Upper Limb Practice Questions

Q: Postoperative examination revealed that the medial border and inferior angle of the left scapula became unusually prominent (projected posteriorly) when the arm was carried forward in the sagittal plane, especially if the patient pushed with outstretched arm against heavy resistance (e.g., a wall). What muscle must have been denervated during the axillary dissection?

Serratus anterior. The clinical presentation described is a classic case of **"Winging of the Scapula."** **1. Why Serratus Anterior is correct:** The **Serratus anterior** muscle originates from the upper eight ribs and inserts into the costal surface of the **medial border of the scapula**. Its primary functions are **protraction** (pulling the scapula forward) and keeping the medial border of the scapula closely applied to the thoracic wall. * **Mechanism:** During axillary dissection (e.g., for breast cancer surgery), the **Long Thoracic Nerve (of Bell)** is at risk [1]. Denervation of the serratus anterior causes the medial border and inferior angle of the scapula to pull away from the rib cage and project posteriorly, especially when the patient pushes against resistance (outstretched arm). **2. Why other options are incorrect:** * **Levator scapulae & Rhomboideus major:** These muscles are supplied by the **Dorsal Scapular Nerve**. While they assist in retracting and elevating the scapula, their paralysis does not cause prominent winging during protraction. * **Pectoralis major:** Supplied by the medial and lateral pectoral nerves, it is a powerful adductor and medial rotator of the humerus [1]. It does not stabilize the scapula against the posterior thoracic wall. **3. High-Yield Clinical Pearls for NEET-PG:** * **Nerve Involved:** Long Thoracic Nerve (Roots: **C5, C6, C7** – *"C5, 6, 7 raise your wings to heaven"*). * **Clinical Sign:** Inability to abduct the arm above 90 degrees (overhead abduction) because the serratus anterior is required for upward rotation of the glenoid cavity. * **Common Causes:** Axillary lymph node dissection, chest tube insertion, or heavy carrying on the shoulder (e.g., "Backpack palsy") [1].

Q: The image shows a clinical finding in a patient's upper limb. Based on these findings, at which anatomical level has the patient most likely sustained a lesion?

Radial groove. ***Radial groove*** - The **wrist drop** shown indicates radial nerve palsy affecting the **posterior interosseous nerve** and **extensor carpi radialis longus**, which branch after the radial groove but before the elbow. - Lesion at the **spiral groove of humerus** typically spares the **triceps** (branches above this level) while affecting wrist and finger extensors, causing the characteristic wrist drop appearance. *Lower third of the forearm* - Injury here would only affect the **posterior interosseous nerve** branches, causing **finger drop** without wrist drop. - The **extensor carpi radialis longus** and **extensor carpi radialis brevis** would be spared, maintaining wrist extension capability. *Neck of the radius* - This would cause **posterior interosseous nerve palsy**, resulting in **finger extension weakness** but preserved wrist extension. - Patients can extend the wrist but cannot extend fingers at the **metacarpophalangeal joints**, unlike the complete wrist drop shown. *At the wrist* - Injury here affects only the **superficial radial nerve**, causing **sensory loss** over the dorsal hand between thumb and index finger. - **Motor function** remains intact as all motor branches have already separated proximally, so no wrist drop would occur.

Q: Cubital tunnel syndrome occurs due to compression of which structure?

