Category: Quiz

Trigeminal neuralgia

TRIGEMINAL NEURALGIA

Q. 1

 Drug of choice for trigeminal neuralgia is?

 A Chlorpromazine
 B

 Carbamezapine

 C Gabapentine
 D

Fluoxetine

Q. 1

 Drug of choice for trigeminal neuralgia is?

 A Chlorpromazine
 B

 Carbamezapine

 C Gabapentine
 D

Fluoxetine

Ans. B

Explanation:

Carbamezapine REF: Harrison’s 17th ed chapter 371

  • Drug of choice for trigeminal neuralgia – Carbamezapine
  • If drug treatment fails, surgical therapy should be offered. The most widely applied procedure creates a heat lesion of the trigeminal (gasserian) ganglion or nerve, a method termed radiofrequency thermal rhizotomy.
  • Gamma knife radiosurgery is also utilized for treatment
  • A third surgical treatment, microvascular decompression to relieve pressure on the trigeminal nerve as it exits the pons, requires a suboccipital craniotom

Q. 2

Which statement is true about carbamazepine ?

 A

Used in trigeminal neuralgia

 B

Carbamazepine is an enzyme inhibitor

 C

Can cause megaloblastic anemia

 D

It is the drug of choice for status epilepticus

Q. 2

Which statement is true about carbamazepine ?

 A

Used in trigeminal neuralgia

 B

Carbamazepine is an enzyme inhibitor

 C

Can cause megaloblastic anemia

 D

It is the drug of choice for status epilepticus

Ans. A

Explanation:

Used in trigeminal neuralgia [Ref K.D.T. 6thie p 406-407]

  • Trigeminal neuralgias are characterized by attacks of high intensity electric shock like stabbing pain, set off by even trivial stimulation of certain trigger zones in the mouth or on the face.
  • Carbamazepine is not an analgesic but has a specific action in these neuralgias. It acts by interrupting temporal summation of afferent impulses (by a selective action on high frequency nerve impulses).
  • “Carbamazepine has become the drug of choke for Trigeminal neuralgias”.
  • Other antiepileptics such as phenytoin and Baclofen are less efficacious alternatives.

More on carbamazepine

  • The most important action of carbamazepine is blockade of voltage dependent sodium ion channels, reducing membrane excitability.
  • It is considered the drug of choice for partial seizures

Pharamacokinetics

  • Carbamazepine is an extensively metabolized drug.
  • One of the notable property of carbamazepine is its ability to induce microsomal enzymes (Paso)
  • The t1/2 of carbamazepine decreases from 36 hrs, seen initially, to as short as 8-12 hrs due to its enzyme inducing property (it induces its own metabolism).
  • Due to its enzyme inducing property, carbamazepine effects the metabolism of other drugs too.

Toxicity:-

  • The most cocoon dose related adverse effects of carbamazepine are diplopia and ataxia.
  • It may also cause hyponatretnia and water intoxication.
  • One more important adverse effect is idiosyncratic blood dyscrasias which may cause aplastic anemia and agranulocytosis.

Q. 3

A Patient presents with recurrent episodes of sharp pain over his right cheek that is precipitated on chewing. Between attacks patient is otherwise normal. The most probable diagnosis is?

 A

Preherpetic neuralgia

 B

Trigeminal neuralgia

 C

Mumps

 D

Thalamic syndrome

Q. 3

A Patient presents with recurrent episodes of sharp pain over his right cheek that is precipitated on chewing. Between attacks patient is otherwise normal. The most probable diagnosis is?

 A

Preherpetic neuralgia

 B

Trigeminal neuralgia

 C

Mumps

 D

Thalamic syndrome

Ans. B

Explanation:

Answer is B (Trigeminal Neuralgia):

Recurrent attacks of sharp pain over the cheek precipitated .from trigger areas or trigger factors such as chewing with the patient being normal in the interval period strongly suggests a diagnosis of Trigeminal Neuralgia. Trigeminal Neuralgia is typically characterized by Paroxysmal attacks of brief electric shock-like pains, abrupt in onset and termination, limited to the distribution of one or more divisions of the trigeminal nerve lasting for a brief period from a fraction of a second to 2 minutes. The most common division of the trigeminal nerve involved in trigeminal neuralgia is the Maxillary division (V2) followed by the mandibular division (V3). The ophthalmic Division (VI) is rarely involved

The pain often evokes spasm of the muscle of the face on the affected side. The clinical association between Trigeminal Neuralgia and hemifacial spasm is called Tic Douloureux.

Typical Features of Trigeminal Neuralgia (Prosopalgia, Fothergill’s disease)

  • Sudden/ Abrupt onset and termination
  • Sharp superficial, stabbing or burning in quality
  • Severe in intensity
  • Brief in duration (lasting for a brief period from a fraction of a second to 2 minutes)
  • Intermittent (Between paroxysms the patient is usually asymptomatic. Following a painful paroxysm there is usually a refractory period during which pain cannot be triggered)
  • Unilateral (The pain never crosses to the opposite side but it may rarely occur bilaterally in which case a central cause such as multiple sclerosis must be considered)
  • Precipitated from trigger areas or by trigger factors in the trigeminal area such as eating or chewing, washing the face, shaving, smoking, talking or brushing the teeth
  • There is no clinically evident neurological deficit

Note :

Trigeminal Neuralgia is More common with advancing age

Trigeminal Neuralgia is More common in women

Trigeminal Neuralgia is More common on right side

Trigeminal Neuralgia attacks are most frequent during the day (but may awaken the patient at night) Trigeminal Neuralgia most frequently arises from the maxillary division of Trigeminal nerve (V2)


Q. 4

All of the following statements about Trigeminal Neuralgia are true Except:

 A

Most commonly involves Ophthalmic Division (V3) of Maxillary Nerve

 B

Attacks most commonly occur during the day

 C

Affects women more than men

 D

More common on the Right Side

Q. 4

All of the following statements about Trigeminal Neuralgia are true Except:

 A

Most commonly involves Ophthalmic Division (V3) of Maxillary Nerve

 B

Attacks most commonly occur during the day

 C

Affects women more than men

 D

More common on the Right Side

Ans. A

Explanation:

Answer is A (Most commonly involves Ophthalmic Division (V3) of Maxillary Nerve):

The most common division of the trigeminal nerve involved in trigeminal neuralgia is the Maxillary division (V2) followed by the mandibular division (V3). The maxillary division (V2) is the most common site ofpain either alone or in combination with the mandibular division (V3). The ophthalmic Division (VI) is rarely involved (<5%). Pain arising from the maxillary division is usually referred to the upper lip nose and cheek while the pain arising from the mandibular division is often referred to the lower lip.

