CHAPTER 2 The Upper Limb Questions DIRECTIONS (Questions 1 through 83): Each of the numbered items or incomplete statements in this sections followed by answers or by completions of the statement. Select the ONE lettered answer or completion that is BEST in each case. 1. Which of the following is NOT true regarding the clavicle? (A) Its medial end is enlarged where it attaches to the sternum. (B) Its lateral end is flat where it articulates with the humerus. (©) The medial two-thirds of the shaft are convex anteriorly (D) The clavicle transmits shock from the upper limb to the axial skeleton. (&) The clavicle is a “long bone” that has no medullary cavi 2. The trapezius attaches to which of the follow- ing regions of the clavicle? (A) lateral one-third of the clavicle (B) conoid tubercle (©) subclavian groove (D) trapezoid line (B) quadrangular tubercle 3. Which of the following is true in respect to the scapula? (A) The spine of the scapula continues later- ally as the coracoid process. (B) The lateral surface of the scapula forms the glenoid cavity 4, (C) The acromion is superior to the glenoid cavity and projects anterolaterally. (D) The scapula is fastened securely to the thoracic cage at the scapulothoracic joint. (£) The acromioclavicular joint represents the true shoulder joint. Which of the following is NOT included in the condyle of the humerus? (A) radial, coronoid, and olecranon fossae (B) epicondyles (C) trochlea (D) capitulum (E) greater tubercle Which of the following is NOT true in respect to the ulna and radius? (A) The brachialis attaches to the tuberosity of the ulna. (B) The ulnar styloid process is much larger than the radial styloid process and extends farther distally. (©) The head of the ulna lies distally, whereas the head of the radius articulates with the humerus (D) The ulna is medial to the radius in the anatomical position, (E) The bodies of these bones are firmly bound, together by the interosseous membrane. "12 2:The Upper Limb 6. 10. Which of the following is true regarding the carpus? (A) The scaphoid articulates proximally with the ulna and has a tubercle. (B) The lunate articulates with the ulna and is broader anteriorly than posteriorly. (C) The triquetrum articulates proximally with the articular disc of the distal radioulnar joint. (D) The pisiform lies on the palmar surface of the trapezium, (E) It is composed of seven bones. Which of the following describes the correct order of the distal row of carpals from lateral to medial? (A) triquetrum, trapezoid, capitate, hamate (B) trapezoid, trapezium, capitate, hamate (C) trapezium, trapezoid, capitate, hamate (D) trapezium, triquetrum, capitate, hamate (B) scaphoid, lunate, triquetrum, pisiform Which of the following is actually a lateral cuta- neous branch of an intercostal nerve, innervat- ing the skin of the medial surface of the arm? (A) intercostobrachial nerve (B) superior lateral cutaneous nerve of the arm (C) inferior lateral cutaneous nerve of the arm (D) medial cutaneous nerve of the arm (£) lateral pectoral nerve Which of the following is NOT a branch of the radial nerve? (A) posterior cutaneous nerve of the arm (B) posterior cutaneous nerve of the forearm (C) inferior lateral cutaneous nerve of the arm (D) superior lateral cutaneous nerve of the arm (E) posterior interosseous nerve Which of the following is NOT an anterior tho- racoappendicular muscle? (A) pectoralis major (B) pectoralis minor (C) delt i. 12, 13. 14, 15. (D) subclavius (B) serratus anterior Which of the following best describes the action of the pectoralis minor? (A) stabilizes scapula by drawing it inferiorly and anteriorly against thoracic wall (B) anchors and depresses clavicle (©) adducts and medially rotates humerus (D) rotates scapula (E) flexes humerus Which of the following muscles attaches to the coracoid process of the scapula? (A) pectoralis minor (B) triceps brachii (©) brachialis (D) pectoralis major (F) subclavius All of the following are medial rotators of the arm EXCEPT (A) latissimus dorsi (B) teres major (C) subscapularis (D) infraspinatus (B) anterior part of deltoid What muscles are necessary to raise the arm above the shoulder? (A) first the supraspinatus, next the deltoid, and then the serratus anterior (B) first the deltoid, next the supraspinatus, and then the serratus anterior (C) first the supraspinatus, next the serratus anterior, and then the deltoid (D) first the serratus anterior, next the deltoid, and then the supraspinatus (E) first the deltoid, next the serratus anterior, and then supraspinatus Which of the following is innervated by the dorsal scapular nerve? (A) serratus anterior (B) rhomboid major and minorQuestions: 6-23 13 16. 17. 18, 19. (©) erector spinae {D) subscapularis (EB) supraspinatus Which of the following is an extrinsic shoulder muscle? (A) deltoid (B) teres major © levator seapulae (D) teres minor (E) supraspinatus Which of the following is true in respect to the trapezius? (A) Itis innervated by the dorsal scapular nerve, (B) Its superior fibers retract the scapula. (©) Its middle fibers elevate the scapula. (D) Its inferior fibers retract the scapula. (B) Its superior and inferior fibers act together in rotating the scapula on the thoracic wall. ‘A patient is asked to place the hands posteriorly on the hips and to push the elbows posteriorly against resistance. Which muscle is being tested? {A) levator scapulae (B) rhomboid (©) trapezius (D) latissimus dorsi (B) serratus anterior Which rotator cuff muscle does NOT rotate the humerus? (A) supraspinatus (B) infraspinatus (© teres minor (D) subscapularis (B) teres major The axillary nerve innervates which of the fol- lowing muscles? {A) coracobrachialis (B) teres minor 21. 