Upper Limb Practice Questions

Q: A 50-year-old woman presented with numbness and weakness of the right hand. On examination, there was atrophy of the thenar eminence and hypoaesthesia in the distribution. Compression of which of the following nerves could explain the presentation?

Median Nerve. ### **Explanation** The clinical presentation of **thenar eminence atrophy** and **hypoaesthesia** (numbness) in the hand is a classic sign of **Median Nerve** compression, most commonly occurring at the wrist within the carpal tunnel (Carpal Tunnel Syndrome). **1. Why Median Nerve is Correct:** The median nerve provides motor innervation to the **LOAF** muscles (Lateral two Lumbricals, Opponens pollicis, Abductor pollicis brevis, and Flexor pollicis brevis). The latter three make up the thenar eminence. Chronic compression leads to denervation and subsequent atrophy of these muscles [1]. Sensitivities are affected in the lateral 3½ fingers and the corresponding palmar surface [1]. **2. Why Other Options are Incorrect:** * **Ulnar Nerve:** Innervates the hypothenar eminence and most intrinsic hand muscles. Injury leads to "Claw Hand" and atrophy of the interossei, not the thenar eminence [1]. * **Radial Nerve:** Primarily supplies the extensors of the forearm and wrist. Injury typically results in "Wrist Drop" and sensory loss on the dorsal aspect of the first web space. * **Axillary Nerve:** Innervates the deltoid and teres minor muscles. Injury results in loss of shoulder abduction and sensory loss over the "regimental badge" area of the lateral arm. **3. NEET-PG High-Yield Pearls:** * **Ape Thumb Deformity:** Caused by median nerve palsy, where the thumb is adducted and extended due to the loss of opponens pollicis and abductor pollicis brevis. * **Pointing Index (Benedict’s Sign):** Seen when attempting to make a fist in high median nerve palsy. * **Tinel’s Sign & Phalen’s Test:** Key clinical provocative tests used to diagnose Carpal Tunnel Syndrome. * **Palmar Cutaneous Branch:** This branch of the median nerve arises *proximal* to the carpal tunnel; therefore, sensation over the central palm is often spared in Carpal Tunnel Syndrome [1].

Q: A man is unable to hold typing paper between his index and middle fingers. Which of the following nerves was likely injured?

Ulnar nerve. ### Explanation The correct answer is **C. Ulnar nerve**. **1. Why the Ulnar Nerve is Correct:** The action described—holding a piece of paper between the fingers—is called **adduction of the fingers**. This movement is performed by the **Palmar Interossei** muscles. All interossei (both palmar and dorsal) are innervated by the **deep branch of the ulnar nerve** (C8, T1) [1]. * **Palmar Interossei (3 muscles):** Adduct the fingers (PAD). * **Dorsal Interossei (4 muscles):** Abduct the fingers (DAB). Inability to adduct the fingers results in a positive "Card Test," where the patient cannot grip a piece of paper between their extended fingers against resistance [2]. **2. Why the Other Options are Incorrect:** * **Radial Nerve:** Primarily supplies the extensors of the elbow, wrist, and fingers [1]. Injury leads to "Wrist Drop," not loss of finger adduction. * **Median Nerve:** Supplies the thenar muscles (LOAF: Lumbricals 1 & 2, Opponens pollicis, Abductor pollicis brevis, Flexor pollicis brevis) [1]. Injury affects thumb opposition and precision grip (Ape thumb deformity). * **Musculocutaneous Nerve:** Supplies the anterior compartment of the arm (Biceps, Coracobrachialis, Brachialis). Injury results in weak elbow flexion and loss of sensation on the lateral forearm. **3. High-Yield Clinical Pearls for NEET-PG:** * **Froment’s Sign:** Another test for ulnar nerve palsy. The patient compensates for a weak **Adductor Pollicis** (ulnar nerve) by using the **Flexor Pollicis Longus** (median nerve), causing the thumb's IP joint to flex when gripping paper [2]. * **Ulnar Paradox:** The higher the lesion (at the elbow), the less prominent the clawing of the fingers, because the long flexors (FDP) are also paralyzed. * **Wartenberg’s Sign:** Inability to adduct the little finger due to ulnar nerve palsy [2].

