Upper Limb Practice Questions

Q: A diabetic worker sustains a stab injury to the central region of his palm. After 3 days, he develops swelling, severe pain, and inability to extend his middle and ring fingers. Pus accumulation is suspected in one of the palmar spaces. Which of the following spaces is most likely involved?

B (Midpalmar space). ***B (Midpalmar space)*** - A stab wound to the central palm directly accesses the **midpalmar space**, which lies deep to the palmar aponeurosis and contains the flexor tendons for the middle, ring, and little fingers. - Infection and pus accumulation in this space lead to **flexor tenosynovitis**, causing severe pain, swelling, and inability to extend the middle and ring fingers, as their tendon sheaths are directly involved. *A (Hypothenar space)* - The **hypothenar space** is located on the ulnar side of the palm and is associated with the intrinsic muscles of the little finger. - An infection in this area would primarily cause swelling and tenderness over the hypothenar eminence and affect the **little finger**, not the middle and ring fingers. *C (Thenar space)* - The **thenar space** is on the radial side of the palm, containing the intrinsic muscles of the thumb and often the flexor tendon sheath of the index finger. - Infection here would cause significant swelling at the base of the thumb (thenar eminence) and primarily affect the function of the **thumb and index finger**. *D (Dorsal subaponeurotic space)* - This space is on the **dorsum (back) of the hand**, whereas the injury occurred on the palm. - While deep palmar space infections can cause significant dorsal swelling due to loose tissue, the primary site of pus collection from a palmar wound is a **palmar space**, not a dorsal one.

Q: Identify the nerve roots involved in the condition depicted in the image.

C5 and C6. ***C5 and C6*** - The image displays a "waiter's tip" or "porter's tip" posture, which is the classic presentation of **Erb's palsy** (or Erb-Duchenne palsy). - This condition results from an injury to the **upper trunk** of the brachial plexus, which is formed by the union of the **C5 and C6** nerve roots, leading to paralysis of shoulder abductors/external rotators and elbow flexors. *C6 and C7* - An injury involving the C7 nerve root, which forms the **middle trunk**, primarily results in weakness of the wrist and finger extensors, a condition known as **wrist drop**. - While C6 is involved in Erb's palsy, the classic "waiter's tip" deformity is not seen with a C7 lesion. *C7 and C8* - A lesion affecting C7 and C8 would involve the middle and part of the lower trunk, leading to a combination of weak wrist extension and weak finger flexion. - This pattern of injury does not correspond to a recognized brachial plexus syndrome and would not produce the specific posture shown. *C8 and T1* - Injury to the C8 and T1 nerve roots affects the **lower trunk** of the brachial plexus, causing **Klumpke's palsy**. - This condition presents with paralysis of the intrinsic muscles of the hand, leading to a **"claw hand"** deformity, which is distinct from the posture seen in the image.

Q: A man fell on his shoulder with his head pushed in the opposite direction. He presented with the following deformity. Which nerve root values are most likely affected?

C5 and C6. ***C5 and C6*** - The clinical presentation of an adducted, internally rotated arm with an extended elbow and pronated forearm is known as the "**waiter's tip**" or "**porter's tip**" position. This is the classic sign of an upper brachial plexus injury, specifically **Erb's Palsy**. - This type of injury typically occurs from trauma that increases the angle between the neck and shoulder, such as a fall or during childbirth, affecting the **C5 and C6** nerve roots. This leads to paralysis of shoulder abductors (deltoid), external rotators (infraspinatus), and elbow flexors (biceps brachii). *C6 and C7* - An injury involving the **C7** root would predominantly cause weakness in the extensors of the elbow, wrist, and fingers, a condition often referred to as "**wrist drop**". - While the C6 root is involved, the primary features of the "waiter's tip" deformity (loss of shoulder abduction and external rotation) are most characteristic of a C5-C6 lesion, not a C6-C7 lesion. *C7 and C8* - A lesion of the **C7 and C8** nerve roots would primarily affect the muscles responsible for finger extension and wrist flexion. - This pattern of weakness does not align with the observed posture, which is defined by deficits in shoulder and elbow movements controlled by C5 and C6. *C8 and T1* - Injury to the **C8 and T1** roots results in a lower brachial plexus injury, known as **Klumpke's Palsy**, which typically occurs from a hyperabduction injury of the arm. - This condition affects the intrinsic muscles of the hand, leading to a "**claw hand**" deformity, which is clinically distinct from the deformity shown in the image.