22, 23. (©) teres major (D) subscapularis (F) levator scapulae Which of the following is NOT contained in the axilla? (A) axillary blood vessels (B) lymph nodes (©) trunks and plexus (D) axillary nerve (E) lymph nodes isions of the brachial Which of the following is most correct? (A) The subscapular artery arises from the third part of the axillary artery and contributes to blood supply of muscles near the scapula and humerus. (B) The second part of the axillary artery typ! cally contains two branches—the thora- coacromial artery and the superior thoracic artery. (©) The first part of the axillary artery lies posterior to the pectoralis minor. (D) The thoracoacromial artery supplies the pectoral muscles, axillary lymph nodes, and most importantly the lateral part of the mammary gland in women, (E) The lateral thoracic artery divides into four branches, the acromial, deltoid, pec- toral, and clavicular. Which of the following is NOT correct? (A) The brachial plexus is formed by the union of the ventral rami of C5 through T1. (B) The roots of the brachial plexus and the subclavian artery pass through the gap between the anterior and middle scalene muscles. (© Gray rami contribute sympathetic fibers to each root (D) Each of the three trunks of the brachial plexus divide into anterior and posterior divisions. (E) The cords of the brachial plexus surround the brachial artery.4 2: The Upper Limb 24. 27. Which of the following is NOT a supraclavieu- lar branch of the brachial plexus? (A) dorsal scapular nerve (B) lateral pectoral nerve (© long thoracic nerve (D) nerve to the subclavius 29, (E) suprascapular nerve Which of the following is true regarding the quadrangular space? (A) It is bounded superiorly by the teres major. (B) Itis bounded inferiorly by the subscapu- laris and teres minor. (© Itis bounded medially by the humerus sa. and laterally by the long head of the triceps, (D) It contains the posterior circumflex humeral artery and the axillary nerve. (£) Brachial plexus herniations occur here. Which of the following is NOT innervated by the suprascapular nerve? (A) supraspinatus 31 (B) infraspinatus : (©) glenohumeral joint (D) skin over superior part of scapula (E) shoulder joint Which of the following is NOT a branch of the posterior cord of the brachial plexus? (A) upper and lower subscapular nerves (B) thoracodorsal nerve (© axillary nerve (D) radial nerve 32. (E) long thoracic nerve Which of the following is NOT true in respect to the brachialis? (A) Is origin is the distal half of the anterior surface of the humerus. (B) Its insertion is the coronoid process and tuberosity of the ulna (©) It flexes the forearm in all positions. (D) Itis primarily innervated by the musculo- cutaneous nerve, but some of its lateral part is innervated by a branch of the radial nerve. (B) Iterosses two joints. A patient is asked to abduct the arm 90 degrees and then to extend the flexed forearm against resistance. Which muscle is being tested? (A) triceps brachii (B) brachialis, (C) coracobrachialis (D) biceps brachii (E) supinator ‘The deep artery of the arm accompanies which of the following before passing around the body of the humerus? (A) radial nerve (B) musculocutaneous nerve (C) median nerve (D) ulnar nerve (© axillary nerve Which muscle assists in extension of the fore- arm, resists abduction of the ulna during prona- tion of the forearm, and tenses the capsule of the elbow joint so that it is not pinched when the it is extended? (A) anconeus (B) triceps brachii (C) coracobrachialis (D) brachialis (E) biceps brachii Which of the following isa branch of the brachial artery? (A) anterior and posterior circumflex humeral arteries deltoid artery superior and inferior ulnar collateral arteries thoracoacromial artery anterior and posterior ulnar recurrent arteries (B) © (oD) @)Questions: 24-4215 35. 37. Which of the following nerves supply NO branches to the arm? (A) musculocutaneous and median (B) radial and ulnar (C) median and ulnar (D) median and radial () musculocutaneous and radial Which of the following nervesis correctly paired with its cutaneous branch? (A) median nerve and medial antebrachial cutaneous nerve (B) musculocutaneous nerve and lateral ante- brachial cutaneous nerve (C) ulnar nerve and posterior antebrachial cutaneous nerve (D) median nerve and medial brachial cuta- neous nerve (©) radial nerve and superior lateral brachial cutaneous nerve ‘The cubital fossa does NOT contain which of the following? (A) terminal part of the brachial artery (B) deep accompanying veins of the arteries (©) median nerve (D) biceps brachii tendon () ulnarnerve A patient is unable to flex the arm and forearm. Where is the lesion likely to be? (A) ventral rami of C3-C4 (B) ventral rami of C5-C6-C7 (©) dorsal rami of C6-C7-C8 (D) ventral rami of C8-T1 (&) dorsal rami of T1 ‘The radial nerve innervates muscles in the exten- sor compartment of the forearm, but it also in- nervates the following flexor (A) brachioradialis (B) pronator teres (©) palmaris longus (D) pronator quadratus (E) palmaris longus 38. 39. 41. Which muscle does NOT cross the elbow joint? (A) flexor pollicis longus (B) pronator teres (©) Alexor carpi radialis: (D) flexor carpi ulnaris (B) flexor digitorum superficialis The ulnar nerve innervates which of the fol- lowing muscles in the flexor compartment? (A) the medial part of the flexor digitorum superficialis (B) flexor carpi radialis (© pronator quadratus (D) pronator teres (6) the medial part of flexor digitorum profundus ‘The radial artery liesjustlateral to the tendon of which muscle? (A) pronator teres (B) flexor carpi radialis (© palmaris longus (D) flexor carpi ulnaris (B) flexor digitorum superficialis ‘The palmaris longus tendon isa useful guide to which nerve at the wrist? (A) anterior interosseous nerve (B) posterior interosseous nerve (© median nerve (D) ulnarnerve (E) radial nerve To pronate the forearm, which of the following must occur? (A) The pronator quadratus initiates prona- tion, assisted later by the pronator teres. (B) The pronator teres initiates pronation, assisted later by the pronator quadratus, (© The anconeus initiates pronation, assisted. later by the pronator teres. (D) The pronator quadratus initiates prona- tion, assisted later by the anconeus. (£) The ulnar nerve must be used.16 43. 45, 46. 