Ulnar nerve. **Explanation:** **Cubital Tunnel Syndrome** is the second most common peripheral nerve compression syndrome (after Carpal Tunnel Syndrome). It occurs due to the compression of the **Ulnar nerve** as it passes through the cubital tunnel [1]. The cubital tunnel is an osteofascial canal located at the medial aspect of the elbow. Its boundaries are formed by the **medial epicondyle** of the humerus (anteriorly), the **olecranon process** of the ulna (laterally), and the **Osborne’s ligament** (arcuate ligament), which connects the two heads of the flexor carpi ulnaris (roof). Compression here leads to paresthesia in the small finger and the ulnar half of the ring finger, along with weakness of the intrinsic hand muscles [1]. **Analysis of Incorrect Options:** * **Median nerve:** Compression typically occurs at the wrist (Carpal Tunnel Syndrome) or in the forearm between the two heads of the pronator teres (Pronator Syndrome). * **Radial nerve:** Compression usually occurs in the spiral groove of the humerus (Saturday Night Palsy) or at the arcade of Frohse (Posterior Interosseous Nerve syndrome). * **Brachial artery:** While it passes through the cubital fossa, its compression or injury is associated with Supracondylar fractures of the humerus, leading to **Volkmann’s Ischemic Contracture**, not a tunnel syndrome. **High-Yield Clinical Pearls for NEET-PG:** * **Froment’s Sign:** Positive in Ulnar nerve palsy due to adductor pollicis paralysis (compensated by Flexor Pollicis Longus). * **Wartenberg’s Sign:** Inability to adduct the little finger. * **Tinel’s Sign:** Percussion over the cubital tunnel elicits "pins and needles" in the ulnar distribution. * **Motor Deficit:** "Claw hand" deformity (Ulnar Claw) is more pronounced in distal lesions (Ulnar Paradox).

Q: The lower lateral cutaneous nerve of the arm is a branch of which nerve?

Radial nerve. The **Radial nerve** is the correct answer. It arises from the posterior cord of the brachial plexus (C5-T1) and provides extensive sensory innervation to the posterior and lateral aspects of the upper limb. In the arm, the radial nerve gives off three significant cutaneous branches: 1. **Posterior cutaneous nerve of the arm:** Arises in the axilla. 2. **Lower lateral cutaneous nerve of the arm (LLCNA):** Arises in the radial groove; it pierces the lateral head of the triceps to supply the skin over the lower lateral part of the arm. 3. **Posterior cutaneous nerve of the forearm:** Arises in the radial groove. **Analysis of Incorrect Options:** * **Axillary nerve:** It gives off the **Upper lateral cutaneous nerve of the arm** (which winds around the posterior border of the deltoid). This is a common point of confusion with the LLCNA. * **Median nerve:** It has no cutaneous branches in the arm; it primarily supplies the skin of the lateral palm and the lateral 3.5 fingers. * **Musculocutaneous nerve:** It continues as the **Lateral cutaneous nerve of the forearm** after piercing the deep fascia near the elbow. **High-Yield Clinical Pearls for NEET-PG:** * **The "Saturday Night Palsy":** Compression of the radial nerve in the spiral groove leads to "Wrist Drop," but sensation from the LLCNA may be preserved if the lesion is distal to its origin. * **Regimental Badge Area:** Sensation over the deltoid is mediated by the **Axillary nerve** (Upper lateral cutaneous nerve). Loss of sensation here is a classic sign of axillary nerve injury or shoulder dislocation. * **Rule of thumb:** If the nerve name contains "Posterior" or "Lower Lateral" (in the arm), think **Radial Nerve**.

Q: Struther's ligament is another name for which of the following?

Third head of coracobrachialis. **Explanation:** **Struther’s ligament** (also known as the ligament of Struthers) is a vestigial fibrous band that extends from an abnormal bony projection called the **supracondylar process** (located on the anteromedial aspect of the lower humerus) to the **medial epicondyle**. 1. **Why the correct answer is right:** Embryologically, Struther’s ligament is considered the **remnant of the third head of the coracobrachialis muscle**. In lower mammals, the coracobrachialis has three heads; in humans, the third head typically disappears, but when present, it persists as this fibrous band. 2. **Why the incorrect options are wrong:** * **Options A & B:** The radial and ulnar collateral ligaments are intrinsic stabilizing structures of the elbow joint capsule. They are anatomical constants and are not synonymous with vestigial muscular remnants. * **Option C:** The brachialis muscle typically has two heads (superficial and deep). While anatomical variations exist, it is not associated with the formation of Struther’s ligament. **Clinical Pearls for NEET-PG:** * **Median Nerve Entrapment:** The median nerve and the brachial artery pass beneath Struther’s ligament. Calcification or thickening of this ligament can lead to compression of the median nerve, mimicking Carpal Tunnel Syndrome but presenting with additional weakness of the forearm pronators (Supracondylar Process Syndrome). * **Location:** It is located approximately 5 cm proximal to the medial epicondyle. * **Differentiation:** Do not confuse this with the **Arcade of Struthers**, which is a thin aponeurotic band in the distal third of the arm that can compress the **ulnar nerve**.