Features of Trigeminal Neuralgia

  • The most common division of the trigeminal nerve involved in trigeminal neuralgia is the Maxillary division (V2)
  • More common with advancing age
  • More common in women
  • More common on right side
  • Attacks are most frequent during the day (but may awaken the patient at night)

Q. 5

Most common cause of trigeminal neuralgia ‑

 A

Infection

 B

Trauma

 C

Vascular compression

 D

Iatrogenic

Q. 5

Most common cause of trigeminal neuralgia ‑

 A

Infection

 B

Trauma

 C

Vascular compression

 D

Iatrogenic

Ans. C

Explanation:

Ans. is ‘c’ i.e., Vascular compression

  • Trigeminal neuralgia (tic douloureux) is characterized by intermittent, shooting pain in the face.
  • It is due to involvement of trigeminal nerve.
  • 95% of causes of trigeminal neuralgia are due to pressure on trigeminal nerve close to where it enters the brain stem, past the Gasserian ganglion. In most cases, this pressure seems to be caused by an artery or vein compressing trigeminal nerve.
  • Other causes are tumor, cysts, AV malformation and multiple sclerosis.
  • Most commonly used drugs for treatment of trigeminal neuralgia are carbamazepine, gabapentin and valproate.


Trigeminal (v) nerve

 

TRIGEMINAL (V) NERVE

Q. 1

Which of the following nerve constitute the afferent component of corneal reflex?

 A Vagus nerve
 B Facial nerve
 C Trigeminal nerve
 D Glossopharyngeal nerve

Q. 1

Which of the following nerve constitute the afferent component of corneal reflex?

 A Vagus nerve
 B Facial nerve
 C Trigeminal nerve
 D Glossopharyngeal nerve
Ans.C

Explanation:

The afferent component of corneal reflex is mediated by trigeminal nerve and efferent component is mediated by facial nerve which innervates the orbicularis oculi muscle. In this reflex, touching the cornea from the side while the subject looks forward evokes blinking.

Ref: Comprehensive Ophthalmology By A K Khurana, 4th Edition, Pages 292-3; Color Atlas of Neurology By Reinhard Rohkamm, Page 26.


Q. 2

Which of the following nerve innervates the anterior belly of the digastric muscle?

 A Facial nerve
 B Trigeminal nerve
 C Vagus nerve
 D Abducens nerve

Q. 2

Which of the following nerve innervates the anterior belly of the digastric muscle?

 A Facial nerve
 B Trigeminal nerve
 C Vagus nerve
 D Abducens nerve
Ans.B

Explanation:

The anterior belly of the digastric muscle is innervated by the mandibular division of the trigeminal nerve.

  • The inferior alveolar nerve which give rise to the mylohyoid nerve innervates the mylohyoid muscle. 

Q. 3

The tensor tympani muscle is inserted to the handle of malleus. The nerve supply to tensor tympani is?

 A Vagus nerve
 B Glossopharyngeal nerve
 C Trigeminal nerve
 D Facial nerve

Q. 3

The tensor tympani muscle is inserted to the handle of malleus. The nerve supply to tensor tympani is?

 A Vagus nerve
 B Glossopharyngeal nerve
 C Trigeminal nerve
 D Facial nerve
Ans.C

Explanation:

The motor pure branches of mandibular division of trigeminal nerve:

  • Masseteric nerve (masseter muscle)
  • Deep temporal nerves (temporalis muscle)
  • Pterygoid nerves (pterygoid muscles)
  • Nerve of the tensor tympani muscle
  • Nerve to the tensor veli palatini muscle

Q. 4

Which of the following opening in the base of the skull transmits the third branch of trigeminal nerve?

 A Foramen ovale
 B Foramen lacerum
 C Foramen magnum
 D Foramen spinosum

Q. 4

Which of the following opening in the base of the skull transmits the third branch of trigeminal nerve?

 A Foramen ovale
 B Foramen lacerum
 C Foramen magnum
 D Foramen spinosum
Ans.A

Explanation:

Foramen ovale is an opening at the base of the lateral pterygoid plate. It transmits the third branch of the trigeminal nerve, the accessory meningeal artery, and occasionally the superficial petrosal nerve.
  • Foramen lacerum transmits the internal carotid artery.
  • Foramen magnum transmits the medulla and its membranes, the spinal accessory nerves, the vertebral arteries, and the anterior and posterior spinal arteries.

Q. 5

Which is the nucleus of Masseteric Reflex?

 A Superior sensory nucleus of trigeminal nerve
 B Spinal nucleus of trigeminal nerve
 C Mesencephalic nucleus of trigeminal nerve
 D Dorsal nucleus of vagus nerve

Q. 5

Which is the nucleus of Masseteric Reflex?

 A Superior sensory nucleus of trigeminal nerve
 B Spinal nucleus of trigeminal nerve
 C Mesencephalic nucleus of trigeminal nerve
 D Dorsal nucleus of vagus nerve
Ans.C

Explanation:

The reflex arc of masseteric reflex involves two nuclei of the trigeminal nerve, namely, the mesencephalic nucleus and the motor nucleus of trigeminal nerve .


Q. 6

False statement about trigeminal nerve:

 A Carries sensation from face and scalp
 B Has motor branch
 C Arise from C8 nerve root
 D Composed of spinal nucleus

Q. 6

False statement about trigeminal nerve:

 A Carries sensation from face and scalp
 B Has motor branch
 C Arise from C8 nerve root
 D Composed of spinal nucleus
Ans.C

Explanation:

C i.e. Arise from C8 nerve root


Q. 7

Identify the Nerve Marked as Nerve A in the Diagram ?

Trigeminal nerve

 A Facial Nerve 
 B Trigeminal Nerve
 C Occulomotor Nerve
 D None of the Above

Q. 7

Identify the Nerve Marked as Nerve A in the Diagram ?

Trigeminal nerve

 A Facial Nerve 
 B Trigeminal Nerve
 C Occulomotor Nerve
 D None of the Above
Ans.B

Explanation:

The Image shows Trigeminal Nerve



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Muscles of pectoral region

MUSCLES OF PECTORAL REGION

Q. 1

Protractor of scapula is? 

 A

Serratus anterior

 B

Rhomboidis major 

 C

Deltoid

 D

Pectoralis major

Q. 1

Protractor of scapula is? 

 A

Serratus anterior

 B

Rhomboidis major 

 C

Deltoid

 D

Pectoralis major

Ans. A

Explanation:

Serratus anterior

Movements of scapula:

Movement

Muscles

Elevation

Trapezius and Levator scapular

Protraction

Serratous anterior and Pectoralis minor

Retraction

Rhomboids and Trapezius

Lateral rotation

upper trapezius and lower serratous

Medial rotation

Levator scapulae , Rhomboids and Pectoralis minor


Q. 2

During breast reconstruction surgery which of the following structure is preserved?

 A Pectoralis minor
 B

Pectoralis major

 C Serratus anterior
 D

Nipple areola complex

Q. 2

During breast reconstruction surgery which of the following structure is preserved?

 A Pectoralis minor
 B

Pectoralis major

 C Serratus anterior
 D

Nipple areola complex

Ans. B

Explanation:

Pectoralis major REF: Oncoplastic and Reconstructive Surgery for Breast Cancer: By A. Fitoussi, M. G. Berry, B. Couturaud, R. J. Salmon Page 45

“As the breast implant is mostly placed beneath the pectoralis major muscle, it is never dissected. A complete musculofascial pocket is created by lateral and inferolateral dissection of the pectoralis minor and serratus anterior. If indicated, mastectomy is performed with preservation of skin envelop, but nipple areola complex is included in the resection with fusiform incision that is more oblique inferiorly”

The four surgical approaches to emplacing a breast implant to the implant pocket are described in anatomical relation to the pectoralis major muscle.