2:The Upper Limb The extensor carpi radialis longus tendon is crossed by which two muscles? (A) abductor pollicis longus and extensor pol licis longus (B) extensor indicis and extensor digitorum (C) extensor digitorum and extensor pollicis brevis (D) abductor pollicis longus and extensor pol- licis brevis (E) extensor indicis and extensor carpi radi- alis brevis Which of the following is true in respect to the supinator? (A) Itisinnervated by the ulnar nerve. (B) It supinates the forearm by rotating the ulna: (C) It forms the floor of the cubital fossa along with the brachioradialis. (D) It supinates the forearm when the forearm is already flexed. (F) Itrotates the radius to turn the palm ante- riorly. Which of the following does NOT take an ori- gin from the lateral epicondyle of the humerus? (A) extensor carpi radialis brevis (B) extensor carpi ulnaris (C) abductor pollicis longus (D) supinator (B) extensor digiti minimi Which of the following is correctly paired with its nerve? (A) flexor pollicis longus and anterior interosseous nerve (B) flexor digitorum profundus and anterior inlerosseous nerve (©) extensor carpi radialis longus and poste- rior interosseous nerve (D) brachioradialis and posterior interosseous nerve (B) abductor pollicis longus and anterior interosseous nerve 47. 49. 51. Which of the following is true in respect to the anatomical snuff box? (A) Itis bounded anteriorly by the tendons of the extensor pollicis longus. (B) It is bounded posteriorly by the tendons of the abductor pollicis longus and exten- sor pollicis brevis. (C) The radial artery lies in the floor of the snuff box. (D) The scaphoid and triquetrum can be pal- pated within the snuff box. (E) The snuff box is visible when the thumb is fully flexed Which of the following does NOT abduct the hand at the wrist joint? (A) flexor carpi radialis (B) extensor carpi radialis longus (C) extensor carpi radialis brevis (D) abductor pollicis longus (E) palmaris longus Which of the following is derived from the radial artery? (A) dorsal and palmar carpal arteries (B) common interosseous artery (C) anterior interosseous artery (D) poster interosseous artery (E) ulnar recurrent artery ‘The median nerve does which of the following? (A) innervates the elbow joint with articular branches (B) innervates the medial half of the flexor digitorum profundus (C) innervates the hypothenar muscles (D) innervates lumbricals 3 and 4 (B) innervates the skin of the dorsum of the hand The ulnar nerve does NOT do which of the fol- lowing? (A) innervate the elbow joint with articular branches (B) innervate the flexor carpi ulnarisQuestions: 43-69 17 55. (C) innervate the skin on the lateral part of the palm and dorsum of the hand (D) innervate the adductor pollicis (E) innervate the dorsal and palmar interossei The radial nerve does NOT clo which of the fol- lowing? (A) give a superficial branch that innervates the dorsum of the hand (8) innervate the brachioradialis and extensor adialis longus carpi give a deep branch that innervates the extensor carpi radialis brevis and supinator give a posterior interosseous branch that innervates all remaining extensor muscles in the posterior compartment of the fore- (E) innervate the glenchumeral joint © (D) 57. Which of the following is NOT true in respect to the flexor pollicis brevis? {A) Itis located medial to the abductor polli- cis brevis, (B) It flexes the thumb at the carpometacarpal joint. (©) It flexes the thumb at the metacarpopha- langeal joint. {D) Its tendon typically contains a sesamoid bone (E) Itis innervated by C5-C6. 58. Which of the following is true in respect to the palmaris brevis? 59, (A) It aids the palmaris longus in tightening the palmar aponeurosis (B) It is innervated by the median nerve. (©) It isin the hypothenar compartment (D) It covers and protects the radial artery. (8) It wrinkles the skin of the hypothenar eminence and deepens the hollow of the palm. ‘The recurrent branch of the median nerve does NOT innervate which of the following? {A) abductor pollicis brevis (B) adductor pollicis (C) flexor pollicis brevis (D) opponens pollicis (E) The recurrent branch of the median nerve innervates all of the above Which of the following muscles is correctly matched with the accompanying description? (A) lumbricals 1 and 2... . bipennate (B) lumbricals 3 and 4... unipennate (©) dorsal interossei 1-4... . bipennate (D) palmar interossei 1-3... bipennate {E) deltoid . .. bipennate The deep branch of the ulnar does NOT inner- vate which of the following? (A) abduetor digiti minimi {B) flexor digiti minimi brevis, (C) lumbricals 1 and 2 (D) dorsal interossei 3. and 4 {E) palmar interossei 1 and 2 ‘The carpal tunnel does NOT contain which of the following? (A) median nerve (B) four tendons of the flexor digitorum, superficialis (©) four tendons of the flexor digitorum pro- fundus (D) the tendon of the flexor pollicis longus (E) ulnarnerve The sternoclavicular joint (A) .. isa'saddle-type synovial joint but functions as a ball-and-socket joint (B) ... is supplied by lateral thoracic and thoracoacromial arteries. (© ... is innervated by the lateral and medial pectoral nerves, (D) ... is the articulation of the clavicle and gladiolus of the sternum. (B) ...dislocates easily.18 2: The Upper Limb 61. Which of the following is true in respect to the acromioclavicular joint? (A) Itis a saddle-type synovial joint (B) Itis strengthened by the coracohumeral and transverse humeral ligaments. (© Itis supplied by the lateral thoracic arteries (D) It is innervated by the nerve to the sub- clavius. (E) When dislocated, it is often referred to as a “separated shoulder.” 6. Which of the following flexes the arm at the glenohumeral joint? (A) deltoid (posterior part) (B) pectoralis major (C) latissimus dorsi (D) subscapularis (B) infraspinatus In respect to movement of the arm at the gleno- humeral joint, which of the following move- ments is correctly paired with its prime mover? () B) 66. extension . .. deltoid (posterior part) abduction ... pectoralis major and latis- simus dorsi (© adduction... . deltoid (D) medial rotation ....infraspinatus (B) lateral rotation . .. subscapularis Which of the following is true in respect to the elbow joint? (A) Itisa plane type of synovial joint. (B) Itis strengthened by the radial and ulnar cruciate ligaments. (©) Itis supplied by the cephalic and basilic arteries. (D) Itis innervated by the median and axil- lary nerves. (E) It is surrounded by the intratendinous ole- cranon bursa, the subtendinous olecranon bursa, and the subcutaneous olecranon bursa. 