Upper Limb Practice Questions

Q: A patient presents with winging of the scapula, noticed when pushing against a wall. The nerve responsible for this condition arises from which part of the brachial plexus?

Root. ***Root*** - **Winging of the scapula** is caused by **long thoracic nerve palsy**, which paralyzes the **serratus anterior muscle**. - The **long thoracic nerve** arises directly from the **roots C5, C6, and C7** of the brachial plexus, making this the correct answer. *Trunk* - Nerves arising from trunks include the **suprascapular nerve** and **nerve to subclavius**. - These nerves do not innervate the **serratus anterior muscle** responsible for preventing scapular winging. *Division* - The **divisions** of the brachial plexus are primarily organizational structures that separate into **anterior and posterior** components. - No major nerves arise directly from the divisions that would cause scapular winging when damaged. *Cord* - Nerves from cords include the **median nerve** (lateral and medial cords), **ulnar nerve** (medial cord), and **radial nerve** (posterior cord). - These nerves primarily innervate **forearm and hand muscles**, not the serratus anterior muscle.

Q: Which muscle causes adduction of the wrist joint?

Flexor carpi ulnaris. **Explanation:** The movement of the wrist joint (radiocarpal joint) occurs along two axes: flexion/extension and abduction/adduction. **Adduction (ulnar deviation)** is primarily performed by the simultaneous contraction of muscles on the medial (ulnar) aspect of the forearm. **Why Flexor Carpi Ulnaris (FCU) is correct:** The FCU is the most medial muscle of the superficial flexor compartment. It inserts into the pisiform, hook of hamate, and the base of the 5th metacarpal [1]. Due to its medial position relative to the axis of the wrist, its contraction pulls the hand toward the midline (ulnar side). It works in synergy with the **Extensor Carpi Ulnaris (ECU)** to produce pure adduction. **Analysis of Incorrect Options:** * **A. Flexor carpi radialis:** This muscle is located on the lateral side of the forearm. Its contraction results in **abduction (radial deviation)** and flexion of the wrist. * **C. Flexor pollicis longus:** This is a deep muscle primarily responsible for flexing the interphalangeal joint of the thumb [1]. While it may weakly assist in wrist flexion, it does not contribute to adduction. * **D. Flexor digitorum profundus:** This muscle primarily flexes the distal interphalangeal (DIP) joints of the fingers and the wrist as a whole, but it does not have a specific vector for ulnar deviation [1]. **High-Yield Clinical Pearls for NEET-PG:** * **Synergy:** Pure adduction requires the co-contraction of FCU (flexor) and ECU (extensor) to cancel out their respective flexion/extension components. * **Nerve Supply:** FCU is a notable exception in the flexor compartment as it is supplied by the **Ulnar Nerve (C8, T1)**, not the Median Nerve. * **Range of Motion:** Adduction (approx. 45°) has a greater range than abduction (approx. 15°) because the radial styloid process extends further distally than the ulnar styloid, limiting lateral movement.

Q: Which of the following muscles is enclosed within the clavipectoral fascia?

Subclavius. **Explanation:** The **clavipectoral fascia** is a strong fascial sheet situated deep to the pectoralis major muscle. It extends vertically from the clavicle above to the axillary fascia below. Its anatomical arrangement is a high-yield topic for NEET-PG due to the specific structures it encloses and those that pierce it. **1. Why Subclavius is Correct:** As the clavipectoral fascia descends from the clavicle, it splits into two layers to enclose the **subclavius** muscle. These layers then fuse to form a single sheet (the costocoracoid membrane) before splitting again to enclose the **pectoralis minor** muscle. Therefore, both the subclavius and pectoralis minor are the only two muscles contained within this fascia. **2. Why Other Options are Incorrect:** * **Pectoralis major:** This muscle lies superficial to the clavipectoral fascia [1]. It is enclosed by its own dedicated pectoral fascia. * **Serratus anterior:** This muscle forms the medial wall of the axilla and is covered by the serratus fascia, not the clavipectoral fascia. * **Coracobrachialis:** This muscle is located in the arm (originating from the coracoid process) and is not enclosed by this fascia, though the fascia attaches to the coracoid process nearby. **3. High-Yield Clinical Pearls:** * **Structures piercing the fascia:** Remember the mnemonic **"CALL"** or **"LACS"**: 1. **L**ateral pectoral nerve 2. **A**cro-thoracic artery (Thoracoacromial artery) 3. **C**ephalic vein 4. **L**ymphatics (from the breast to apical axillary nodes) * **Suspensory ligament of axilla:** The part of the fascia extending from the pectoralis minor to the axillary fascia is called the suspensory ligament; it maintains the characteristic concavity of the armpit.