Q: Which nerve is affected in the hand deformity shown in the image at rest? ![img-59.jpeg](img-59.jpeg)

Ulnar. ***Ulnar*** - The image displays a characteristic **claw hand** deformity, specifically affecting the 4th and 5th digits, which is a classic sign of **ulnar nerve** palsy. - This occurs due to paralysis of the ulnar-innervated muscles, primarily the **medial two lumbricals** and the **interossei**, leading to unopposed extension at the metacarpophalangeal (MCP) joints and flexion at the interphalangeal (IP) joints of the ring and little fingers. *Median* - A **median nerve** injury typically causes an **“ape hand”** deformity due to thenar muscle atrophy or a **“hand of benediction”** sign, where the patient cannot flex the 2nd and 3rd fingers when asked to make a fist. - Unlike the ulnar claw seen at rest, the hand of benediction is an **active sign** (seen on attempted action) and involves different digits. *Musculocutaneous* - The **musculocutaneous nerve** supplies the muscles in the anterior compartment of the arm, such as the **biceps brachii** and **brachialis**, which are responsible for elbow flexion. - An injury to this nerve results in a weak elbow flexion and forearm supination, but it does not cause any deformity in the hand. *None* - The deformity shown is a well-recognized clinical sign known as the **claw hand**. - This sign is specifically and directly linked to a lesion of the **ulnar nerve**, making this option incorrect.

Q: Which among the following is a pressure epiphysis?

Head of Humerus. ***Head of Humerus*** - **Pressure epiphyses** are located at the ends of long bones where they transmit weight-bearing forces and facilitate movement across joints - The **head of humerus** is a classic example of a pressure epiphysis, articulating with the glenoid cavity of the scapula at the glenohumeral joint - It transmits forces from the upper limb and bears the load during various shoulder movements - Other examples include femoral head, humeral head, and tibial condyles *Elbow joint* - The elbow is a **synovial hinge joint**, not an epiphysis - While the joint contains epiphyses (distal humerus, proximal radius and ulna), the joint itself is not an epiphysis - Joints are articulations between bones, whereas epiphyses are the rounded ends of long bones *Sternum* - The sternum is a **flat bone** in the anterior chest wall, not a long bone - It does not have typical epiphyses like long bones - Flat bones ossify differently through intramembranous ossification, not endochondral ossification with distinct epiphyseal plates *Wrist joint* - The wrist is a **complex synovial joint** (radiocarpal joint), not an epiphysis - It is formed by articulation of the distal radius with carpal bones - Like the elbow, it contains epiphyseal regions but is not itself an epiphysis

Q: A 45-year-old woman presented with tingling sensation of lateral 3 digits with loss of sensation of base of thumb on the dorsal aspect of the hand. Which is the nerve involved?

Radial nerve. ***Radial nerve*** - The **superficial branch of the radial nerve** provides sensory innervation to the dorsal aspect of the hand, including the dorsal surface of the thumb, index, middle, and the radial half of the ring finger up to the nail beds [1]. - The patient's symptoms of sensory loss at the **dorsal base of the thumb** (anatomical snuffbox) and tingling in the lateral digits are classic signs of superficial radial nerve involvement [1]. *Ulnar nerve* - The **ulnar nerve** provides sensation to the medial one and a half digits (the little finger and the medial half of the ring finger) on both the palmar and dorsal sides [1]. - Involvement of the ulnar nerve would not cause sensory changes in the lateral three digits or the thumb. *Median nerve* - The **median nerve** supplies sensation to the palmar aspect of the lateral three and a half digits and the nail beds on the dorsal side [1]. - It does not supply the dorsal aspect of the hand or the base of the thumb, which is a key localizing feature in this case. Common entrapment leads to **carpal tunnel syndrome** [2]. *AIN* - The **Anterior Interosseous Nerve (AIN)** is a purely **motor** branch of the median nerve [2]. - An injury to the AIN would result in motor weakness, specifically an inability to flex the thumb and index finger to make an 'OK' sign, but would not cause any sensory loss [2].