67. 68. Which of the following joints is paired correctly with its type? (A) proximal and distal radioulnar joints condyloid type of synovial joint (B) radiocarpal joint... pivot type of synovial joint (C) intercarpal joints ... plane type of syn- ovial joints (D) metacarpophalangeal joints... . hinge type of synovial joints (E) interphalangeal joints... condyloid type of synovial joints All carpometacarpal and intermetacarpal joints are plane types of synovial joints EXCEPT for (A) the carpometacarpal joint of the thumb. (B) the carpometacarpal joint of the fifth metacarpal. (C) the carpometacarpal joint of the third metacarpal. (D) the intermetacarpal joint of the 4th and Sth metacarpals. (E) the intermetacarpal joint of the Ist and 2nd metacarpals. Which of the following is NOT true in respect to the clavicle? (A) The clavicle varies more in shape than most other long bones. (B) The dlavicle can be pierced by a branch of the supraclavicular nerve. (C) The clavicle is thicker and more curved in. manual workers. (D) The right clavicle is stronger than the left and is usually shorter. (E) The clavicle isa compact bone. Fractures of the scapula typically involve (A) the acromion. (B) the coracoid process. (©) the spine. (D) the inferior angle. (E) the suprascapular notch. Which of the following parts of the humerus is, matched correctly with the nerve with which it isin direct contact?Questions: 60-76 19 7. (A) distal end of humerus... . radial nerve (B) surgical neck (C) radial groove (D) medial epicondyle .. (©) scapular notch -musculocutaneous nerve - smusculocutaneous nerve -ulnar nerve . Suprascapular nerve “Winging” of the scapula is most likely caused by which of the following? (A) a lesion to the long thoracic nerve (B) alesion to the thoracodorsal nerve (C) injury to the suprascapular nerve (D) damage to the dorsal scapular nerve (&) damage to the upper and lower subscapu- Jar nerves Which of the following is correct regarding the triangle of auscultation? (A) Its borders are the latissimus dorsi, scapula, and trapezius. (B) Itis a good location to hear heart murmurs. (C) The 8th and 9th ribs and the 8th inter- costal space are subcutaneous here. (D) Itisa location of back trauma. (G) Iisa location for dorsal rami to pass to the superficial back. A patient cannot raise the trunk (as in climb- ing). What is most likely the problem? (A) damage to the ventral rami of C5-C6-C7 (B) paralysis of the latissimus dorsi (C) injury to the dorsal scapuilar nerve (D) damage to the dorsal rami of C8-T1 (E) injury to the axillary nerve The scapula on one side of a patient is located farther from the midline than that on the nor- mal side. What might be the problem? (A) paralysis of the rhomboids on one side (B) injury to the long thoracie nerve (C) alesion of C7-C8 (D) dislocated shoulder (E) separated shoulder The axillary nerve is damaged. What is the likely result? 74. 75. 76. (A) The teres major atrophies. (B) The rounded contour of the shoulder dis- appears (C) A loss of sensation may occur in the lateral forearm (D) The patient may lose the ability to adduct the arm. (E) The patient may exhibit “wrist-drop.” Which of the following is true regarding rotator cuff injuries? (A) Injury or disease may damage the rotator cuff, causing instability of the acromio- clavicular joint. (B) The supraspinatus tendon is the most commonly torn part of the rotator cuff. (©) The teres major takes the longest to reha- bilitate of the rotator cusf muscles. (D) The injuries occur when the muscles pull away from their origin on the acromion. (E) Acute tears are common in young persons. A patient has been thrown from a motorcycle, landing on the shoulder such that the neck and shoulder are widely separated. You suspect an upper brachial plexus injury. What signs do you expect? (A) “clawhand” (B) paralysis of flexor carpi ulnaris, flexor digitorum superficialis, and flexor digito- rum profundus (©) adducted shoulder, medially rotated arm, and extended elbow (D) loss of sensation in the medial forearm (B) “wrist-drop” A patient exhibits “clawhand.” What might have happened? (A) upper brachial plexus injury (B) acute brachial plexus neuritis (©) compression of the cords of the brachial plexus (D) lower brachial plexus injury {E) damage to dorsal rami that send fibers to the brachial plexus20 77. 2: The Upper Lim’ A patient receives a knife wound to the axilla What problems do you expect? {A) damage to the axillary nerve (B) paralysis of the coracobrachialis, biceps, and brachialis (© inability to extend the wrist and digits at the metacarpophalangeal joints (D) loss of sensation on the medial surface of the arm (® “clawhand” A patient tries to make a fist, but digits 2 and 3 remain partially extended, What nerve is injured? (A) ulnar nerve (B) radial nerve (©) median nerve (D) musculocutaneous ner (E) axillary nerve Which of the following is true in respect to ulnar nerve injuries? (A) The injury often occurs where the nerve passes posterior to the medial epicondyle of the humerus. (B) The patient experiences numbness and tingling on the lateral part of the palm and the thumb. (© The patient may exhibit “waiter's tip hand.” (D) Patients have difficulty because they can- not flex their first, second, and third digits at the DIP joints. (E) Power of abduction is impaired, and when the patient attempts to flex the wrist, the flexor carpi ulnaris brings the hand to the medial side. Which limb defect is correctly matched with its definition? (A) meromelia... complete absence of one or more extremities (B) phocomelia . . all segments of extremities are present but abnormally short (C) micromelia . .. partial absence of one or more extremities 81. (D) amelia. . . Jong bones are absent, and small hands or feet are attached to the trunk by short, irregular bones (®) cleft hand (lobster claw deformity) absent third metacarpal, fusion of digits 1-2 and 4-5 Syndactylyl involves (A) extra fingers or toes. (B) absence of a digit or limb. (©) abnormal fusion of fingers and toes. (D) small hands or feet being attached to trunk by short bones instead of long