  1. Subglandular — the breast implant is emplaced to the retromammary space, between the breast tissue (the gland) and the pectoralis major muscle, which most approximates the plane of normal breast tissue, and affords the most aesthetic results. Yet, in women with thin pectoral soft-tissue, the subglandular position is likelier to show the ripples and wrinkles of the underlying implant. Moreover, the capsular contracture incidence rate is slightly greater with subglandular implantation.
  2. Subfascial- the breast implant is emplaced beneath the fascia of the pectoralis major muscle; this is a variant of the subglandular position. The technical advantages of the subfascial implant-pocket technique are debated; proponent surgeons report that the layer of fascial tissue provides greater implant coverage and better sustains its position.
  3. Subpectoral (dual plane) — the breast implant is emplaced beneath the pectoralis major muscle, after the surgeon releases the inferior muscular attachments, with or without partial dissection of the subglandular plane. Resultantly, the upper pole of the implant is partially beneath the pectoralis major muscle, while the lower pole of the implant is in the subglandular plane.
  4. Submuscular — the breast implant is emplaced beneath the pectoralis major muscle, without releasing the inferior origin of the muscle proper. Total muscular coverage of the implant can be achieved by releasing the lateral muscles of the chest wall — either the serratus muscle or the pectoralis minor muscle, or both — and suturing it, or them, to the pectoralis major muscle. In breast reconstruction surgery, the submuscular implantation approach effects maximal coverage of the breast implants.

Q. 3

Boundary of triangle of auscultation is not formed by:

 A >Serratus anterior
 B >Scapula
 C >Trapezius
 D >Latissimus dorsi
Q. 3

Boundary of triangle of auscultation is not formed by:

 A >Serratus anterior
 B >Scapula
 C >Trapezius
 D >Latissimus dorsi
Ans. A

Explanation:

Serratus anterior [Ref: B.D.C. Anatomy 4/e vol. 1 p64]Repeat.from Nov 08

The triangle of auscultation is a small triangular space on the back where the relatively thin musculature allows for respiratory sounds to be heard more clearly with a stethoscope.

It has the following boundaries:

  • medially, by the Trapezius
  • laterally by the scapula
  • inferiorly by the Latissimus dorsi

The floor is formed by

–      7th rib

–      6th & 7th intercostal spaces

–     Rhomboideus major

On the left side, the cardiac orifice of the stomach lies deep to the triangle, and in days before X-rays were discovered the sounds of swallowed liquids were auscultated over this triangle.



Q. 4

Muscle most commonly affected by congenital absence is?

 A

Pectoralis major

 B

Semi membranosus

 C

Teres minor

 D

Gluteus maximus

Q. 4

Muscle most commonly affected by congenital absence is?

 A

Pectoralis major

 B

Semi membranosus

 C

Teres minor

 D

Gluteus maximus

Ans. A

Explanation:

Pectoralis major and minor muscles are the most common congenitally absent muscles in humans.

Ref: Ultrasound of the Musculoskeletal System, 2007, Pages 51, 285; Principles of Neurology By Allan H. Ropper, Raymond Delacy Adams, Maurice Victor, Robert H. Brown, Page 1245; Clinical Pediatric Urology By A. Barry Belman, Lowell R. King, Stephen Alan Kramer, Page 947


Q. 5

A day after a left-sided lumpectomy and axillary dissection, a 63-year-old woman is experiencing difficulty elevating her left arm. She cannot fully raise her upper arm from the side of her body. The median border and inferior angle of the left scapula become unusually prominent when she pushes against the wall with both hands. The innervation of which of the following muscles was most likely injured during the surgery?

 A

Deltoid

 B

Latissimus dorsi

 C

Pectoralis major

 D

Serratus anterior

Q. 5

A day after a left-sided lumpectomy and axillary dissection, a 63-year-old woman is experiencing difficulty elevating her left arm. She cannot fully raise her upper arm from the side of her body. The median border and inferior angle of the left scapula become unusually prominent when she pushes against the wall with both hands. The innervation of which of the following muscles was most likely injured during the surgery?

 A

Deltoid

 B

Latissimus dorsi

 C

Pectoralis major

 D

Serratus anterior

Ans. D

Explanation:

This patient most likely sustained an injury to the long thoracic nerve (C5-C7), which innervates the serratus anterior muscle.

This muscle is located on the lateral portion of the thorax, attaching to the external surface of the lateral parts of the 1st – 8th ribs proximally and the anterior surface of the medial border of the scapula distally.

It is responsible for keeping the scapula applied to the thoracic wall, and protracts and rotates the scapula.

Other muscles and bones rely on the scapula to be “fixed”, as they use it as an anchor when producing movements of the humerus.

Injury to the long thoracic nerve, which lies on the medial wall of the axilla, can occur during weight lifting, thoracic or axillary surgery, or from a stab wound. The clinical features of a long thoracic nerve injury include a “winged” scapula (the protrusion of the scapula as the patient presses against a wall) and an inability to abduct the arm.

The deltoid and teres minor muscles are innervated by the axillary nerve (C5-C6), which winds around the humeral neck, and may be injured during the dislocation of the shoulder or a fracture to the neck of the humerus.

Injuries to this nerve present with weakness of shoulder abduction, and atrophy of the shoulder.

“Winging” of the scapula is not a prominent clinical feature of an axillary nerve injury.

The latissimus dorsi muscle is innervated by the thoracodorsal nerve (C6-C8), and is a large, fan-shaped muscle that extends, adducts, and medially rotates the humerus, and helps raise the body toward the arms during climbing and performing chin-ups.

Injury to the nerve that innervates this muscle can occur during surgical operations in the axilla, and makes the patient unable to perform a chin-up or go climbing.

The patient’s clinical findings in this case are inconsistent with an injury to the thoracodorsal nerve.

The pectoralis major muscle, which is innervated by the medial and lateral pectoral nerves, is involved in the adduction and medial rotation of the arm.

Injury to the nerves that innervate this muscle does not typically result in any disability, however the anterior axillary fold is absent on the affected side.


Q. 6

All of the following forms the boundaries of the lower triangular space of arm, EXCEPT?

 A

Teres major

 B

Shaft of humerus

 C

Pectoralis major

 D

Long head of triceps

Q. 6

All of the following forms the boundaries of the lower triangular space of arm, EXCEPT?

 A

Teres major

 B

Shaft of humerus

 C

Pectoralis major

 D

Long head of triceps

Ans. C

Explanation:

Boundaries of lower triangular space of arm are: medially it is bounded by long head of triceps, laterally by medial border of humerus and superiorly by teres major. Radial nerve and profunda brachii vessels are the contents of the lower triangular space.


Q. 7

Cord of brachial plexus are named as per their relation with the axillary artery behind which muscle?

 A

Deltoid

 B

Subclavius

 C

Teres major

 D

Pectoralis minor

Q. 7

Cord of brachial plexus are named as per their relation with the axillary artery behind which muscle?