Q: A cut injury of the ulnar nerve results in what clinical presentation?

Paralysis of all interossei. The ulnar nerve is often referred to as the **"Musician’s Nerve"** because it controls the fine, intrinsic movements of the hand. ### **Explanation of the Correct Option** **C. Paralysis of all interossei:** The ulnar nerve (specifically the deep branch) supplies all **8 interossei** (4 dorsal and 4 palmar) [1]. These muscles are responsible for abduction (DAB) and adduction (PAD) of the fingers. Therefore, a complete ulnar nerve injury invariably leads to paralysis of all interossei, resulting in the inability to fan the fingers or grip a piece of paper between them (Positive Froment’s sign/Card test). ### **Why Other Options are Incorrect** * **A. Total claw hand:** Ulnar nerve injury causes **Ulnar Claw Hand** (affecting only the ring and little fingers). A "Total Claw Hand" involves both the ulnar and median nerves (e.g., Klumpke’s paralysis). * **B. Paralysis of all lumbricals:** The ulnar nerve supplies only the **medial two lumbricals** (3rd and 4th). The lateral two lumbricals (1st and 2nd) are supplied by the median nerve [1]. * **D. Paralysis of all slips of FDP:** The ulnar nerve supplies only the **medial half** (slips to the 4th and 5th digits) of the Flexor Digitorum Profundus [1]. The lateral half is supplied by the Anterior Interosseous branch of the median nerve. ### **High-Yield Clinical Pearls for NEET-PG** * **Ulnar Paradox:** A lesion at the **wrist** causes more prominent clawing than a lesion at the **elbow**. This is because, in elbow lesions, the medial half of the FDP is also paralyzed, reducing the flexion of the IP joints [1]. * **Froment’s Sign:** Tests for **Adductor Pollicis** (ulnar nerve) paralysis; the patient compensates by using Flexor Pollicis Longus (median nerve), causing flexion of the thumb IP joint [1]. * **Guyon’s Canal:** A common site for ulnar nerve compression at the wrist.

Q: Which of the following statements regarding peripheral nerve injuries in the upper limb are true? 1. Radial nerve injury causes anesthesia over the anatomical snuff box. 2. Median nerve injury causes wrist drop. 3. Ulnar nerve injury causes a claw hand. 4. Index finger anesthesia is caused by median nerve injury. 5. Thumb anesthesia is caused by ulnar nerve injury.

1, 3, and 4 are true, while 2 and 5 are false.. This question tests your knowledge of the motor and sensory distribution of the major nerves of the upper limb. ### **Analysis of Statements** 1. **Radial Nerve (Statement 1):** The superficial branch of the radial nerve provides sensory innervation to the skin over the **anatomical snuffbox** and the lateral 2.5 digits on the dorsum of the hand [1]. Injury leads to anesthesia in this region. (**True**) 2. **Median Nerve (Statements 2 & 4):** The median nerve supplies the lateral 3.5 digits on the palmar aspect (including the **index finger**). Injury causes "Ape thumb" deformity and sensory loss over the index finger [1], [2]. **Wrist drop** is caused by Radial nerve injury [3], not Median. (**2: False; 4: True**) 3. **Ulnar Nerve (Statements 3 & 5):** The ulnar nerve supplies the intrinsic muscles of the hand (except LOAF) [2]. Injury leads to a **claw hand** (hyperextension at MCP joints and flexion at IP joints). It provides sensation to the medial 1.5 digits (little finger and medial half of ring finger) [1]; **thumb anesthesia** is related to the Median or Radial nerves. (**3: True; 5: False**) ### **High-Yield Clinical Pearls for NEET-PG** * **Radial Nerve:** "Saturday Night Palsy" or "Crutch Palsy" → **Wrist Drop** [3]. * **Median Nerve:** "Laborer’s Nerve." Injury at the wrist (Carpal Tunnel Syndrome) causes thenar atrophy. Pointing Index (Ape Hand) is characteristic. * **Ulnar Nerve:** "Musician’s Nerve." Injury at the elbow (Cubital Tunnel) or wrist (Guyon’s Canal) leads to the **Ulnar Paradox** (higher lesion = less obvious clawing). * **Sensory Testing:** The **tip of the index finger** is the autonomous zone for the Median nerve; the **tip of the little finger** for the Ulnar nerve; and the **first dorsal webspace** for the Radial nerve.