bones. (E) congenital dislocation of glenohumeral joint. Which of the following is NOT correct? (A) During development, dorsal cells orga- nize as the epimere and ventral cells orga- ize as the hypomere. (B) Dorsal rami innervate muscles derived from the epimere. (© Ventral rami innervate muscles derived from the hypomere. (D) Myoblasts of the hypomere form the ‘extensor muscles of the vertebral column. (8) Somites and somitomeres form the mus- culature of the limbs A patient in surgery has no pectoralis major. What do you suspect? (A) trauma (B) dominant pectoralis minor (© drug-induced muscle hypoplasia (D) atrophy of the muscle (®) congenital absence of the muscleQuestions: 77-93 24 DIRECTIONS (Questions 84 through 88); Identify the anatomical features indicated on the art below.22___ 2: The UpperLimb DIRECTIONS (Questions 94 through 98): Identify the anatomical features indicated on the art below.5. Answers and Explanations (B) The lateral end of the clavicle is flat where it articulates with the acromion at the acromio~ clavicular (AC) joint (Moore, pp 665-666). (A) The trapezius attaches to the lateral third of the clavicle, acromion, and spine of the scapula The deltoid attaches to the deltoid tubercle, the conoid ligament attaches to the conoid tubercle, the subclavius attaches to the subclavian groove, and the trapezoid ligament attachesto the trape- z0id line (Moore, pp 666, 691). (B) ‘The lateral surface of the scapula forms the glenoid cavity, superior to which the coracoid process projects anterolaterally, The glenchum- ral joint itself represents the true shoulder joint, whereas the scapulothoraciejoint, which isa con- ceptual joint, is a location where the scapula moves easily on the thoracic wall. The spine of the scapula continues laterally as the acromion (Moore, pp 668-669) (B) The condyle of the humerus (the distal end) includes the epicondyles, trochlea, capitulum, and the three fossae (radial, coronoid, and radial) (Moore, p 670) (B) The radial styloid process is much larger than the ulnar styloid process and extends far- ther distally (Moore, p 671-672). (©) The scaphoid articulates proximally with the radius and has a large tubercle. The lunate articulates with the radius and is broader anteri- orly than posteriorly. The triquetrum articulates proximally with the articular disc of the distal radioulnar joint. The pisiform lies on the palmar surface of the triquetrum (Moore, p 674) 9. 10. 1. 12. 4. (©) From lateral to medial, the four bones of the distal row of carpals are the trapezium, trape- zoid, capitate, and hamate (Moore, p 674) (A) The intercostobrachial nerve is the lateral cutaneous branch of the second intercostal nerve from T2, innervating the skin of the medial sur- face of the arm (Moore, p 684). (D) The posterior cutaneous nerve of the arm, posterior cutaneous nerve of the forearm, and inferior lateral cutaneous nerve of the arm are branches of the radial nerve, The superior lateral cutaneousnerve isa branch of the axillary nerve (Moore, p 684). (C) The pectoralis major, pectoralis minor, sub- clavius, and serratus anterior are anterior tho- racoappendicular muscles, The deltoid is a scapulohumeral (shoulder) muscle (Moore, pp 688, 691) (A) The pectoralis minor stabilizes the seapula by drawing it inferiorly and anteriorly against the thoracic wall (Moore, p 688). (A) The pectoralis minor, biceps brachii (short head), and coracobrachialis attach to the cora- coid process of the scapula (Moore, p 688). (D) The latissimus dorsi, teres major, and sub- scapularis medially rotate the arm. The infra- spinatus and teres minor rotate the arm laterally The deltoid is unique in that its anterior part, rotates the arm medially, and its posterior part rotates the arm laterally (Moore, p 691). (A) The supraspinatus initiates abduction of the arm. The deltoid becomes fully effective as 232: The Upper Limb 15, 16. V7. 18. 19. a. an abductor following the initial 15 degrees of abduction. The serratus anterior rotates the scapula, elevating its glenoid cavity so that the atm can be raised above the shoulder (Moore, 7p 695, 696, 689). (B) The dorsal scapular nerve innervates the levator scapulae, rhomboid major, and rhom- boid minor (Moore, p 691) (© The trapezius, latissimus dorsi, levator scapulae, and rhomboids are extrinsic shoulder muscles. The deltoid, teres major, supraspinatus, infraspinatus, teres minor, and subscapularis are intrinsic shoulder muscles (Moore, pp 691-692). (E) The trapezius, innervated by the spinal root of the accessory nerve (XI), is composed of three types of fibers. Its superior fibers elevate the scapula, its middle fibers retract the scapula, and itsinferior fibers depress the scapula. Its superior and inferior fibers act together in rotating the scapula on the thoracic wall (Moore, p 694). (B) To test the rhomboids, the patient is asked to place the hands posteriorly on the hipsand to push the elbows posteriorly against resistance (Moore, p 695). (A) The supraspinatus is the only rotator cuff muscle that does not rotate the humerus (Moore, pp 697-698). (B) The axillary nerve innervates both the del- toid and the teres minor (Moore, p 651). (C) The axilla contains axillary blood vessels, lymph nodes, the cords and branches of the brachial plexus, and the axillary nerve. The trunks and divisions are found superior to the axilla in the neck (Moore, p 699). (A) The subscapular artery arises from the third part of the axillary artery and contributes to blood supply of muscles near the scapula and humerus (Moore, p 700. (©) The brachial plexus is formed by the union of the ventral rami of C5 through T1. The roots of the brachial plexus and the subclavian artery 26. 27. 