Q: Which of the following clinical signs is observed in median nerve injury?

Pointing Index. **Explanation:** The **Median Nerve** is the "nerve of precision" and the "laborer’s nerve." Injury to this nerve, particularly at or above the elbow (High Median Nerve Palsy), results in the **Pointing Index** (also known as the **Ochsner’s Clasping Test**). 1. **Why Pointing Index is Correct:** When a patient is asked to clasp their hands together, the index finger remains extended. This occurs because the median nerve [1] supplies the **Flexor Digitorum Profundus (FDP)** to the index and middle fingers and the **Flexor Digitorum Superficialis (FDS)**. Paralysis of these muscles prevents flexion of the PIP and DIP joints of the index finger, leaving it "pointing." 2. **Analysis of Incorrect Options:** * **Wristdrop:** Caused by **Radial Nerve** injury (typically at the mid-shaft of the humerus). It results from paralysis of the wrist extensors. * **Wartenberg’s Sign:** Observed in **Ulnar Nerve** palsy. It is the inability to adduct the little finger due to weakness of the 3rd palmar interosseous muscle. * **Regimental Badge Sign:** A patch of sensory loss over the lateral aspect of the shoulder (deltoid area) caused by **Axillary Nerve** injury. **High-Yield Clinical Pearls for NEET-PG:** * **Ape Thumb Deformity:** Seen in median nerve injury due to paralysis of the Thenar muscles (Opponens pollicis), leading to loss of thumb opposition. * **Benediction Deformity:** Seen when the patient attempts to make a fist; the index and middle fingers stay extended (similar mechanism to Pointing Index). * **Carpal Tunnel Syndrome:** The most common site of compression for the median nerve at the wrist [1].

Q: The axillary artery is divided into three parts by which muscle?

Pectoralis minor. The **axillary artery** is the direct continuation of the subclavian artery, beginning at the outer border of the first rib and ending at the lower border of the teres major muscle. ### Why Pectoralis Minor is Correct The **pectoralis minor muscle** crosses the axillary artery anteriorly, serving as the key anatomical landmark that divides it into three functional parts: 1. **First Part:** Proximal to the muscle (between the 1st rib and upper border of pectoralis minor). It has **one** branch. 2. **Second Part:** Posterior (deep) to the muscle. It has **two** branches. [1] 3. **Third Part:** Distal to the muscle (between the lower border of pectoralis minor and lower border of teres major). It has **three** branches. ### Why Other Options are Incorrect * **Pectoralis Major:** While it forms the anterior wall of the axilla, it does not anatomically segment the artery into three distinct parts. [1] * **Teres Major:** This muscle marks the **termination** of the axillary artery, where it becomes the brachial artery. * **Teres Minor:** This muscle forms part of the posterior wall of the axilla and is a boundary for the quadrangular and triangular spaces, but it does not divide the artery. ### High-Yield Clinical Pearls for NEET-PG * **Mnemonic for Branches:** "Save The Lions And Pity She-devils" (Superior thoracic, Thoraco-acromial, Lateral thoracic, Subscapular, Anterior circumflex humeral, Posterior circumflex humeral). * **The "Rule of Numbers":** The part number corresponds to the number of branches (1st part = 1 branch; 2nd part = 2; 3rd part = 3). * **Largest Branch:** The **subscapular artery** (from the 3rd part) is the largest branch of the axillary artery. * **Surgical Landmark:** The cords of the brachial plexus are named (Lateral, Medial, Posterior) based on their relationship to the **second part** of the axillary artery. [1]

Q: The lesion of Klumpke's paralysis is in which part of the nerve plexus?