Q: Which bursa communicates with the shoulder joint space?

Subscapular bursa. The shoulder joint (glenohumeral joint) is characterized by a lax capsule that features specific openings, allowing the synovial membrane to protrude and form bursae that communicate directly with the joint cavity [1]. **1. Why Subscapular Bursa is Correct:** The **subscapular bursa** lies between the tendon of the subscapularis muscle and the neck of the scapula. It communicates with the shoulder joint through an opening in the anterior part of the joint capsule, located between the superior and middle glenohumeral ligaments. This communication is a constant anatomical feature and serves to reduce friction for the subscapularis tendon during rotation. **2. Analysis of Incorrect Options:** * **Infraspinatous bursa:** Located between the infraspinatus tendon and the joint capsule. While it may occasionally communicate with the joint, it is not a constant or primary communication like the subscapular bursa. * **Subcoracoid bursa:** Situated below the coracoid process; it is typically a separate synovial sac and does not usually communicate with the joint space. * **Subacromial bursa:** This is the largest bursa of the shoulder, located between the acromion/coracoacromial ligament and the supraspinatus tendon. **Crucially, it does NOT communicate with the joint cavity** under normal physiological conditions. Communication here only occurs pathologically, such as in full-thickness rotator cuff tears. **High-Yield NEET-PG Pearls:** * **Two constant communications:** The shoulder joint cavity communicates with (1) the **subscapular bursa** and (2) the **synovial sheath surrounding the long head of the biceps brachii** (which is intracapsular but extrasynovial). * **Subacromial Bursa Clinical:** Inflammation here leads to "Subacromial Bursitis," causing a painful arc syndrome (60°–120° of abduction). * **Weakest point of the capsule:** The inferior aspect (axillary tail), as it is not supported by the rotator cuff muscles.

Q: Which of the following two muscles act together for climbing on a tree?

Latissimus dorsi & Pectoralis major. The act of climbing involves pulling the trunk upward toward a fixed upper limb. This movement requires powerful **adduction and extension** of the humerus at the shoulder joint. **1. Why the Correct Answer is Right:** * **Latissimus Dorsi:** Known as the "Climber’s Muscle," it is the most powerful extensor, adductor, and internal rotator of the humerus. [1] When the arms are fixed (e.g., holding a branch), it acts from its insertion to pull the trunk upward and forward. * **Pectoralis Major:** While primarily a flexor and adductor, its sternocostal fibers act as a powerful adductor and internal rotator. [1] Working in tandem with the Latissimus dorsi, it helps "hoist" the body weight during the upward phase of climbing. Both muscles insert into the bicipital groove (intertubercular sulcus) of the humerus, allowing them to exert massive leverage on the trunk. **2. Analysis of Incorrect Options:** * **Serratus Anterior (Options A, B, D):** This is the "Boxer’s Muscle." Its primary role is protraction of the scapula and rotation of the scapula for overhead abduction. It does not provide the downward pulling force required for climbing. * **Teres Major (Option B):** While it assists the Latissimus dorsi in adduction and internal rotation, it is a much smaller muscle and lacks the mechanical advantage of the Pectoralis major to lift the entire body weight. **High-Yield NEET-PG Pearls:** * **The "Lady between two Majors":** Latissimus dorsi (the Lady) inserts into the floor of the bicipital groove, while Pectoralis major and Teres major insert into the lateral and medial lips, respectively. * **Nerve Supply:** Latissimus dorsi is supplied by the **Thoracodorsal nerve** (C6-C8). [1] Injury to this nerve results in the inability to use a crutch or pull the body up during climbing. * **Serratus Anterior** is supplied by the **Long Thoracic Nerve** (C5-C7); injury leads to "Winged Scapula."