29. pass through the gap between the anterior and middle scalene muscles. Gray rami contribute sympathetic fibers to each root. The roots of the brachial plexus form three trunks, each of which, divides into anterior and posterior divisions, The cords of the brachial plexus surround the axillary artery (Moore, p 708). (B) The dorsal scapular nerve, long thoracic nerve, nerve to the subclavius, and supra- scapular nerve are supraclavicular branches of the brachial plexus, whereas the lateral pectoral nerve is an infraclavicular branch, originating, from the lateral cord (Moore, pp 708-703). (D) The quadrangular space is bounded superi- orly by the subscapularis and teres minor, infe- riorly by the teres major, medially by the long head of triceps, and laterally by the humerus. It contains the axillary nerve and the posterior cir cumflex humeral artery (Moore, p 711). (D) The suprascapular nerve innervates the supraspinatus, infraspinatus, and glenohumeral (shoulder) joint (Moore, p 710). {E) The posterior cord gives rise to the upperand lower subscapular nerves, thoracodarsal nerve, axillary nerve, and radial nerve. The long tho- racic nerve originates from C5-C6~C7 (Moore, pp 71D. {E) The brachialis originates from the distal half of the anterior surface of the humerus and inserts on the coronoid process and tuberosity of the ulna. It crosses one joint, flexing the forearm in all positions, While itis primarily innervated by the musculocutaneous nerve, some of its lateral partis innervated by a branch of the radial nerve (Moore, p 722). (A) Totest the triceps brachii, the arm is abducted 90 degrees and then the flexed forearm is extended. against resistance (Moore, p 724). (A) The deep artery of the arm accompanies the radial nerve through the radial groove and passes around the body of the humerus (Moore, p 728).31. 32. 35. (A) The anconeusassists in extension of the fore- arm, resists abduction of the ulna during prona~ tion of the forearm, and tenses the capsule of the elbow joint so that it is not pinched when the joint is extended (Moore, p 724) (© Theanillary artery gives rise to the superior thoracic, thoracoacromial, lateral thoracic, sub- scapular, and anterior and posterior circumflex humeral arteries. The brachial artery givesrrise to the deep artery of the arm, the nutrient humeral artery, and the superior and inferior collateral arteries. The ulnar artery gives rise to the anterior and posterior ulnar recurrent, common inter- osseous, anterior and posterior interosseous, and dorsal and palmar carpal branch arteries (Moore, pp 699, 727-728, 750). (©) The median and ulnar nerves supply no branches to the arm (Moore, p 730). (B) The median nerve gives rise to a palmar cutaneous branch; the ulnar nerve as well has a palmarcutaneous branch. The radial nerve gives ise to the posterior brachial cutaneous nerve, the posterior antebrachial cutaneous nerve, the inferior lateral brachial cutaneous nerve, and a superficial branch that innervates the dorsum of the hand and the digits. The musculocutaneous nerve continues as the lateral antebrachial cute neous nerve. The axillary nerve gives rise to the superior lateral brachial cutaneous nerve. The medial cord of the brachial plexus gives rise to the medial brachial cutaneous nerve and the medial antebrachial cutaneous nerve. The supra- clavicular nerves (from C3-C4) and the inter- costobrachial nerve (from T2) also contribute to the cutaneous innervation of the arm (Moore, pp 684, 758-759). (E) The cubital fossa contains the terminal part of the brachial artery (and the beginning of the ulnar and radial arteries), deep accompanying veins, the median nerve, and the biceps brachii tendon. In the tissue superficial to the fossa are the median cubital vein and medial and lateral antebrachial cutaneous nerve. The deep and superficial branches of the radial nerve are in the floor of the fossa (Moore, pp 731-732) 36. 37. 38. 39. 40. 41. a2. 43, 44, Answers and Explanations: (B) A patient who is unable to flex the arm and forearm is likely to have a lesion in the ventral rami of C5, C6, and C7. The biceps brachii and brachialis receive fibers from C5 and C6, and the coracobrachialis receives fibers from C5, C6, and C7. C6 is the main source of fibers for each (Moore, p 722). (A) The brachioradialis isa flexor of the forearm, butit is located in the extensor compartment and is innervated by the radial nerve (Moore, p 734). (A) The superficial muscles (pronator teres, flexor carpi radialis, palmaris longus, flexor carpi ulnaris, and flexor digitorum superficialis) cross the elbow joint. The deep muscles (flexor digitorum profundus, flexor pollicis longus, and pronator quadratus) do not (Moore, p 734). (8) All muscles in the anterior compartment of the forearm are innervated by the median nerve, except for the flexor carpi ulnaris and the medial part of the flexor digitorum profundus, which are innervated by the ulnar nerve (Moore, pp 736-737) (B) The radial artery lies lateral to the tendon of the flexor carpi radialis (Moore, p 737). (C) The palmaris longus tendon is a guide for locating the median nerve at the wrist (Moore, p77). (A) To pronate the forearm, the pronator quad- ralus initiates pronation, assisted later by the pronator teres (Moore, p 741). (D) The extensor carpi radialis longus tendon, is crossed by the abductor pollicis longus and extensor pollicis brevis (Moore, p 745). (E) The supinator, which forms the floor of the cubital fossa along with the brachioradialis, is innervated by the deep branch of the radial nerve. It supinates the forearm by rotating the radius. The biceps brachii also supinates the forearm when the forearm is already flexed (Moore, p 746).2: The Upper Limb 45. 46. 47. 48. 49, 50. 