 A

Deltoid

 B

Subclavius

 C

Teres major

 D

Pectoralis minor

Ans. D

Explanation:

Pectoralis minor crosses in front of axillary artery and divides it into three parts. The anterior relation of each part are; First part lies behing the pectoralis major muscle, second part lies behind the pectoralis minor and major muscle and third part lies behind pectoralis major.

The cords of brachial plexus are named according to their relation with the second part of  axillary artery, lateral cord runs lateral to the axillary artery, as well the medial and posterior cord lies medially and posterior to the axillary artery. Thus the muscle anteriorly to second part is pectoralis minor and major.


Q. 8

All of the following structures forms the border of Quadrangular space, EXCEPT?

 A

Teres major

 B

Teres minor

 C

Pectoralis minor

 D

Long head of the triceps brachii muscle

Q. 8

All of the following structures forms the border of Quadrangular space, EXCEPT?

 A

Teres major

 B

Teres minor

 C

Pectoralis minor

 D

Long head of the triceps brachii muscle

Ans. C

Explanation:

Structures forming the borders of Quadrangular space are teres major and teres minor muscles, long head of the triceps brachii muscle, and the humerus. 
 
Contents of this space are: axillary nerve and the posterior circumflex humeral artery.
 
Structures forming the border of triangular space are:
  • Teres major and teres minor muscles and the long head of the triceps brachii muscle.
  • Its contents is Circumflex scapular artery.

Q. 9

Which of the following is the only shoulder girdle muscle which is not inserted on the bone in free upper limb?

 A

Coracobrachialis

 B

Pectoralis major

 C

Pectoralis minor

 D

None of the above

Q. 9

Which of the following is the only shoulder girdle muscle which is not inserted on the bone in free upper limb?

 A

Coracobrachialis

 B

Pectoralis major

 C

Pectoralis minor

 D

None of the above

Ans. C

Explanation:

Pectoralis minor is the only shoulder girdle muscle which is not inserted on the bone in free upper limb. It arises from the 3rd to 5th ribs and is inserted on the coracoid process. It lowers and rotates the scapula. It is innervated by pectoral nerves (C6-8).
 
Coracobrachialis: It arise from the coracoid process together with the short head of the biceps brachii. It is inserted on the medial surface of the humerus on the continuation of the crest of the lesser tubercle. It is innervated by musculocutaneous nerve.
 
Pectoralis major: The three parts of the muscle get inserted on the crest of the greater tubercle of humerus. It forms the muscular basis of the anterior axillary fold. 

Q. 10

Axillary artery is divided into 3 parts. Which of the following muscle divides axillary artery into 3 parts?

 A

Teres major

 B

Teres minor

 C

Pectoralis major

 D

Pectoralis minor

Q. 10

Axillary artery is divided into 3 parts. Which of the following muscle divides axillary artery into 3 parts?

 A

Teres major

 B

Teres minor

 C

Pectoralis major

 D

Pectoralis minor

Ans. D

Explanation:

Axillary artery is divided into 3 parts by pectoralis minor muscle. Axillary artery extends from the outer border of the first rib to inferior border of teres major muscle where it becomes the brachial artery. 
 
Branches of the axillary artery:
 
First part:
  • Superior thoracic artery
Second part:
  • Thoracoacromial artery
  • Lateral thoracic artery
Third part:
  • Subscapular artery
  • Anterior humeral circumflex artery
  • Posterior humeral circumflex artery

Q. 11

A male patient presented with winging of scapula following a trauma. Nerve involved in this lesion is?

 A

Nerve supplying serratus anterior

 B

Pectoral nerve

 C

Subscapular nerve

 D

Ulnar nerve

Q. 11

A male patient presented with winging of scapula following a trauma. Nerve involved in this lesion is?

 A

Nerve supplying serratus anterior

 B

Pectoral nerve

 C

Subscapular nerve

 D

Ulnar nerve

Ans. A

Explanation:

Long thoracic nerve (C5–C7) descends posteriorly to the roots of the plexus and the axillary artery and along the lateral surface of the serratus anterior muscle, with the lateral thoracic artery, while supplying the muscle. Injury to the long thoracic nerve results in paralysis of the serratus anterior muscle. This presents with the medial border of the scapula sticking straight out of the back (winged scapula).

Q. 12

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

 A

Levator scapulae

 B

Pectoralis major

 C

Rhomboideus major

 D

Serratus anterior

Q. 12

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

 A

Levator scapulae

 B

Pectoralis major

 C

Rhomboideus major

 D

Serratus anterior

Ans. D

Explanation:

Serratus Anterior, innervated by the long thoracic nerve, draws the scapula forward. If it is denervated, there is no muscle to oppose the motion of the trapezius which is elevating and retracting the scapula. The medial border of the scapula falls away from the posterior chest wall and begins to look like an angel’s wing. This is termed a “winged scapula.” A winged scapula commonly occurs after an injury to the long thoracic nerve, which runs on the superficial surface of serratus anterior and is particularly vulnerable to trauma. The long thoracic nerve contains contributions from C5, 6, and 7, so remember the saying “C5, 6, and 7 keep the wings from heaven.”


Q. 13

Which of the following DOES NOT form boundary of triangle of auscultation?

 A

Serratus anterior

 B

Scapula

 C

Trapezius

 D

Latissimus dorsi

Q. 13

Which of the following DOES NOT form boundary of triangle of auscultation?

 A

Serratus anterior

 B

Scapula

 C

Trapezius

 D

Latissimus dorsi

Ans. A

Explanation:

The triangle of auscultation is a small triangular space on the back where the relatively thin musculature allows for respiratory sounds to be heard more clearly with a stethoscope. It has the following boundaries:

  • Medial wall is formed by lateral border of trapezius
  • Lateral wall is formed by medial border of scapula
  • Inferiorly by the upper border of latissimus dorsi
  • Floor is formed by: 7th rib, 6th and 7th intercostal spaces, rhomboids major
 
On the left side, the cardiac orifice of the stomach lies deep to the triangle, and in days before X-rays were discovered the sounds of swallowed liquids were auscultated over this triangle.

Q. 14

Which of the following arteries supply pectoralis major muscle?

1. Pectoral branches of thoracoacromial artery
2. Intercostal artery
3. Lateral thoracic artery
4. Subclavian artery
5. Internal mammary artery
 
 A

1, 2 & 3

 B

2, 3 & 4

 C

1, 2 & 5

 D

1, 2, 4 & 5

Q. 14

Which of the following arteries supply pectoralis major muscle?

1. Pectoral branches of thoracoacromial artery
2. Intercostal artery
3. Lateral thoracic artery
4. Subclavian artery
5. Internal mammary artery
 
 A

1, 2 & 3

 B

2, 3 & 4

 C

1, 2 & 5

 D

1, 2, 4 & 5

Ans. C

Explanation:

Blood supply of pectoralis major:

  • Pectoralis major derives it blood supply mainly from pectoral branch of the thoracoacromial artery.
  • Other arteries supplying the muscle are: First perforating branch of the internal thoracic artery (Internal mammary artery) and intercostal artery.