Lower brachial plexus. **Explanation:** **1. Why Option B is Correct:** Klumpke’s paralysis is a form of brachial plexus injury caused by an injury to the **lower trunk**, specifically the **C8 and T1 nerve roots**. This typically occurs due to hyperabduction of the arm (e.g., clutching an object while falling from a height or during a breech delivery). The T1 fibers primarily supply the intrinsic muscles of the hand; thus, their loss leads to the characteristic "total claw hand" deformity. **2. Why Other Options are Incorrect:** * **Option A (Cervical Plexus):** This plexus (C1-C4) supplies the skin and muscles of the head, neck, and the diaphragm (via the phrenic nerve). It is not involved in upper limb motor control. * **Option C (Upper Brachial Plexus):** Injury to the upper trunk (C5-C6) results in **Erb’s Paralysis**, characterized by the "Policeman’s tip" or "Waiter’s tip" deformity. * **Option D (Sacral Plexus):** This plexus (L4-S4) supplies the lower limbs and pelvic floor; it has no anatomical connection to the upper limb. **3. High-Yield Clinical Pearls for NEET-PG:** * **Deformity:** Klumpke’s paralysis results in a **Total Claw Hand** (hyperextension at MCP joints and flexion at IP joints) due to the paralysis of lumbricals and interossei. * **Horner’s Syndrome:** Often associated with Klumpke’s paralysis if the T1 root is avulsed proximal to the sympathetic chain (causing miosis, ptosis, and anhidrosis). * **Sensory Loss:** Occurs along the ulnar aspect of the forearm and hand (C8-T1 dermatomes). * **Contrast:** Remember **E**rb’s = **E**levated (Upper trunk) vs. **K**lumpke’s = **K**low (Lower trunk).

Q: A 42-year-old female presents with a shoulder injury requiring surgical repair of the supraspinatus muscle. Which of the following is true of the supraspinatus muscle?

It is innervated chiefly by the C5 spinal nerve.. ### Explanation **1. Why Option C is Correct:** The supraspinatus muscle is innervated by the **suprascapular nerve**, which arises from the **superior trunk** of the brachial plexus. Its fibers are derived primarily from the **C5** spinal nerve (with some contribution from C6). In the context of NEET-PG, C5 is considered the "chief" root for the supraspinatus and infraspinatus muscles. **2. Why the Other Options are Incorrect:** * **Option A:** The supraspinatus inserts on the **highest (superior) impression of the greater tubercle** of the humerus. The lesser tubercle is the insertion site for the subscapularis muscle. * **Option B:** While traditionally taught as the "initiator" (0–15°), current electromyographic studies show it is active throughout the entire range of abduction. However, the **deltoid** is the primary muscle for abduction beyond 15°. (Note: If this were a "best function" question, B is a common distractor, but C is an anatomical fact regarding innervation). * **Option D:** The supraspinatus is supplied by the **suprascapular nerve**, not the subscapular nerve. The upper and lower subscapular nerves (C5-C6) supply the subscapularis and teres major. **3. Clinical Pearls & High-Yield Facts:** * **Rotator Cuff (SITS):** Supraspinatus, Infraspinatus, Teres minor, and Subscapularis. * **Most Common Injury:** The supraspinatus is the most frequently torn tendon in the rotator cuff due to its location under the acromion (impingement zone). * **Suprascapular Notch:** The suprascapular nerve passes *under* the superior transverse scapular ligament (the "Army" goes over the bridge—artery; the "Navy" goes under—nerve). * **Painful Arc Syndrome:** Pain during abduction between 60° and 120° often indicates supraspinatus tendinitis.

Q: A 40-year-old man sustains a left elbow fracture in a car accident. He presents with numbness in his fourth and fifth fingers, and a weakened hand grip. Neurologic examination reveals diminished sensation over the fifth finger and the ulnar aspect of the fourth finger, along with weakness in finger abduction and adduction. What is the most likely diagnosis?

Ulnar nerve injury. **Explanation:** The clinical presentation is a classic case of **Ulnar Nerve Injury**, likely occurring at the level of the medial epicondyle (cubital tunnel) following the elbow fracture. **1. Why Ulnar Nerve is Correct:** * **Sensory Loss:** The ulnar nerve provides sensation to the medial 1.5 fingers (5th finger and ulnar half of the 4th finger) [1]. * **Motor Deficit:** It innervates all **Interossei muscles** (Dorsal for abduction, Palmar for adduction). Weakness in finger abduction/adduction and a weakened grip (due to loss of intrinsic muscle power) are hallmark signs. * **Anatomical Context:** The ulnar nerve runs posterior to the medial epicondyle of the humerus, making it highly vulnerable in elbow fractures or dislocations. **2. Why Other Options are Incorrect:** * **Radial Nerve Injury:** Typically presents with **Wrist Drop** due to paralysis of the extensors. Sensory loss occurs on the dorsal aspect of the first web space. * **Median Nerve Injury:** Would result in "Ape Hand" deformity, loss of thumb opposition, and sensory loss over the lateral 3.5 fingers (palmar aspect) [1]. * **Carpal Tunnel Syndrome:** This involves compression of the **Median nerve** at the wrist. It would not cause weakness in finger abduction/adduction (interossei) and would not be caused by an elbow fracture [1]. **Clinical Pearls for NEET-PG:** * **Froment’s Sign:** Tests for adductor pollicis palsy (Ulnar nerve). * **Claw Hand:** Distal ulnar nerve lesions cause more prominent clawing than proximal lesions (the **Ulnar Paradox**). * **Point of Injury:** Elbow injuries affect the Flexor Carpi Ulnaris (FCU), whereas wrist injuries spare it.