Q: Which nerve can be injured when a fracture is sustained in the area marked with the red arrow in the image? ![img-54.jpeg](img-54.jpeg)

Ulnar nerve. ***Ulnar nerve*** - The arrow points to the **medial epicondyle** of the humerus. The ulnar nerve runs in a groove on the posterior surface of the medial epicondyle, making it vulnerable to injury in this location. - A fracture of the medial epicondyle can cause direct trauma or entrapment of the ulnar nerve, leading to numbness and tingling in the fourth and fifth digits and weakness of the intrinsic hand muscles. *Radial nerve* - The radial nerve is most commonly injured in fractures of the **mid-shaft of the humerus**, where it travels in the **radial groove**. - Injury to the radial nerve typically results in **wrist drop**, characterized by the inability to extend the wrist and fingers. *Median nerve* - The median nerve is most at risk with **supracondylar fractures** of the humerus, as it passes anterior to the elbow joint. - This nerve is also famously associated with **carpal tunnel syndrome** when compressed at the wrist. *Musculocutaneous nerve* - The musculocutaneous nerve is located in the **anterior compartment** of the arm and is not in close proximity to the medial epicondyle. - Injury to this nerve, which is rare from fractures, results in weakness of elbow flexion (**biceps brachii** and **brachialis**) and sensory loss over the lateral forearm.

Q: Identify the nerve indicated by the arrow in the image.

Ulnar nerve. ***Ulnar nerve*** - The arrow points to the area posterior to the **medial epicondyle** of the humerus, which is the location of the **cubital tunnel**. - The **ulnar nerve** passes superficially through this tunnel, making it susceptible to compression or injury, and is commonly known as the "funny bone". *Radial nerve* - The **radial nerve** travels down the posterior aspect of the humerus in the **radial groove** and then crosses the elbow joint anterior to the **lateral epicondyle**. - It is primarily responsible for innervating the **extensor muscles** of the forearm and hand. *Median nerve* - The **median nerve** descends through the **anterior compartment** of the arm and passes through the **cubital fossa**, which is anterior to the elbow joint. - It innervates most of the **flexor muscles** of the forearm and the **thenar muscles** of the hand. *Musculocutaneous nerve* - The **musculocutaneous nerve** is found in the **anterior compartment** of the arm, where it pierces the coracobrachialis muscle and runs between the biceps brachii and brachialis muscles. - It supplies the **flexor muscles** of the arm and provides sensory innervation to the **lateral forearm**.

Q: A patient presents with inability to abduct the arm beyond 15 degrees following a shoulder dislocation. The patient can initiate abduction but cannot continue past the initial range. Which of the following muscles is most likely injured?

Deltoid muscle. ***Deltoid*** - The **Deltoid muscle** (primarily the middle fibers) is the main agonist for shoulder abduction between **15 and 90 degrees**. - This pattern of paralysis (initiation present, mid-range lost) is highly characteristic of an **Axillary nerve injury**, which commonly occurs during anterior shoulder dislocation, leading to deltoid muscle denervation. *Supraspinatus* - The **Supraspinatus** muscle is responsible for the **initiation** of shoulder abduction, covering the first 0 to 15 degrees. - If the supraspinatus tendon were torn or the associated nerve damaged, the patient would be unable to *start* the movement, which contradicts the clinical findings. *Subscapularis* - The **Subscapularis** is the largest rotator cuff muscle and functions primarily as a powerful **internal rotator** of the shoulder. - Injury to this muscle would cause significant weakness in internal rotation and may be seen in posterior (or severe anterior) dislocations, but it is not the main abductor. *Infraspinatus* - The **Infraspinatus** muscle is the primary muscle responsible for **external rotation** of the shoulder. - While often part of general rotator cuff pathology, isolated injury to this muscle would manifest as poor external rotation strength, not poor mid-range abduction.