Q. 15

A 24 year old college student presented with ‘winged scapula’ after a fall. Winging of the scapula is due to injury to?

 A

Nerve supplying serratus anterior

 B

Pectoral nerve

 C

Subscapular nerve

 D

Ulnar nerve

Q. 15

A 24 year old college student presented with ‘winged scapula’ after a fall. Winging of the scapula is due to injury to?

 A

Nerve supplying serratus anterior

 B

Pectoral nerve

 C

Subscapular nerve

 D

Ulnar nerve

Ans. A

Explanation:

Branches off the C5–C7 roots, descends posteriorly to the roots of the plexus and the axillary artery and along the lateral surface of the serratus anterior muscle, with the lateral thoracic artery, while supplying the muscle.
 
Injury to the long thoracic nerve results in paralysis of the serratus anterior muscle. This presents with the medial border of the scapula sticking straight out of the back (winged scapula).

Q. 16

Which is the muscle that draws the scapula forward ?

 A

Trapezuis

 B

Rhomboides

 C

Serratus anterior

 D

Levator scapulae

Q. 16

Which is the muscle that draws the scapula forward ?

 A

Trapezuis

 B

Rhomboides

 C

Serratus anterior

 D

Levator scapulae

Ans. C

Explanation:

Serratus anterior protracts the scapula, it acts as a main muscle in reaching and pushing movements. It also helps in raising the arm fully. The muscular digitations of serratus anterior can be seen and felt when the outstretched hand pushes against resistance. In case of paralysis, the lower angle of the scapula stands out prominently, there is projection of scapula also termed as winging of scapula.

Must know:

Seratus anterior is innervated by the long thoracic nerve also known as nerve of bell.

Good to know:

Dropped shoulder occurs as a result of paralysis of the trapezius muscle. With paralysis of the trapezius muscle a drop shoulder with rotation of the angle of the scapula towards the midline and restricted abduction of the arm is caused. Trapezius is supplied by accessory nerve.


Q. 17

What is the root value of long thoracic nerve which supplies serratus anterior muscle?

 A

C 3,4,5

 B

C 5,6,7

 C

C 7,8 & T1

 D

C 2,3,4

Q. 17

What is the root value of long thoracic nerve which supplies serratus anterior muscle?

 A

C 3,4,5

 B

C 5,6,7

 C

C 7,8 & T1

 D

C 2,3,4

Ans. B

Explanation:

Long thoracic nerve (C5–C7). Branches off the C5–C7 roots, descends posteriorly to the roots of the plexus and the axillary artery and along the lateral surface of the serratus anterior muscle, with the lateral thoracic artery, while supplying the muscle. 

Injury to the long thoracic nerve results in paralysis of the serratus anterior muscle. This presents with the medial border of the scapula sticking straight out of the back (winged scapula).

Q. 18

After a jarring blow to the left anterior shoulder region, a young field hockey player was told by an examining physician that she had a muscle tear that resulted directly from the superolateral distraction of a fractured coracoid process. Which muscle was torn?

 A

Deltoid

 B

Pectoralis major

 C

Pectoralis minor

 D

Serratus anterior

Q. 18

After a jarring blow to the left anterior shoulder region, a young field hockey player was told by an examining physician that she had a muscle tear that resulted directly from the superolateral distraction of a fractured coracoid process. Which muscle was torn?

 A

Deltoid

 B

Pectoralis major

 C

Pectoralis minor

 D

Serratus anterior

Ans. C

Explanation:

Of the muscles listed, pectoralis minor is the only one which is attached to the coracoid process. The deltoid originates from the clavicle, acromion and scapular spine and inserts on the deltoid process of the humerus. Pectoralis major originates from the clavicle, sternum, and ribs and inserts on the crest of the greater tubercle of the humerus. Serratus anterior originates on the ribs and inserts on the medial border of the costal surface of the scapula. So, none of these other muscles would be detached by a fracture of the coracoid process. 

NOTE:
Coracobrachialis and the short head of biceps are attached to the coracoid process.

Q. 19

Which of the following arteries supply pectoralis major muscle:

 A

Pectoral branches of thoracoacromial artery

 B

Intercostal artery

 C

Lateral thoracic artery

 D

All

Q. 19

Which of the following arteries supply pectoralis major muscle:

 A

Pectoral branches of thoracoacromial artery

 B

Intercostal artery

 C

Lateral thoracic artery

 D

All

Ans. D

Explanation:

A i.e. Pectoral branches of thoracoacromial artery; B i.e. Intercotal artery; C i.e. Lateral thoracic artery

  • Pectoralis major muscle is supplied by one dominant vascular pedicle from pectoral branch of thoraco-acromial artery, supplied by several smaller secondary segmental vessels from deltoid & clavicular branches of thoracoacromial artery, and perforating branches of, intercostal, internal thoracic/internal mammary, superior thoracic and lateral thoracic arteries.
  • Intercostal arteries supply blood to intercostal muscle, pectoral muscles, breast, skin, (by both anterior & posterior intercostal, arteries); spinalis, longissimus thoracic, iliocostalis, medial aspects of latissimus dorsi & trapezius (by dorsal branch of posterior intercostal artery) and serratus anterior (by muscular branch of posterior intercostal artery).

Q. 20

True about serratus anterior is/are:

 A

Laterally rotates the scapula

 B

It is attached to the medial side of scapula

 C

protects scapula

 D

All

Q. 20

True about serratus anterior is/are:

 A

Laterally rotates the scapula

 B

It is attached to the medial side of scapula

 C

protects scapula

 D

All

Ans. D

Explanation:

A i.e. Laterally rotates the scapula B i.e. It is attached to the medial side of scapula C i.e. protects scapula


Q. 21

True about the Serratus anterior muscle is

 A

Originates from the lower four ribs

 B

Bipennate muscle

 C

Supplied by the subscapular nerve

 D

Helps in forced inspiration

Q. 21

True about the Serratus anterior muscle is

 A

Originates from the lower four ribs

 B

Bipennate muscle

 C

Supplied by the subscapular nerve

 D

Helps in forced inspiration

Ans. D

Explanation:

Serratus anterior helps in vertical overhead abductionQ (assisted by trapezius), forward punchQ (assisted by pectoralis minor) & forced inspirationQ; it’s paralysis leads to winging of scapulaQ


Q. 22

Which of these muscles is not cut in postero lateral thoractomy :

 A

Serratus anterior

 B

Pectoralis major

 C

Latissimus dorsi

 D

Intercostals

Q. 22

Which of these muscles is not cut in postero lateral thoractomy :

 A

Serratus anterior

 B

Pectoralis major

 C

Latissimus dorsi

 D

Intercostals

Ans. B

Explanation:

B. i.e. Pectoralis major


Q. 23

In patients with breast cancer, chest wall involvement means involvement of any one of the following structures except

 A

Serratus anterior

 B

Pectoralis major

 C

Intercoastal musclesBreast / 3

 D

Ribs

Q. 23

In patients with breast cancer, chest wall involvement means involvement of any one of the following structures except

 A

Serratus anterior

 B

Pectoralis major

 C

Intercoastal musclesBreast / 3

 D

Ribs

Ans. B

Explanation:

Ans. is ‘b’ i.e. Pectoralis major 

The chest wall includes ribs, intercostal muscles and serratus anterior muscle, but not the pectoral muscles.


