Upper Limb Practice Questions

Q: Dupuytren's contracture is seen in

Palmar fascia. ***Palmar fascia*** - **Dupuytren's contracture** is characterized by the thickening and shortening of the **palmar fascia (palmar aponeurosis)**, leading to progressive flexion contracture of fingers. - It results in the inability to fully extend the affected fingers, predominantly the **ring finger (4th)** and **little finger (5th)**. - The condition involves **nodular thickening** and cord formation in the palmar fascia, with fibroblast proliferation and collagen deposition. *Plantar fascia* - While the **plantar fascia** can be affected by a similar fibrotic condition called **Ledderhose disease (plantar fibromatosis)**, this is distinct from Dupuytren's contracture. - Plantar fasciitis (inflammation) is different from plantar fibromatosis (nodular thickening). - Dupuytren's contracture specifically refers to the palmar fascia involvement. *Cremaster fascia* - The **cremaster fascia** is associated with the **cremaster muscle** in the male inguinal canal, playing a role in testicular elevation. - It has no involvement in the formation or pathology of Dupuytren's contracture. *Leg muscle* - **Leg muscles** are involved in locomotion and various lower limb movements. - There is no anatomical or pathological connection between leg muscles and Dupuytren's contracture, which is a fascial (not muscular) disorder.

Q: Rotator interval is between:

Supraspinatus and subscapularis. ***Supraspinatus and subscapularis*** - The **rotator interval** is a triangular space found between the **supraspinatus** tendon superiorly and the **subscapularis** tendon inferiorly. - This anatomical space is covered by the **rotator interval capsule** and contains structures like the **long head of the biceps tendon** and the **superior glenohumeral ligament**. *Subscapularis and infraspinatus* - This space is not recognized as the rotator interval; the **infraspinatus** lies posterior to the **supraspinatus** and **subscapularis**. - The rotator interval refers specifically to the anterior superior aspect of the shoulder capsule. *Teres major and teres minor* - The **teres major** and **teres minor** muscles are located more inferiorly and posteriorly in the shoulder compared to the rotator interval. - The interval between these two muscles is not anatomically defined as the rotator interval. *Supraspinatus and teres minor* - The **teres minor** is situated posterior to the rotator cuff and is separated from the **supraspinatus** by the **infraspinatus** muscle. - Therefore, the space between the supraspinatus and teres minor is not the rotator interval, which is more anterior.

Q: A 6-week-old boy is brought to the pediatrician. His parents report that he has not had significant use of his right arm since birth. Birth history is significant for a prolonged labor with difficult breech delivery. On physical examination, his arm hangs at his side and is in a medially rotated position with the forearm in pronation. He will actively use his left arm but does not move his affected right arm or hand. Injury to which of the following cervical nerve roots accounts for this patient's posture?

C5 and C6. ***C5 and C6*** - The described "waiter's tip" posture – arm adducted, internally rotated, and forearm pronated – is classic for **Erb-Duchenne palsy**, resulting from damage to the **C5 and C6 nerve roots** [1]. - This injury commonly occurs during **difficult deliveries** involving shoulder traction, as seen in **breech presentations** [1]. *C7 and C8* - Damage to **C7 and C8** (and often T1) typically results in **Klumpke's palsy**, affecting the **intrinsic hand muscles** and causing a **claw hand deformity** [1]. - While a difficult birth can cause this, the patient's posture (medially rotated arm, pronated forearm) is not characteristic of Klumpke's palsy, which primarily affects lower brachial plexus elements. *C4 and C5* - Injury to **C4** can affect the **diaphragm** via the phrenic nerve, and along with C5, would primarily cause weakness of the **shoulder abductors** and **external rotators**. - While C5 is involved in the observed posture, isolated C4-C5 injury does not fully explain the severe adduction and internal rotation with forearm pronation that defines Erb's palsy. *C6 and C7* - Involvement of **C6 and C7** would lead to weakness in wrist extension, finger extension, and some elbow flexion. - While C6 is involved in Erb's palsy, the additional involvement of C7 alone would alter the specific presentation, often leading to more prominent wrist and finger extensor weakness, which is not the dominant feature described.

Q: Muscle inserting on medial border of scapula -

Serratus anterior. ***Serratus anterior*** - The **serratus anterior** muscle originates from the outer surface of the upper eight or nine ribs and inserts along the entire medial border of the scapula. - Its primary action is to **protract the scapula** (pull it forward around the chest wall) and stabilize it against the thoracic wall. *Subscapularis* - The **subscapularis** muscle originates from the **subscapular fossa** (anterior surface) of the scapula and inserts onto the **lesser tubercle of the humerus**. - It is a rotator cuff muscle involved in **medial rotation of the humerus**. *Teres minor* - The **teres minor** muscle originates from the lateral border of the scapula and inserts onto the **greater tubercle of the humerus**. - It is another rotator cuff muscle, primarily responsible for **lateral rotation and adduction of the humerus**. *Latissimus dorsi* - The **latissimus dorsi** is a large, broad muscle of the back that originates from the thoracolumbar fascia, iliac crest, and lower ribs, inserting into the **intertubercular groove of the humerus** [1]. - It has no direct insertion on the medial border of the scapula; it primarily extends, adducts, and internally rotates the humerus.