Q: All of the following muscles of the shoulder girdle assist in abduction of the upper limb, EXCEPT:

Latissimus dorsi. **Explanation:** Abduction of the shoulder is a complex movement involving multiple muscles acting in a coordinated sequence. The correct answer is **Latissimus dorsi** because it is a powerful **adductor**, extensor, and medial rotator of the humerus—actions diametrically opposed to abduction. **Analysis of Options:** * **Latissimus dorsi (Correct):** Known as the "Climber's muscle," it pulls the trunk toward the arms. Because its insertion is on the floor of the bicipital groove (anterior humerus), its contraction brings the arm toward the midline (adduction). * **Deltoid:** The multipennate middle fibers are the primary abductors of the arm from 15° to 90°. * **Supraspinatus:** This rotator cuff muscle initiates the first 0–15° of abduction. It also stabilizes the humeral head in the glenoid cavity, providing a fulcrum for the deltoid. * **Long head of biceps brachii:** While primarily a flexor of the elbow and supinator, its tendon passes over the head of the humerus. When the arm is laterally rotated, it acts as a weak accessory abductor and helps stabilize the glenohumeral joint. **NEET-PG High-Yield Pearls:** 1. **The Abduction Sequence:** * 0–15°: Supraspinatus (Suprascapular nerve). * 15–90°: Deltoid (Axillary nerve). * >90° (Overhead): Serratus anterior and Trapezius (Scapular rotation). 2. **The "Lady between two Majors":** Latissimus dorsi inserts into the bicipital groove between the Pectoralis major (lateral lip) and Teres major (medial lip). All three are adductors. 3. **Clinical Correlation:** In a Supraspinatus tear, the patient cannot initiate abduction and may lean toward the affected side to use gravity to "jumpstart" the deltoid's range.

Q: What is the deformity caused by the involvement of the 1st and 2nd lumbrical muscles called?

Median claw hand. ### Explanation **1. Why Median Claw Hand is Correct:** The **1st and 2nd lumbricals** are innervated by the **Median nerve** [1]. The physiological role of lumbricals is to flex the metacarpophalangeal (MCP) joints and extend the interphalangeal (IP) joints ("L-shaped" position). When these muscles are paralyzed (typically due to a distal median nerve lesion), the antagonistic muscles take over, resulting in the opposite posture: **hyperextension at the MCP joints and flexion at the IP joints** of the index and middle fingers. This specific deformity is known as the **Median claw hand**. **2. Analysis of Incorrect Options:** * **A. Ulnar claw hand:** Caused by paralysis of the **3rd and 4th lumbricals** (and all interossei) due to ulnar nerve injury [1]. It affects the ring and little fingers. * **C. Total claw hand:** Occurs when there is a combined lesion of both the **Median and Ulnar nerves** (or a Klumpke’s paralysis/C8-T1 injury), leading to clawing of all four fingers. * **D. Pointing finger (Ochsner’s clasping test):** This occurs in **proximal** median nerve injuries. When the patient attempts to make a fist, the index and middle fingers remain extended due to loss of the Long Flexors (FDS and lateral half of FDP), not just the lumbricals. **3. Clinical Pearls for NEET-PG:** * **Lumbrical Innervation:** Remember the **"12-23" rule**: 1st and 2nd lumbricals = Median nerve; 3rd and 4th lumbricals = Ulnar nerve [1]. * **The Paradox:** Clawing is more prominent in **distal** lesions (at the wrist) than proximal lesions because the long flexors (FDP) remain intact and pull the IP joints into deeper flexion. * **Ape Thumb Deformity:** Also caused by median nerve injury, specifically due to paralysis of the *Abductor Pollicis Breis*, leading to loss of thumb opposition [1].

Q: A 13-year-old boy is brought to the emergency department after losing control during a motorbike race in which he was run over by several of the other racers. Physical examination reveals several cuts and bruises. He is unable to extend the left wrist, fingers, and thumb, although he can extend the elbow. Sensation is lost in the lateral half of the dorsum of the left hand. Which of the following nerves has most likely been injured, and in what part of the arm is the injury located?