51. (©) The abductor pollicis longus originates from the posterior surfaces of the ulna, radius, and interosseous membrane. The following muscles take at least one of their origins from the lateral epicondyle of the humerus: extensor carpi radi- alis brevis, extensor digitorum, extensor digiti minimi, extensor carpi ulnaris, and supinator (Moore, p 742). (A) The flexor pollicis longus is innervated by the anterior interosseous nerve from the median nerve (Moore, pp 736-737, 742-743). (©) The snuff box is bounded anteriorly by the tendons of the abductor pollicis longus and ex- tensor pollicis brevis. Posteriorly it is bounded by the tendon of the extensor pollicis longus. The radial artery can be felt in the floor, along with the radial styloid process, first metacarpal, scaphoid, and trapezium (Moore, p 749), (2) Thehand is abducted at the wrist jointby the flexor carpi radialis, abductor pollicis longus, extensor carpi radialis longus, and extensor carpi radialis brevis (Moore, pp 736, 742). (A) The radial artery gives rise to the radial recurrent artery as well as dorsal and palmar carpal branches. The ulnar artery gives rise to the common interosseous artery, anterior and poste- rior interosseous arteries, anterior and posterior ulnar recurtent arteries, and dorsal and palmar carpal branches (Moore, p 750). (A) The median nerve assists in the innervation of the elbow joint and gives muscular branches to pronator teres, flexor carpi radialis, palmaris longus, and flexor digitorum superficialis. The median nerve also has an anterior interosseous branch that innervates the lateral part of the flexor digitorum profundus, flexor pollici longus, and pronator quadratus. The recurrent branch of the median nerve innervates the thenar muscles, and the palmar cutaneous branch innervates the skin of the lateral part of the palm (Moore, pp 757-759). (C) The ulnar nerve gives rise to articular branches that innervate the elbow joint and mus- cular branches that innervate the flexor carpi 52. 55. 56. ulnaris and medial half of the flexor digitorum, profundus. The palmar cutaneous branch inner- vates the skin of the medial part of the palm, and the dorsal cutaneous branch innervates the pos- terior surface of the medial part of the hand and digits. The deep branch innervates the hypo- thenar muscles, adductor pollicis, interossei, and the 3rd and 4th lumbricals (Moore, ppp 759-760). (B) The radial nerve gives a superficial branch that innervates skin on the dorsum of the hand. The radial nerve itself innervates the brachiora- dialis and extensor carpi radialis longus. It then gives a deep branch that innervates the extensor carpi radialis brevis and the supinator before continuing as the posterior interosseous nerve, which innervates the extensor digitorum, ex- tensor digiti minimi, extensor carpi ulnaris, ab- ductor pollicis longus, extensor pollicis brevis, extensor pollicis longus, and extensor indic (Moore, pp 742, 761). (E) The flexor pollicis brevis is located medial to the abductor pollicis brevis. It flexes the thumb at the carpometacarpal and metacarpophalan- geal joints and assists in opposition. Its tendon typically contains a sesamoid bone. It is inner- vated by the recurrent branch of the median nerve (C8-T) (Moore, p 767) as (E) The palmaris brevis, innervated by the ulnar nerve, wrinkles the skin of the hypothenar emi- nence and deepens the hollow of the palm, assist- ing the palmar grip. The muscle actually covers and protects the ulnar artery and the ulnarnerve, which innervates it. The muscle is not by defi- nition in the hypothenar compartment. The pal- maris longus, on the other hand, flexes the hand. at the wrist and tightens the palmar aponeuro- sis (Moore, p 768). (B) The recurrent branch of the median nerve innervates the abductor pollicis brevis, flexor pollicis brevis, and opponens pollicis, but the deep branch of the ulnar nerve innervates adduc- tor pollicis (Moore, pp 769-770). (©) Lumbricals 1-2 and palmar interossei 1-3 are unipennate muscles. Lumbricals3~4 and dor- sal interossei 1-4 are bipennate muscles. The del- toid is multipennate (Moore, p 770).Answors and Explanations: 45-70__ 27 57. 5B. 61. 62. (© The deep branch of the ulnar nerve inner- vates the adductor pollicis, abductor digiti min- imi, flexor digiti minimi brevis, opponens digiti minimi, lumbricals 3 and 4, dorsal interossei 1~4, and palmar interossei 1-3. The median nerve innervates lumbricals 1 and 2 (Maore, p 770). (£) The carpal tunnel contains the median nerve, the four tendons of the flexor digitorum superfi- cialis, the four tendons of the flexor digitorum profundus, and the tendon of the flexor pollicis longus (Moore, p 774) (A) The stemoclavicular joint, which does not dislocate easily, is a saddle-type synovial joint but functions as a ball-and-socket joint, It is the articulation of the sternal end of the clavicle with the manubrium of the stemum. The joint is sup plied by the internal thoracic and supraseapular arteries and is innervated by branches of the medial supraclavicular nerve and the nerve to the subclavius (Moore, pp 781-782) (E) The actomioclavicular joint is a plane-type synovial jointand is strengthened by the AC lig- amentand the coracoclavicular ligament, which is composed of the conoid and trapezoid liga- ments. It is supplied by the suprascapular and thoracoacromial arteries and is innervated by the supraclavicular, lateral pectoral, and axillary nerves. When dislocated, it is referred to as a “separated shoulder” (Moore, pp 784, 787). (B) The pectoralis major (clavicular head) and deltoid (anterior part) flex the arm at the gleno- humeral joint. The coracobrachialis and the bi- ceps brachii assist (Moore, p 792) (A) The posterior portion of the deltoid causes extension of the arm at the glenohumeral joint. The deltoid (as a whole, but especially the cen- tral part) causes abduction, whereas the pec- toralis major and latissimus dorsi cause adduc- tion. The subscapularis causes medial rotation, whereas the infraspinatus causes lateral rota~ tion (Moore, p 792), (E) The elbow is a hinge type of synovial joint, strengthened by radial and ulnar collateral liga- ments. Itissupplied by arteries derived from the 65. 67. 