only long bone held horizontally and the only one with no medullary cavity. * **Shoulder Joint:** It is the most mobile joint in the body but also the most frequently dislocated (usually in an anterior-inferior direction). * **Rotator Cuff (SITS):** Supraspinatus, Infraspinatus, Teres minor, and Subscapularis. The Supraspinatus is the most commonly injured muscle in this group.

Q: Which tendon is absent in the palm?

Extensor pollicis brevis. **Explanation:** The correct answer is **Extensor pollicis brevis (EPB)**. To answer this question, one must distinguish between the muscles of the anterior (flexor) compartment and the posterior (extensor) compartment of the forearm and hand. **1. Why Extensor Pollicis Brevis is the Correct Answer:** The EPB is a muscle of the **posterior compartment** of the forearm [1]. Its tendon passes through the first dorsal compartment of the extensor retinaculum and inserts onto the **dorsal surface** of the base of the proximal phalanx of the thumb [1]. Because it is an extensor, its course is entirely restricted to the dorsal aspect of the wrist and hand; it never enters the palmar (volar) surface. **2. Analysis of Incorrect Options:** * **Flexor digitorum superficialis (FDS) & Flexor digitorum profundus (FDP):** These are long flexor tendons that originate in the forearm, pass through the carpal tunnel, and traverse the **palm** to reach the fingers [2]. * **Opponens pollicis:** This is an intrinsic muscle of the hand located specifically in the **thenar eminence (palm)** [2]. It originates from the flexor retinaculum and inserts into the lateral border of the first metacarpal. **3. High-Yield Clinical Pearls for NEET-PG:** * **Anatomical Snuffbox:** The EPB forms the anterior (radial) boundary of the snuffbox, along with the Abductor pollicis longus (APL) [1]. * **De Quervain’s Tenosynovitis:** This clinical condition involves inflammation of the tendons in the first dorsal compartment (EPB and APL) [1]. It is tested using **Finkelstein’s test**. * **The "Outcroppers":** EPB, APL, and Extensor pollicis longus are known as the "outcropping" muscles of the deep posterior forearm. * **Rule of Thumb:** All "Flexor" tendons and "Opponens" muscles are found on the palmar side, while "Extensor" tendons are found on the dorsal side.

Q: A 69-year-old man has numbness in the middle three digits of his right hand and finds it difficult to grasp objects with that hand. He has atrophy of the thenar eminence. Which of the following conditions is the most likely cause of the problems in his hand?

Compression of the median nerve in the carpal tunnel. ### Explanation **1. Why the Correct Answer is Right:** The patient presents with the classic triad of **Carpal Tunnel Syndrome (CTS)**: sensory loss in the lateral 3.5 digits, motor weakness (difficulty grasping), and **thenar atrophy**. The **median nerve** passes through the carpal tunnel; its compression leads to paresthesia in its cutaneous distribution and denervation of the "LOAF" muscles (Lateral two lumbricals, Opponens pollicis, Abductor pollicis brevis, and Flexor pollicis brevis). [2] Thenar atrophy is a late sign indicating significant motor nerve damage. **2. Why the Incorrect Options are Wrong:** * **Options B & D (Ulnar Nerve):** Ulnar nerve injury (at the elbow or Guyon’s canal) would cause numbness in the medial 1.5 digits (pinky and half of ring finger) and atrophy of the **hypothenar eminence** and interossei (leading to a "claw hand"), which contradicts this patient's symptoms. * **Option C (Cervical Spondylosis):** While cervical radiculopathy (e.g., C6-C7) can cause hand numbness, it typically presents with neck pain, weakness in more proximal muscle groups (like triceps or wrist extensors), and diminished reflexes (e.g., triceps reflex), rather than isolated thenar atrophy. **3. NEET-PG High-Yield Pearls:** * **Contents of Carpal Tunnel:** Median nerve + 9 tendons (4 Flexor Digitorum Superficialis, 4 Flexor Digitorum Profundus, 1 Flexor Pollicis Longus). * **Sensory Sparing:** The **palmar cutaneous branch** of the median nerve arises *proximal* to the carpal tunnel; therefore, sensation over the central palm is usually **preserved** in CTS. [1] * **Clinical Tests:** **Phalen’s test** (forced flexion) and **Tinnel’s sign** (percussion over the retinaculum) are classic bedside maneuvers. * **Most Common Cause:** Idiopathic; however, associated with pregnancy, hypothyroidism, diabetes, and rheumatoid arthritis.

Q: Ulnar paradox is seen in which of the following conditions?

High ulnar nerve lesion. **Explanation:** The **Ulnar Paradox** refers to the clinical observation that a **High Ulnar Nerve Lesion** (at or above the elbow) results in a **less severe** claw hand deformity than a low lesion, despite the injury being more proximal. **1. Why Option A is Correct:** In a **Low Ulnar Nerve Lesion** (at the wrist), the Medial 2 Lumbricals are paralyzed, but the **Flexor Digitorum Profundus (FDP)** to the ring and little fingers remains intact (as it is supplied by the nerve in the forearm). The unopposed action of the intact FDP causes marked flexion at the Interphalangeal (IP) joints, making the "clawing" very prominent. In a **High Ulnar Nerve Lesion**, the FDP is also paralyzed. Since there is no long flexor force to pull the fingers into flexion, the clawing appears **milder**. The "paradox" is that a higher (worse) injury results in a better-looking hand. **2. Why Other Options are Incorrect:** * **Option B:** Low ulnar nerve lesions produce the most severe clawing (Main en Griffe). * **Option C & D:** Triple nerve or combined injuries result in complex deformities (like a "Total Claw Hand"), but they do not demonstrate the specific biomechanical trade-off between the FDP and lumbricals that defines the ulnar paradox. **Clinical Pearls for NEET-PG:** * **Claw Hand Mechanism:** Hyperextension at MCP joints (unopposed Extensor Digitorum) + Flexion at IP joints (paralyzed Lumbricals). * **Froment’s Sign:** Tests for Adductor Pollicis palsy (Ulnar nerve); patient compensates by flexing the thumb IP joint using the Median nerve (FPL). * **Mnemonic:** "The higher the lesion, the lesser the claw."