Question 1

A 50-year-old woman presented with numbness and weakness of the right hand. On examination, there was atrophy of the thenar eminence and hypoaesthesia in the distribution. Compression of which of the following nerves could explain the presentation?

Accepted Answer

Median Nerve

Answer

Ulnar Nerve

Answer

Radial Nerve

Answer

Axillary Nerve

Question 2

A 40-year-old male patient presented to the ER with pain and deformity in the left arm after a fall. An x-ray of the affected area was ordered. The nerve most likely involved in this condition supplies which of the following muscles?

Accepted Answer

Muscle A

Answer

Muscle B

Answer

Muscle D

Answer

Muscle C

Question 3

Which arteries form the arterial anastomosis around the shoulder?

Accepted Answer

1st part of subclavian artery with 3rd part of axillary artery

Answer

2nd part of subclavian artery with 2nd part of axillary artery

Answer

3rd part of subclavian artery with 1st part of axillary artery

Answer

3rd part of subclavian artery with 3rd part of axillary artery

Question 4

A man is unable to hold typing paper between his index and middle fingers. Which of the following nerves was likely injured?

Accepted Answer

Ulnar nerve

Answer

Radial nerve

Answer

Median nerve

Answer

Musculocutaneous nerve

Question 5

Which of the following clinical signs is observed in median nerve injury?

Accepted Answer

Pointing Index

Answer

Wristdrop

Answer

Wartenberg's Sign

Answer

Regimental badge sign

Question 6

The axillary artery is divided into three parts by which muscle?

Accepted Answer

Pectoralis minor

Answer

Pectoralis major

Answer

Teres major

Answer

Teres minor

Question 7

A 32-year-old man presents with multiple fractures of his right upper limb following a severe car crash. He underwent surgery with fixation of bony fragments using metallic plates. Five months postoperatively, he presents with the ability to abduct his arm and extend his forearm. Sensation in the forearm and hand is intact. However, his hand grasp is very weak, and he cannot extend his wrist against gravity. Which of the following nerves was most likely injured during the surgical procedure?

Accepted Answer

Radial nerve at the distal third of the humerus

Answer

Posterior cord of the brachial plexus

Answer

Radial and ulnar nerves

Answer

Radial, ulnar, and median nerves

Question 8

The lesion of Klumpke's paralysis is in which part of the nerve plexus?

Accepted Answer

Lower brachial plexus

Answer

Cervical plexus

Answer

Upper brachial plexus

Answer

Sacral plexus

Question 9

A 42-year-old female presents with a shoulder injury requiring surgical repair of the supraspinatus muscle. Which of the following is true of the supraspinatus muscle?

Accepted Answer

It is innervated chiefly by the C5 spinal nerve.

Answer

It inserts on the lesser tubercle of the humerus.

Answer

It initiates abduction of the shoulder.

Answer

It is supplied by the upper subscapular nerve.

Question 10

A 40-year-old man sustains a left elbow fracture in a car accident. He presents with numbness in his fourth and fifth fingers, and a weakened hand grip. Neurologic examination reveals diminished sensation over the fifth finger and the ulnar aspect of the fourth finger, along with weakness in finger abduction and adduction. What is the most likely diagnosis?

Accepted Answer

Ulnar nerve injury

Answer

Radial nerve injury

Answer

Median nerve injury

Answer

Carpal tunnel syndrome

Upper Limb — MCQs

Upper Limb — MCQs

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