69. anastomosis around the elbow and is inner- vated by the musculocutaneous, radial, and ulnar nerves. It is surrounded by the intratendi- nous olecranon bursa, the subtendinous olec- ranon bursa, and the subcutaneous olecranon bursa (Moore, pp 795-798). (©) The proximal and distal radioulnar joints are pivot-type synovial joints. The radiocarpal (wrist) jointisa condyloid type of synovial joint, Intercarpal joints are plane-type synovial joints Metacarpophalangeal joints are condyloid types of synovial joints. Interphalangeal joints are hinge-type synovial joints (Moore, pp 800, 603, 807, 809). (A) All carpometacarpal and intermetacarpal joints are the plane-type synovial joints except for the carpometacarpal joint of the thumb, which is a saddle joint (Moore, p 809). (E) The clavicle varies more in shape than most other long bones and is thicker and more curved inmanual workers. The right davicleis stronger than the left and is usually shorter. The clavicle can also be pierced by a branch of the supracla- vicular nerve. The claviele is a long bone with no medullary cavity. It consists of spongy (cancel lous) bone with a shell of compact bone (Moore, 667). (A) Fractures of the scapula typically involve the protruding subcutaneous acromion. The remain- der of the scapula is well protected by muscles and the thoracie wall itself (Moore, p 669). (D) The surgicalneck of the humerusisin direct contact with the axillary nerve, the radial nerve runs in the radial groove, the distal end of the humerus is in direct contact with the median nerve, and the medial epicondyl with the ulnar nerve (Moore, p 670) is in contact (A) Damage to the long thoracic nerve results in “winging” of the scapula (Moore, p 689), (A) The triangle of auscultation, a good place to examine lung sounds, is bounded by the supe- rior horizontal border of the latissimus dorsi, the medial border of the scapula, and the inferolat-2: The Upper Limb 2. 74, 75. 76. 7 eral border of the trapezius. The 6th and 7th ribs and the 6th intercostal space is subcutaneous (Moore, p 693). (B) With paralysis of the latissimus dorsi, the patient is unable to raise the trunk as necessary for climbing. The cause could be injury to the thoracodorsal nerve (C6-C7-C8) (Moore, p 693). (A) Injury to the dorsal scapular nerve (C1-C5) can paralyze the thomboids, causing the scapula ‘on one side to be located farther from the midline than that on the normal side (Moore, » 695). (B) The deltoid atrophies when the axillary nerve (C5-C6) is damaged. Therefore, the rounded contour of the shoulder often dis- appears. A loss of sensation may occur on the lateral side of the proximal part of the arm (Moore, pp 696-697) (B) Injury or disease may damage the rotator cuff, causing instability of the glenohumeral joint. The supraspinatus tendon is the most commonly torn part of the rotator cuff, Acute tears are uncommon in young persons (Maore, pp 698-699). (©) Inan upper brachial plexus injury causing Erb-Duchenne palsy, one would expect damage to C5-C6, resulting in “waiter’s tip position” (adducted shoulder, medially rotated arm, and extended elbow). This results from paralysis of the deltoid, biceps, brachialis, and brachioradi- alis. The lateral aspect of the upper limb also experiences loss of sensation (Moore, p 716). (D) Damage to the inferior trunks of the brachial plexus (C8-Tl) affects the short muscles of the hand, résulting in “clawhand,” The patient might have grabbed a tree limb to catch himself while falling to cause this injury. “Clawhand” may also bbe caused by an injury to the ulnar nerve (Moore, pp 716-717, 761). (B) A knife wound to the axilla would dam- age the musculocutaneous nerve and result in paralysis of the coracobrachialis, biceps, and brachialis. Therefore, flexion of the elbow joint and supination of the forearm would be weak- 78. 79. 80. 81. ened. The patient would also lose sensation on. the lateral surface of the forearm (Moore, p 731). (©) When the median nerve is injured, the pa- tient often exhibits the “hand of benediction.” When the patient tries to make a fist, digits 2 and 3 remain partially extended because flexion of the PIP joints is lost in digits 1-3 and weakened in digits 4-5. Flexion of the DIP joints is lost in digits 2-3 but maintained in digits 4-5 (since the ulnar nerve controls the medial part of the flexor digitorum profundus). Flexion of the MCP joints of digits 2-3 will also be affected due to a loss of the lumbricals 1 and 2 (Moore, pp 757, 774, 776). (A) The ulnar nerve is often injured where it passes posterior to the medial epicondyle of the humerus. The patient experiences loss of sensa- tion in the medial part of the palm as well as in the medial 1 digits. Most intrinsic hand mus- cles are paralyzed, and the patient loses the ability to adduict the hand at the wrist. Patients cannotmakea fist since they are unable to flex the 4th and 5th digits at the DIP joints. The result- ing deformity is known as “clawhand” (Moore, pp 761, 76-777). (8) Amelia is the complete absence of one or more extremities while meromelia is the partial absence of ane or more extremities. All segments of extremities are present but abnormally short in micromelia. In phocomelia, long bones are absent, and small hands or feet are attached to the trunk by short, irregular bones. In clefthand (lobster claw deformity), the third metacarpal is absent and digits 1-2 and 4-5 are fused (Sadler, p 179), (C) Syndactyly involves abnormal fusion of fin- gers and toes. Cleft hand (lobster claw defor- mity) consists of an abnormal cleft between the 2nd and 4th metacarpal bones, with the 3rd metacarpal and phalangeal bones being absent and with digits 1-2 and 4-5 being fused. Poly- dactyly involves extra fingers or toes, while ectrodactyly involves the absence of a digit. Mutations in HOXA13 result in hand-foot-geni- tal syndrome, where carpals and short digits are fused and the genitalia have altered structures (Sadler, p 181)Answers and Explanations: 71-98 29 82. (D) During development, dorsal cells organize as the epimere and ventral cells organize as the hypomere, Dorsal rami innervate muscles de- rived from the epimere, whereas ventral rami innervate muscles derived from the hypomere. Myoblasts of the epimere form the extensor muscles of the vertebral column, and those of the hypomere give rise to muscles of the limbs and body wall. Somites and somitomeres form the musculature of the limbs (Sadler, pp 189-190). (8) Partial or complete absence of one or more muscles is rather common. One of the best- known examplesis total or partial absence of the pectoralis major (Poland anomaly). Similarly, the palmaris longus, serratus anterior, and quad- ratus femoris may be partially or entirely absent (Sadler, p 192). biceps brachii cephalic vein radial nerve 87. 88. 89. 91. 92. 94, 95. 97. 98. brachial artery median nerve lateral cord musculocutaneous nerve medial antebrachial cutaneous nerve ulnar nerve lateral pectoral nerve coracobrachialis brachialis ulna Jong head of triceps brachii lateral head of triceps brachii