Q. 24

In Patey’s mastectomy the step not done is

 A

Nipple and areola removed

 B

Surrounding normal tissue of tumor is removed.

 C

Pectoralis major removed

 D

Pectoralis minor removed

Q. 24

In Patey’s mastectomy the step not done is

 A

Nipple and areola removed

 B

Surrounding normal tissue of tumor is removed.

 C

Pectoralis major removed

 D

Pectoralis minor removed

Ans. C

Explanation:

Ans. is ‘c’ i.e. (Pectoralis major removed) 

Lets see the nomenclature of various surgeries on breast

  • Simple or Total mastectomy

– it removes all breast tissue, the nipple-areola complex, and skin.

  • Extended simple mastectomy

– Simple mastectomy + removal of level I axillary lymph nodes.

  • Modified radical mastectomy

it removes all breast tissue, the nipple-areola complex, skin and the level I and level II axillary lymph nodes.

  • Halstead’s Radical mastectomy

removes all breast tissue and skin, the nipple areola complex, the pectoralis major and minor muscles and the level I, II and III axillary lymph nodes.

  • Modified Radical Mastectomy
  • Two forms of modified radical mastectomy are in use
  • Auchincloss (pronounced as ‘aushincloss’) procedure

Here both the pectoralis major and minor muscles are preserved with removal of level I and II axillary lymph nodes

Patey’s Procedure

here the pectoralis minor muscle is removed to allow complete dissection of level III axillary lymph nodes

  • Scanlon’s modification of Patey’s procedure

here the pectoralis minor muscle is divided instead of removing. Division of pectoralis minor muscle allows complete removal of level III lymph nodes

  • Halstead Radical Mastectomy
  • In this operation following structures are removed.

i)         the whole breast

ii)       the portion of skin overlying the tumor, which includes the nipple-areola complex.

iii)    the subcutaneous fat and the deep fascia vertically from the lower border of the clavicle upto the upper quarter of the sheath of the rectus abdominis and horizontally from the strenum to the anterior border of lattissimus dorsi

iv)     pectoralis major muscle

v)       pectoralis minor muscle and clavipectoral fascia

vi)     upper part of the aponeurosis of the external oblique and anterior parts of a few digitations of the serratus anterior muscle

vii)    all fatty and loose areolar tissue along with level I, II & III axillary lymph nodes

  • Structures saved are :

i)         the axillary vein and the cephalic vein

ii)       the long thoracic nerve of Bell (Nerve to serratus anterior). The nerve to latissimus dorsi may be sacrified if required.

  • Also know
  • Extended Radical Mastectomy – Radical mastectomy + removal of internal mammary lymph nodes

Super Radical Mastectomy – Radical mastectomy + removal of internal mammary, mediastinal and supraclavicular lymph nodes.


Q. 25

All of the following are used for reconstruction of breast except –

 A

Transverse rectus abdominis myocutaneous flap

 B

Latissimus dorsi myocutaneous flap

 C

pectoralis major myocutoneous flap

 D

Transversus rectus abdominis free flap

Q. 25

All of the following are used for reconstruction of breast except –

 A

Transverse rectus abdominis myocutaneous flap

 B

Latissimus dorsi myocutaneous flap

 C

pectoralis major myocutoneous flap

 D

Transversus rectus abdominis free flap

Ans. C

Explanation:

Ans. is ‘c’ Pectoralis major myocutaneous flap 


Q. 26

All form the posterior wall of axilla EXCEPT:

 A

Subscapularis

 B

Subclavius

 C

Teres major

 D

Latissimus dorsi

Q. 26

All form the posterior wall of axilla EXCEPT:

 A

Subscapularis

 B

Subclavius

 C

Teres major

 D

Latissimus dorsi

Ans. B

Explanation:

Subclavius forms the anterior wall of axilla


Q. 27

Insertion of pectoralis major is at:         

 A

Lateral lip of bicipital groove of humerus

 B

Medial lip of bicipital groove of humerus

 C

In the bicipital groove of humerus

 D

Clavicle

Q. 27

Insertion of pectoralis major is at:         

 A

Lateral lip of bicipital groove of humerus

 B

Medial lip of bicipital groove of humerus

 C

In the bicipital groove of humerus

 D

Clavicle

Ans. A

Explanation:

Pectoralis major arises from the anterior surface of the sternal half of the clavicle; from breadth of the half of the anterior surface of the sternum, as low down as the attachment of the cartilage of the sixth or seventh rib; from the cartilages of all the true ribs, with the exception, frequently, of the first or seventh and from the aponeurosis of the abdominal external oblique muscle. From this extensive origin the fibers converge in a flat tendon, about 5 cm in breadth, which is inserted into the lateral lip of the bicipital groove of the humerus.


Q. 28

Structure preserved in Modified radical [Patey] mastectomy is:      

September 2006, 2009

 A

Axillary vein

 B

Pectoralis major muscle

 C

Nerves to serratus anterior

 D

All of the above

Q. 28

Structure preserved in Modified radical [Patey] mastectomy is:      

September 2006, 2009

 A

Axillary vein

 B

Pectoralis major muscle

 C

Nerves to serratus anterior

 D

All of the above

Ans. D

Explanation:

Ans. D: All of the above


Q. 29

Anterior axillary fold is due to which muscle ‑

 A

Pectoralis major

 B

Pectoralis minor

 C

Subscapularis

 D

Teres major

Q. 29

Anterior axillary fold is due to which muscle ‑

 A

Pectoralis major

 B

Pectoralis minor

 C

Subscapularis

 D

Teres major

Ans. A

Explanation:

Anterior axillary fold is rounded in shaped and is formed by pectoralis major (lower border). Posterior axillary fold is formed by teres major and latisimus dorsi.


Q. 30

True about serratus anterior ‑

 A

Causes protraction

 B

Causes lateral rotation

 C

Supplied by thoracodorsal nerve

 D

Forms lateral boundary of axilla

Q. 30

True about serratus anterior ‑

 A

Causes protraction

 B

Causes lateral rotation

 C

Supplied by thoracodorsal nerve

 D

Forms lateral boundary of axilla

Ans. A

Explanation:

Serratus anterior causes protraction of scapula.

  • It is supplied by long thoracic nerve (Nerve of Bell).
  • It forms medial boundary of axilla.

Serratus anterior

  • Origin : Outer surface of upper 8 ribs by 8 digitations (multipennate muscles).
  • Insertion : Medial border of scapula and inferior angle.
  • Nerve supply : Long thoracic nerve (nerve of bell).
  • Actions : Action of serratus anterior are –
  • Rotates the scapula so that glenoid cavity is raised upward & forward – Helps in Vertical over head abduction (in this action assisted by trapezius).
  • Draws the scapula forward around the throcic wall so paralysis leads to winging of scapula.°
  • Also used when arm is pushed forward in horizontal position as in forward punch (helped by Pectoralis minor in this action)e.
  • Steadies the scapula during weight carrying.
  • Helps in forced inspiration.2 (Accessory muscle of inspiration).
  • Because of greater pull exerted on the inferior angle, inferior angle passes laterally and forward and the glenoid cavity is raised upward & forward; in this action the muscle is assisted by trapezius.