Q: Which muscles are supplied by the ulnar nerve?

All of the options. ***All of the options*** - The **ulnar nerve** supplies the **intrinsic muscles of the hand**, excluding the three thenar muscles (Abductor pollicis brevis, Flexor pollicis brevis-superficial head, Opponens pollicis) and the lateral two lumbricals (1st and 2nd). - The complete list of intrinsic hand muscles supplied by the ulnar nerve includes all interossei (dorsal and palmar), the hypothenar muscles (Abductor digiti minimi, Flexor digiti minimi brevis, Opponens digiti minimi), the third and fourth lumbricals, the palmaris brevis, the adductor pollicis, and the deep head of the flexor pollicis brevis [1]. *Dorsal interossei* - There are four **dorsal interossei** muscles, responsible for **ABduction** (DAB) of the fingers. - All four dorsal interossei are solely supplied by the **deep branch of the ulnar nerve**. *4th lumbrical* - The **lumbricals** are small muscles that flex the MCP joints and extend the IP joints [1]. - The **medial two lumbricals** (3rd and 4th) are supplied by the **deep branch of the ulnar nerve**, while the lateral two are supplied by the median nerve. *Abductor digiti minimi* - This is one of the three **hypothenar muscles** (muscles of the little finger eminence). - Like the other hypothenar muscles, it is exclusively supplied by the **deep branch of the ulnar nerve** [1].

Question 1

A diabetic worker sustains a stab injury to the central region of his palm. After 3 days, he develops swelling, severe pain, and inability to extend his middle and ring fingers. Pus accumulation is suspected in one of the palmar spaces. Which of the following spaces is most likely involved?

Accepted Answer

B (Midpalmar space)

Answer

A (Hypothenar space)

Answer

D (Dorsal subaponeurotic space)

Answer

C (Thenar space)

Question 2

Identify the nerve roots involved in the condition depicted in the image.

Accepted Answer

C5 and C6

Answer

C6 and C7

Answer

C7 and C8

Answer

C8 and T1

Question 3

A man fell on his shoulder with his head pushed in the opposite direction. He presented with the following deformity. Which nerve root values are most likely affected?

Accepted Answer

C5 and C6

Answer

C7 and C8

Answer

C6 and C7

Answer

C8 and T1

Question 4

Which nerve is affected in the hand deformity shown in the image at rest? ![img-59.jpeg](img-59.jpeg)

Accepted Answer

Ulnar

Answer

Median

Answer

Musculocutaneous

Answer

None

Question 5

Which among the following is a pressure epiphysis?

Accepted Answer

Head of Humerus

Answer

Elbow joint

Answer

Sternum

Answer

Wrist joint

Question 6

A 45-year-old woman presented with tingling sensation of lateral 3 digits with loss of sensation of base of thumb on the dorsal aspect of the hand. Which is the nerve involved?

Accepted Answer

Radial nerve

Answer

Median nerve

Answer

AIN

Answer

Ulnar nerve

Question 7

Which nerve can be injured when a fracture is sustained in the area marked with the red arrow in the image? ![img-54.jpeg](img-54.jpeg)

Accepted Answer

Ulnar nerve

Answer

Radial nerve

Answer

Musculocutaneous nerve

Answer

Median nerve

Question 8

Identify the nerve indicated by the arrow in the image.

Accepted Answer

Ulnar nerve

Answer

Radial nerve

Answer

Musculocutaneous nerve

Answer

Median nerve

Question 9

A patient presents with inability to abduct the arm beyond 15 degrees following a shoulder dislocation. The patient can initiate abduction but cannot continue past the initial range. Which of the following muscles is most likely injured?

Accepted Answer

Deltoid muscle

Answer

Supraspinatus muscle

Answer

Teres minor muscle

Answer

Infraspinatus muscle

Question 10

Which muscles are supplied by the ulnar nerve?

Accepted Answer

All of the options

Answer

Dorsal interossei

Answer

4th lumbrical

Answer

Abductor digiti minimi

Upper Limb — MCQs

Upper Limb — MCQs

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