Question 1

Postoperative examination revealed that the medial border and inferior angle of the left scapula became unusually prominent (projected posteriorly) when the arm was carried forward in the sagittal plane, especially if the patient pushed with outstretched arm against heavy resistance (e.g., a wall). What muscle must have been denervated during the axillary dissection?

Accepted Answer

Serratus anterior

Answer

Levator scapulae

Answer

Pectoralis major

Answer

Rhomboideus major

Question 2

All of the following statements about the brachial plexus are true EXCEPT:

Accepted Answer

The C4 root contributes to the brachial plexus in a post-fixed arrangement.

Answer

The lower trunk is formed by the C8 and T1 roots.

Answer

The lateral cord is formed by the anterior divisions of the upper and middle trunks.

Answer

The posterior cord is formed by the posterior divisions of all three trunks.

Question 3

The image shows a clinical finding in a patient's upper limb. Based on these findings, at which anatomical level has the patient most likely sustained a lesion?

Accepted Answer

Radial groove

Answer

Lower third of the forearm

Answer

Neck of the radius

Answer

At the wrist

Question 4

Cubital tunnel syndrome occurs due to compression of which structure?

Accepted Answer

Ulnar nerve

Answer

Median nerve

Answer

Radial nerve

Answer

Branchial artery

Question 5

The lower lateral cutaneous nerve of the arm is a branch of which nerve?

Accepted Answer

Radial nerve

Answer

Axillary nerve

Answer

Median nerve

Answer

Musculocutaneous nerve

Question 6

Struther's ligament is another name for which of the following?

Accepted Answer

Third head of coracobrachialis

Answer

Radial collateral ligament of the elbow joint

Answer

Ulnar collateral ligament of the elbow joint

Answer

Third head of brachialis

Question 7

A cut injury of the ulnar nerve results in what clinical presentation?

Accepted Answer

Paralysis of all interossei

Answer

Total claw hand

Answer

Paralysis of all lumbricals

Answer

Paralysis of all slips of the flexor digitorum profundus

Question 8

Which of the following statements regarding peripheral nerve injuries in the upper limb are true?
1. Radial nerve injury causes anesthesia over the anatomical snuff box.
2. Median nerve injury causes wrist drop.
3. Ulnar nerve injury causes a claw hand.
4. Index finger anesthesia is caused by median nerve injury.
5. Thumb anesthesia is caused by ulnar nerve injury.

Accepted Answer

1, 3, and 4 are true, while 2 and 5 are false.

Answer

1, 2, and 3 are true, while 4 and 5 are false.

Answer

2, 3, and 4 are true, while 1 and 5 are false.

Answer

1 and 2 are false, while 3, 4, and 5 are true.

Question 9

Which bursa communicates with the shoulder joint space?

Accepted Answer

Subscapular bursa

Answer

Infraspinatous bursa

Answer

Subcoracoid bursa

Answer

Subacromian bursa

Question 10

Which of the following two muscles act together for climbing on a tree?

Accepted Answer

Latissimus dorsi & Pectoralis major

Answer

Latissimus dorsi & Serratus anterior

Answer

Serratus anterior & Teres major

Answer

Serratus anterior & Pectoralis major

Upper Limb — MCQs

Upper Limb — MCQs

On this page

Practice by Chapter

Want unlimited practice?