Q. 31

Artery which is shown by arrow  is divided into 3 parts. Which of the following muscle divides this artery into 3 parts

 A

Teres major

 B

Teres minor

 C

Pectoralis major

 D

Pectoralis minor

Q. 31

Artery which is shown by arrow  is divided into 3 parts. Which of the following muscle divides this artery into 3 parts

 A

Teres major

 B

Teres minor

 C

Pectoralis major

 D

Pectoralis minor

Ans. D

Explanation:

Axillary artery is divided into 3 parts by pectoralis minor muscle. Axillary artery extends from the outer border of the first rib to inferior border of teres major muscle where it becomes the brachial artery. 
 
Branches of the axillary artery:
 
First part:
  • Superior thoracic artery
Second part:
  • Thoracoacromial artery
  • Lateral thoracic artery
Third part:
  • Subscapular artery
  • Anterior humeral circumflex artery
  • Posterior humeral circumflex artery


Axillary artery

AXILLARY ARTERY

Q. 1

Axillary artery occlusion affects all EXCEPT:

 A

Post circumflex humeral.

 B

Suprascapular artery

 C

Subscapular artery

 D

Superior thoracic artery

Q. 1

Axillary artery occlusion affects all EXCEPT:

 A

Post circumflex humeral.

 B

Suprascapular artery

 C

Subscapular artery

 D

Superior thoracic artery

Ans. B

Explanation:

Suprascapular artery 

“Suprascapular artery is a branch of thyrocervical trunk of the subclavian artery, not axillary artery”

Branches of axillary artery:

The branches of the axillary artery are superior thoracic, thoraco-acromial, lateral thoracic, subscapular, anterior and posterior circumflex humeral. The Suprascapular artery usually arises from the thyrocervical trunk of the subclavian artery


Q. 2

Cord of brachial plexus are named as per their relation with the axillary artery behind which muscle?

 A

Deltoid

 B

Subclavius

 C

Teres major

 D

Pectoralis minor

Q. 2

Cord of brachial plexus are named as per their relation with the axillary artery behind which muscle?

 A

Deltoid

 B

Subclavius

 C

Teres major

 D

Pectoralis minor

Ans. D

Explanation:

Pectoralis minor crosses in front of axillary artery and divides it into three parts. The anterior relation of each part are; First part lies behing the pectoralis major muscle, second part lies behind the pectoralis minor and major muscle and third part lies behind pectoralis major.

The cords of brachial plexus are named according to their relation with the second part of  axillary artery, lateral cord runs lateral to the axillary artery, as well the medial and posterior cord lies medially and posterior to the axillary artery. Thus the muscle anteriorly to second part is pectoralis minor and major.


Q. 3

Which of the following is least likely to be involved in a collateral anastomosis which bypasses an obstruction of the first part of the axillary artery?

 A

Suprascapular artery

 B

Subscapular Artery

 C

Dorsalscapular Artery

 D

Posterior humeral circumflex artery

Q. 3

Which of the following is least likely to be involved in a collateral anastomosis which bypasses an obstruction of the first part of the axillary artery?

 A

Suprascapular artery

 B

Subscapular Artery

 C

Dorsalscapular Artery

 D

Posterior humeral circumflex artery

Ans. D

Explanation:

The suprascapular, dorsal scapular, subscapular, and scapular circumflex arteries participate in a potential collateral anastomoses around the scapula. The suprascapular and dorsal scapular arteries arise, directly or indirectly, from the subclavian artery while the subscapular and scapular circumflex arteries are from the third part of the axillary artery, thus providing a bypass for obstructions of the first or second parts of the axillary artery.


Q. 4

Which of the following artery is a branch of the first part of axillary artery?

 A

Lateral thoracic artery

 B

Superior thoracic artery

 C

Subscapular artery

 D

Thoracoacromial artery

Q. 4

Which of the following artery is a branch of the first part of axillary artery?

 A

Lateral thoracic artery

 B

Superior thoracic artery

 C

Subscapular artery

 D

Thoracoacromial artery

Ans. B

Explanation:

Superior thoracic artery is the only branch from the first part of the axillary artery. The axillary artery is a continuation of the subclavian artery and is divided into three parts. 
 
Branches from the second part of the axillary artery are:
  • Lateral thoracic artery
  • Thoracoacromial artery
Branches from the third part of the axillary artery are:
  • Subscapular artery
  • Anterior circumflex humeral artery
  • Posterior circumflex humeral artery

Q. 5

Axillary artery is divided into 3 parts. Which of the following muscle divides axillary artery into 3 parts?

 A

Teres major

 B

Teres minor

 C

Pectoralis major

 D

Pectoralis minor

Q. 5

Axillary artery is divided into 3 parts. Which of the following muscle divides axillary artery into 3 parts?

 A

Teres major

 B

Teres minor

 C

Pectoralis major

 D

Pectoralis minor

Ans. D

Explanation:

Axillary artery is divided into 3 parts by pectoralis minor muscle. Axillary artery extends from the outer border of the first rib to inferior border of teres major muscle where it becomes the brachial artery. 
 
Branches of the axillary artery:
 
First part:
  • Superior thoracic artery
Second part:
  • Thoracoacromial artery
  • Lateral thoracic artery
Third part:
  • Subscapular artery
  • Anterior humeral circumflex artery
  • Posterior humeral circumflex artery

Q. 6

Axillary artery give rise to 6 main branches. Which of the following is the largest branch of axillary artery?

 A

Lateral thoracic artery

 B

Subscapular artery

 C

Superior thoracic artery

 D

Thoracoacromial artery

Q. 6

Axillary artery give rise to 6 main branches. Which of the following is the largest branch of axillary artery?

 A

Lateral thoracic artery

 B

Subscapular artery

 C

Superior thoracic artery

 D

Thoracoacromial artery

Ans. B

Explanation:

Subscapular artery is the largest branch of the axillary artery. It arise at the lower border of the subscapularis muscle and descend along the axillary border of the scapula. It give rise to two branches thoracodorsal artery and circumflex scapular artery.

Q. 7

A 42 year old man in Mumbai is being treated for Atrial Fibbrillation (AF). You suspect thromboembolism on further investigatins. Thromboembolism of axillary artery can affect all of the following vessels, EXCEPT:

 A

Post circumflex humeral

 B

Suprascapular artery

 C

Subscapular artery

 D

Superior thoracic artery

Q. 7

A 42 year old man in Mumbai is being treated for Atrial Fibbrillation (AF). You suspect thromboembolism on further investigatins. Thromboembolism of axillary artery can affect all of the following vessels, EXCEPT:

 A

Post circumflex humeral

 B

Suprascapular artery

 C

Subscapular artery

 D

Superior thoracic artery

Ans. B

Explanation:

Suprascapular artery is a branch of thyrocervical trunk of the subclavian artery, not axillary artery.