Radial nerve, midhumerus. ### Explanation **1. Why the Correct Answer is Right:** The clinical presentation describes **Wrist Drop** (inability to extend the wrist, fingers, and thumb) with preserved elbow extension. This indicates an injury to the **Radial Nerve** distal to the origin of the branches to the Triceps brachii. [1] The radial nerve enters the **spiral groove** of the humerus (midshaft), where it is highly vulnerable to fractures or direct trauma. [2] At this level, the branches to the long and medial heads of the triceps have already departed (preserving elbow extension), but the branches to the brachioradialis, extensor carpi radialis longus, and the posterior interosseous nerve (which supplies the finger/thumb extensors) are affected. [1] The sensory loss in the **lateral half of the dorsum of the hand** (first dorsal web space) confirms radial nerve involvement. **2. Why the Other Options are Wrong:** * **Options A & B (Median Nerve):** Median nerve injury typically presents with "Ape Hand" deformity, loss of thumb opposition, and sensory loss on the palmar aspect of the lateral 3.5 digits. It does not control wrist or finger extension. [1] * **Option D (Ulnar Nerve):** Ulnar nerve injury leads to "Claw Hand" (at the wrist) and sensory loss on the medial 1.5 digits. It does not cause wrist drop. [1] **3. Clinical Pearls for NEET-PG:** * **High-Yield Rule:** The higher the radial nerve lesion, the more "drop" you see. * **Axilla:** Loss of elbow extension + Wrist drop. * **Spiral Groove (Midhumerus):** Normal elbow extension + Wrist drop + Sensory loss. * **Posterior Interosseous Nerve (PIN):** Finger drop ONLY; **No** sensory loss and **No** true wrist drop (ECRL is spared). * **Saturday Night Palsy:** Compression of the radial nerve in the spiral groove, presenting identically to this case. * **Holstein-Lewis Fracture:** A fracture of the distal third of the humerus resulting in radial nerve palsy. [2]

Q: At what age does the radial head ossify?

4 years. The ossification of the elbow joint is a high-yield topic for NEET-PG, typically remembered using the mnemonic CRITOE, which represents the chronological order of appearance of the secondary ossification centers. 1. Capitellum: 1 year 2. Radial Head: 4 years (Correct Answer) 3. Internal (Medial) Epicondyle: 5–6 years 4. Trochlea: 9–10 years 5. Olecranon: 10 years 6. External (Lateral) Epicondyle: 11–12 years Why Option B is correct: The secondary ossification center for the head of the radius typically appears at 4 years of age (range 3–5 years). It eventually fuses with the shaft of the radius at puberty (approximately 15–17 years). Analysis of Incorrect Options: * Option A (2 years): At this age, only the capitellum is usually visible. The radial head has not yet begun to ossify. * Option C (6 years): By age 6, the medial epicondyle has usually appeared. While the radial head is visible on X-ray by this time, it first appears earlier, at age 4. * Option D (10 years): This age corresponds to the appearance of the trochlea and the olecranon process. Clinical Pearls for NEET-PG: * CRITOE Mnemonic: Always remember the sequence 1-3-5-7-9-11 (approximate ages in years) to identify elbow ossification centers on pediatric X-rays. * Pulled Elbow (Nursemaid’s Elbow): This involves subluxation of the radial head through the annular ligament, common in children aged 1–4 years (before the radial head is fully formed and ossified). * Fracture Identification: Knowledge of these ages is crucial to avoid mistaking a normal ossification center for an avulsion fracture in pediatric trauma cases.

Q: A teenager is struck on the back of her carpals by a sharp-edged flying wedge while watching her boyfriend split wood. Her extensor digitorum tendons are exposed, though not severed, indicating that the surrounding synovial sheath has been opened. What other muscle has its tendon surrounded by the same synovial sheath?