Q: A patient loses the ability to flex their forefinger. The nerve that supplies the muscles responsible for this action is formed from which of the following cord(s) of the brachial plexus?

Medial and lateral cords. The ability to flex the forefinger (index finger) is primarily mediated by the **Median Nerve** [1]. Specifically, the **Flexor Digitorum Profundus (FDP)** to the index finger and the **Flexor Digitorum Superficialis (FDS)** are responsible for flexion at the distal and proximal interphalangeal joints, respectively [1]. Both are innervated by the median nerve. The median nerve is formed by the union of two roots: 1. The **Lateral root**, which arises from the **Lateral cord** (C5, C6, C7). 2. The **Medial root**, which arises from the **Medial cord** (C8, T1). Therefore, the nerve responsible for this action is derived from both the medial and lateral cords. **Analysis of Incorrect Options:** * **A & C:** Neither the lateral nor the medial cord alone forms the median nerve. The lateral cord alone forms the Musculocutaneous nerve, while the medial cord alone forms the Ulnar nerve. * **D:** The posterior cord forms the Radial and Axillary nerves. While the radial nerve handles extension, it does not supply the primary flexors of the fingers. **High-Yield NEET-PG Pearls:** * **The "M" of the Brachial Plexus:** Formed by the Musculocutaneous, Median, and Ulnar nerves. * **Pointing Index (Benedict’s Sign):** When a patient with a median nerve injury attempts to make a fist, the index and middle fingers remain extended due to loss of FDS and the lateral half of FDP [1]. * **Anterior Interosseous Nerve (AIN):** A branch of the median nerve that supplies the FDP to the index finger. Damage to the AIN results in the inability to make the "OK" sign.

Question 1

A 45-year-old woman presents with neck pain. An MRI reveals a herniated disk in the cervical region. Physical examination demonstrates weakness in wrist extension and paresthesia on the back of her arm and forearm. Which of the following spinal nerves is most likely injured?

Accepted Answer

C7

Answer

C5

Answer

C6

Answer

C8

Question 2

The capitate bone articulates with all of the following EXCEPT:

Accepted Answer

Trapezium

Answer

Second metacarpal

Answer

Lunate

Answer

Scaphoid

Question 3

Compression of a nerve within the carpal tunnel produces inability to?

Accepted Answer

Oppose the thumb

Answer

Abduct the thumb

Answer

Adduct the thumb

Answer

Flex the distal phalanx of the thumb

Question 4

Identify the ligament:

Accepted Answer

Coraco-acromial ligament

Answer

Acromio-clavicular ligament

Answer

Coraco-humeral ligament

Answer

Sterno-clavicular ligament

Question 5

Which of the following statements best describes the pectoral girdle and shoulder?

Accepted Answer

The clavicle starts ossifying in the fetus.

Answer

The clavicle most commonly fractures at the junction of the medial and middle third.

Answer

The subscapularis bursa is separate from the capsule of the shoulder joint.

Answer

The capsule of the shoulder joint communicates with the subacromial bursa.

Question 6

Which tendon is absent in the palm?

Accepted Answer

Extensor pollicis brevis

Answer

Flexor digitorum superficialis

Answer

Flexor digitorum profundus

Answer

Opponens pollicis

Question 7

A 69-year-old man has numbness in the middle three digits of his right hand and finds it difficult to grasp objects with that hand. He has atrophy of the thenar eminence. Which of the following conditions is the most likely cause of the problems in his hand?

Accepted Answer

Compression of the median nerve in the carpal tunnel

Answer

Repeated trauma to the ulnar nerve

Answer

Osteoarthritis of the cervical spine

Answer

Formation of osteophytes that compress the ulnar nerve at the medial epicondyle

Question 8

Ulnar paradox is seen in which of the following conditions?

Accepted Answer

High ulnar nerve lesion

Answer

Low ulnar nerve lesion

Answer

Triple nerve injuries

Answer

Combined ulnar and median nerve injuries

Question 9

All of the following structures pass through the deltopectoral triangle, EXCEPT?

Accepted Answer

Axillary nerve

Answer

Cephalic vein

Answer

Deltopectoral lymph nodes

Answer

Branch of thoracoacromial artery

Question 10

A patient loses the ability to flex their forefinger. The nerve that supplies the muscles responsible for this action is formed from which of the following cord(s) of the brachial plexus?

Accepted Answer

Medial and lateral cords

Answer

Lateral cord only

Answer

Medial cord only

Answer

Medial and posterior cords

Upper Limb — MCQs

Upper Limb — MCQs

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