Q: Wasting of the intrinsic muscles of the hand can be expected to follow injury of the -

Ulnar nerve. Ulnar nerve - The ulnar nerve innervates most of the intrinsic muscles of the hand, including all interossei, medial two lumbricals, adductor pollicis, and hypothenar muscles [1]. - While the median nerve also supplies some intrinsic muscles (thenar eminence and lateral two lumbricals), the ulnar nerve innervates the majority (~15 of 20 intrinsic hand muscles) [1]. - Injury to the ulnar nerve significantly compromises function and leads to prominent wasting of these muscles, classic for a claw hand deformity. Brachial plexus - Injury to the brachial plexus can certainly affect hand muscles, but it's a more generalized deficit involving multiple nerves or distributions. - Wasting of the intrinsic hand muscles would be one of many symptoms, not necessarily the sole or most specific one to brachial plexus injury over ulnar nerve injury. Radial nerve - The radial nerve primarily innervates the extensor muscles of the forearm and hand, as well as the supinator. - Injury typically results in wrist drop and weakness in extending the wrist and fingers, not wasting of the intrinsic hand muscles. Axillary nerve - The axillary nerve innervates the deltoid and teres minor muscles. - Injury leads to weakness in shoulder abduction and external rotation, with sensory loss over the lateral shoulder, and does not directly affect the intrinsic hand muscles.

Q: A boy presents with complaints of hypoaesthesia and wasting of thenar eminence. The nerve most likely to be damaged in this patient -

Median nerve. ***Median nerve*** - The **median nerve** innervates the muscles of the **thenar eminence** (abductor pollicis brevis, opponens pollicis, and superficial head of flexor pollicis brevis), and sensory supply to the radial side of the palm and digits [1]. - Damage to the median nerve would therefore cause **wasting of the thenar eminence** (motor loss) and **hypoaesthesia** in its sensory distribution [1]. *Radial nerve* - The **radial nerve** primarily innervates the **extensor muscles** of the forearm and hand, as well as providing sensory supply to the posterior arm, forearm, and radial side of the dorsal hand. - Damage would typically result in **wrist drop** and sensory loss on the posterior aspect of the hand, not thenar wasting. *Ulnar nerve* - The **ulnar nerve** innervates most of the intrinsic hand muscles, including the **hypothenar eminence** and interossei, and provides sensory supply to the ulnar side of the hand. - Damage leads to a "claw hand" deformity and wasting of the **hypothenar eminence**, not the thenar eminence. *Musculocutaneous nerve* - The **musculocutaneous nerve** innervates the muscles of the **anterior compartment of the arm** (biceps brachii, brachialis, coracobrachialis) and provides sensory supply to the lateral forearm. - Damage would result in weakness of elbow flexion and sensory loss on the lateral forearm, with no direct impact on the thenar eminence.

Q: Which of the following is not intracapsular -

Lateral epicondyle. **Lateral epicondyle** - The **lateral epicondyle** is an extracapsular structure, sitting superior and lateral to the capitulum and serving as an attachment site for the **radial collateral ligament** and the **common extensor tendon**. - Its position outside the joint capsule means it does not directly articulate within the synovial space of the elbow joint. *Olecranon fossa* - The **olecranon fossa** is a deep depression on the posterior aspect of the **distal humerus** that accommodates the **olecranon process** of the ulna during full elbow extension. - It is located within the joint capsule, allowing the olecranon to articulate freely within the joint. *Coronoid fossa* - The **coronoid fossa** is an anterior depression on the **distal humerus** that receives the **coronoid process** of the ulna during elbow flexion. - This fossa is located within the joint capsule, facilitating the articulation of the ulna with the humerus. *Radial fossa* - The **radial fossa** is a shallow depression on the anterior surface of the distal humerus, superior to the capitulum, that accommodates the **head of the radius** during elbow flexion. - It is located within the joint capsule, enabling smooth movement between the radius and the humerus.