Extensor indicis. ### Explanation The key to solving this question lies in understanding the **Extensor Compartments of the Wrist**. The extensor tendons pass deep to the extensor retinaculum, where they are organized into six distinct osteofascial compartments, each lined by a synovial sheath to reduce friction. **The Correct Answer: D. Extensor indicis** The **fourth compartment** of the wrist contains five tendons: the four tendons of the **Extensor Digitorum (ED)** and the single tendon of the **Extensor Indicis (EI)**. Because they share the same anatomical space and are enclosed within a single, common synovial sheath, an injury that opens the sheath of the extensor digitorum will inherently involve the sheath of the extensor indicis. **Analysis of Incorrect Options:** * **A & B (ECRB and ECRL):** These tendons are located in the **second compartment** [1]. They have their own separate synovial sheath and are separated from the fourth compartment by the dorsal tubercle of the radius (Lister’s tubercle). * **C (Extensor digiti minimi):** This tendon is located in the **fifth compartment**, situated just superficial to the distal radioulnar joint. It possesses its own independent synovial sheath. **NEET-PG High-Yield Pearls:** * **Compartment 1:** Abductor pollicis longus & Extensor pollicis brevis (Involved in De Quervain’s Tenosynovitis) [1]. * **Compartment 2:** ECRL & ECRB [1]. * **Compartment 3:** Extensor pollicis longus (Loops around Lister’s tubercle). * **Compartment 4:** ED & EI (Shared sheath). * **Compartment 5:** Extensor digiti minimi. * **Compartment 6:** Extensor carpi ulnaris. * **Mnemonic:** "2-2-1-5-1-1" (Number of tendons in compartments 1 through 6).

Question 1

A patient presents with winging of the scapula, noticed when pushing against a wall. The nerve responsible for this condition arises from which part of the brachial plexus?

Accepted Answer

Root

Answer

Trunk

Answer

Division

Answer

Cord

Question 2

Which muscle causes adduction of the wrist joint?

Accepted Answer

Flexor carpi ulnaris

Answer

Flexor carpi radialis

Answer

Flexor pollicis longus

Answer

Flexor digitorum profundus

Question 3

Which of the following muscles is enclosed within the clavipectoral fascia?

Accepted Answer

Subclavius

Answer

Pectoralis major

Answer

Serratus anterior

Answer

Coracobrachialis

Question 4

A 48-year-old female piano player presented with numbness and tingling in her left hand. She was diagnosed with carpal tunnel syndrome and underwent an endoscopic nerve release. Two weeks postoperatively, she developed profound weakness in her thumb with loss of thumb opposition. Sensation to the hand was unaffected. Which of the following nerves was injured during the operation?

Accepted Answer

Recurrent branch of median nerve

Answer

The first common digital branch of the median nerve

Answer

The second common digital branch of the median nerve

Answer

Deep branch of the ulnar nerve

Question 5

All of the following muscles of the shoulder girdle assist in abduction of the upper limb, EXCEPT:

Accepted Answer

Latissimus dorsi

Answer

Deltoid

Answer

Supraspinatus

Answer

Long head of biceps brachii

Question 6

What is the deformity caused by the involvement of the 1st and 2nd lumbrical muscles called?

Accepted Answer

Median claw hand

Answer

Ulnar claw hand

Answer

Total claw hand

Answer

Pointing finger

Question 7

A 13-year-old boy is brought to the emergency department after losing control during a motorbike race in which he was run over by several of the other racers. Physical examination reveals several cuts and bruises. He is unable to extend the left wrist, fingers, and thumb, although he can extend the elbow. Sensation is lost in the lateral half of the dorsum of the left hand. Which of the following nerves has most likely been injured, and in what part of the arm is the injury located?

Accepted Answer

Radial nerve, midhumerus

Answer

Median nerve, anterior wrist

Answer

Median nerve, arm

Answer

Ulnar nerve, midlateral forearm

Question 8

Which of the following is NOT a feature of anterior interosseous nerve (AIN) syndrome?

Accepted Answer

There is sensory loss on the medial 2 fingers.

Answer

Inability to perform OK-sign (approximate thumb and tip of index finger).

Answer

AIN is entrapped under pronator teres, flexor digitorum profundus, and flexor carpi radialis.

Answer

Conservative treatment is generally preferred, with surgery rarely indicated.

Question 9

At what age does the radial head ossify?

Accepted Answer

4 years

Answer

2 years

Answer

6 years

Answer

10 years

Question 10

A teenager is struck on the back of her carpals by a sharp-edged flying wedge while watching her boyfriend split wood. Her extensor digitorum tendons are exposed, though not severed, indicating that the surrounding synovial sheath has been opened. What other muscle has its tendon surrounded by the same synovial sheath?

Accepted Answer

Extensor indicis

Answer

Extensor carpi radialis brevis

Answer

Extensor carpi radialis longus

Answer

Extensor digiti minimi

Upper Limb — MCQs

Upper Limb — MCQs

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