Q: Middle palmar space ends distally:

Into the web space. ***Into the web space*** - The **middle palmar space** is a potential space in the palm that communicates distally with the **web spaces** between the fingers [1]. - Infections in the middle palmar space can spread to the web spaces, causing characteristic swelling and pain between the digits [1]. *By connecting with the superficial palmar space.* - The concept of a separate "superficial palmar space" distinct from the thenar and midpalmar spaces is not anatomically accurate; the main deep palmar spaces are the **thenar** and **midpalmar (middle palmar)** spaces [1]. - These deep spaces are generally separated by fascial septa and do not directly connect with a broad superficial palmar space in the manner suggested for distal spread [1]. *Extending into the flexor tendon sheaths.* - While the **flexor tendons** pass through the palm, the middle palmar space is lateral to the flexor tendon sheaths of the index, middle, ring, and little fingers, not directly extending into them. - Infections of the middle palmar space can affect these sheaths indirectly via communication with the **lumbrical canals**, but it's not a direct extension. *Extending along the digital sheaths.* - The digital flexor tendon sheaths are distinct enclosed structures surrounding the tendons within the fingers. - The middle palmar space primarily communicates with the loose connective tissue in the **web spaces**, which then allows for indirect spread to the digital sheaths or to the fingers via the lumbrical canals, rather than directly extending into the sheaths themselves [1].

Q: A cut injury on wrist causes the inability of thumb to touch the tip of little finger, the nerve likely to be damaged is -

Median. ***Median*** - The inability of the thumb to touch the tip of the little finger, known as **"ape hand"** or **"median claw,"** results from paralysis of the thenar muscles, which are primarily innervated by the **median nerve** [1]. - The median nerve supplies the **opponens pollicis**, **abductor pollicis brevis**, and superficial head of the **flexor pollicis brevis**, all crucial for intricate thumb movements including opposition [1]. *Radial* - Damage to the radial nerve primarily affects **wrist and finger extension**, leading to **"wrist drop"** [1]. - It would not specifically impair the ability of the thumb to touch the little finger. *Ulnar* - An ulnar nerve injury would primarily cause **"ulnar claw hand,"** affecting the little and ring fingers' flexion, and loss of **adduction and abduction of fingers** [1]. - While it causes weakness in some intrinsic hand muscles, it does not directly prevent thumb opposition in the way described [1]. *Deep branch of ulnar nerve* - Damage to the deep branch of the ulnar nerve affects most of the **interossei** and **lumbricals**, leading to a more pronounced ulnar claw and affecting fine motor control and grip [1]. - However, the primary muscles for thumb opposition are innervated by the median nerve [1].

Question 1

Dupuytren's contracture is seen in

Accepted Answer

Palmar fascia

Answer

Cremaster fascia

Answer

Plantar fascia

Answer

Leg muscle

Question 2

Rotator interval is between:

Accepted Answer

Supraspinatus and subscapularis

Answer

Subscapularis and infraspinatus

Answer

Teres major and teres minor

Answer

Supraspinatus and teres minor

Question 3

A 6-week-old boy is brought to the pediatrician. His parents report that he has not had significant use of his right arm since birth. Birth history is significant for a prolonged labor with difficult breech delivery. On physical examination, his arm hangs at his side and is in a medially rotated position with the forearm in pronation. He will actively use his left arm but does not move his affected right arm or hand. Injury to which of the following cervical nerve roots accounts for this patient's posture?

Accepted Answer

C5 and C6

Answer

C7 and C8

Answer

C4 and C5

Answer

C6 and C7

Question 4

Muscle inserting on medial border of scapula -

Accepted Answer

Serratus anterior

Answer

Subscapularis

Answer

Teres minor

Answer

Latissimus dorsi

Question 5

Wasting of the intrinsic muscles of the hand can be expected to follow injury of the -

Accepted Answer

Ulnar nerve

Answer

Brachial plexus

Answer

Radial nerve

Answer

Axillary nerve

Question 6

A boy presents with complaints of hypoaesthesia and wasting of thenar eminence. The nerve most likely to be damaged in this patient -

Accepted Answer

Median nerve

Answer

Radial nerve

Answer

Ulnar nerve

Answer

Musculocutaneous nerve

Question 7

Which of the following is not intracapsular -

Accepted Answer

Lateral epicondyle

Answer

Olecranon fossa

Answer

Coronoid fossa

Answer

Radial fossa

Question 8

All are true regarding brachial plexus injury, except:

Accepted Answer

Preganglionic lesions have a better prognosis than postganglionic lesions

Answer

In Klumpke's palsy, Horner's syndrome may be present on the ipsilateral side

Answer

Erb's palsy causes paralysis of the abductors and external rotators of the shoulder

Answer

Histamine test is useful to differentiate between the preganglionic and postganglionic lesions

Question 9

Middle palmar space ends distally:

Accepted Answer

Into the web space

Answer

By connecting with the superficial palmar space

Answer

Extending into the flexor tendon sheaths

Answer

Extending along the digital sheaths

Question 10

A cut injury on wrist causes the inability of thumb to touch the tip of little finger, the nerve likely to be damaged is -

Accepted Answer

Median

Answer

Radial

Answer

Ulnar

Answer

Deep branch of ulnar nerve

Upper Limb — MCQs

Upper Limb — MCQs

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