The axillary artery has several smaller branches.

First part (1 branch)

  • Superior thoracic artery

Second part (2 branches)

  • Thoraco-acromial artery
  • Lateral thoracic artery
Third part (3 branches)
  • Subscapular artery
  • Anterior humeral circumflex artery
  • Posterior humeral circumflex artery
It continues as the brachial artery past the inferior border of the teres major.

Q. 8

In case of occlusion occurs at the 2nd part of Axillary artery, blood flow is maintained by collateral/ anastomosis between:

 A

Anterior and posterior circumflex humoral artery

 B

Suprascapular and posterior circumflex artery

 C

Deep branch of the transverse cervical artery and Subscapular artery

 D

Anterior circumflex artery and subscapular artery

Q. 8

In case of occlusion occurs at the 2nd part of Axillary artery, blood flow is maintained by collateral/ anastomosis between:

 A

Anterior and posterior circumflex humoral artery

 B

Suprascapular and posterior circumflex artery

 C

Deep branch of the transverse cervical artery and Subscapular artery

 D

Anterior circumflex artery and subscapular artery

Ans. C

Explanation:

C i.e., Deep branch of the transverse cervical artery and subscapular artery

Axillary artery is a continuation of subclavian artery from lateral border of 1st rib to lateral border of teres major muscle(2 after which it becomes brachial artery. Because of extensive collateral circulation between thyrocervical trunk of subclavian artery and subscapular artery, which is branch distal axillary artery. Ligation, thrombosis or trauma of axillary artery anywhere between origins of thyrocervical trunk & sub scapular arteries will not lead to compromise of flow to distal arm.



Brachial artery

BRACHIAL ARTERY

Q. 1

In a fracture shaft humerus, which of the following complication requires immediate surgery?

 A

Compound fracture

 B

Nerve injury

 C

Brachial artery occlusion

 D

Comminuted fracture

Q. 1

In a fracture shaft humerus, which of the following complication requires immediate surgery?

 A

Compound fracture

 B

Nerve injury

 C

Brachial artery occlusion

 D

Comminuted fracture

Ans. C

Explanation:

C i.e. Brachial artery occulsion

The absolute indications for immediate operative management of fracture shaft humerus are – associated vascular injuryQ (eg. branchial artery rupture, occlusion etc) and associated higher grade (not all) open woundsQ


Q. 2

Bicipital aponeurosis lies over which structure in cubital fossa‑

 A

Ulnar nerve

 B

Radial nerve

 C

Brachial artery

 D

Anterior interosseous artery

Q. 2

Bicipital aponeurosis lies over which structure in cubital fossa‑

 A

Ulnar nerve

 B

Radial nerve

 C

Brachial artery

 D

Anterior interosseous artery

Ans. C

Explanation:

 

  • Bicipital aponeurosis  passes superficial to the brachial artery and median nerve. It lies deep to superficial veins.
  • During venipuncture, the bicipital aponeurosis provides limited protection for brachial artery and median nerve.

Q. 3

BP is measured in ‑

 A

Axillary artery

 B

Carotid artery

 C

Brachial artery

 D

Radial artery

Q. 3

BP is measured in ‑

 A

Axillary artery

 B

Carotid artery

 C

Brachial artery

 D

Radial artery

Ans. C

Explanation:

Ans. is ‘c’ i.e., Brachial artery

The standard location for noninvasive blood pressure measurement is the brachial artery, although there are several other sites where it can be done.


Q. 4

 

 

Bicipital aponeurosis lies over which structure in the triangle as shown in this picture

 A

Ulnar nerve

 B

Radial nerve

 C

Brachial artery

 D

Anterior interosseous artery

Q. 4

 

 

Bicipital aponeurosis lies over which structure in the triangle as shown in this picture

 A

Ulnar nerve

 B

Radial nerve

 C

Brachial artery

 D

Anterior interosseous artery

Ans. C

Explanation:

  • Bicipital aponeurosis  passes superficial to the brachial artery and median nerve. It lies deep to superficial veins.
  • During venipuncture, the bicipital aponeurosis provides limited protection for brachial artery and median nerve.


Median-nerve

MEDIAN NERVE

Q. 1 Median Nerve supplies all EXCEPT:
 A

Opponens pollicis

 B

Adductor pollicis

 C

Flexor pollicis brevis

 D

Abductor pollicis brevis

Q. 1 Median Nerve supplies all EXCEPT:
 A

Opponens pollicis

 B

Adductor pollicis

 C

Flexor pollicis brevis

 D

Abductor pollicis brevis

Ans. B

Explanation:

Adductor pollicis

REF: http://en.wikipedia.org/wiki/Median_nerve, Gray’s anatomy, 39th edition, P 931,932 See chart of previous question for explanation


Q. 2 In  cubital  fossa,  which  structure  is  medial most
 A Median nerve              
 B Brachial artery
 C Biceps tendon             
 D Radial nerve
Q. 2 In  cubital  fossa,  which  structure  is  medial most
 A Median nerve              
 B Brachial artery
 C Biceps tendon             
 D Radial nerve
Ans. A

Explanation:

Median nerve.

Cubital fossa

-This area is clinically important for venepuncture  and for blood pressure  measurement. It is an imaginary triangle with borders being:

* Laterally, the medial border of brachioradialis  muscle

* Medially, the lateral border of pronator teres muscle

* Superiorly, the intercondylar  line, an imaginary line between the two condyles of the humerus

* The floor is the brachialis & supinator muscle

* The roof is the skin and fascia of the arm and forearm

– Contents of cubital fossa (lateral to medial) are: Radial nerve, Biceps tendon, Artery and Median nerve.


Q. 3

If median nerve is injured at the wrist then loss of function of all of the following will take place except?

 A

Lumbrical muscles to the Index finger.

 B

Lumbrical muscles to the middle finger.

 C

Muscles of the thenar eminence

 D

Adductor pollicis

Q. 3

If median nerve is injured at the wrist then loss of function of all of the following will take place except?

 A

Lumbrical muscles to the Index finger.

 B

Lumbrical muscles to the middle finger.

 C

Muscles of the thenar eminence

 D

Adductor pollicis

Ans. D

Explanation:

Motor nerve supply of Median nerve in the hand:

Thenar muscles which include

  1. Flexor pollicis brevis
  2. Opponens pollicis
  3. Abductor pollicis

Q. 4

Median nerve lesion at the wrist causes all of the following, EXCEPT:

 A

Thenar Atrophy

 B

Weakness of Adductor Pollicis

 C

Weakness of 1st and 2nd Lumbricals

 D

Weakness of Flexor Pollicis Brevis

Q. 4

Median nerve lesion at the wrist causes all of the following, EXCEPT:

 A

Thenar Atrophy

 B

Weakness of Adductor Pollicis

 C

Weakness of 1st and 2nd Lumbricals

 D

Weakness of Flexor Pollicis Brevis

Ans. B

Explanation:

Median nerve lesion at wrist  will lead to atrophy of thenar eminence, weakness to flexor pollicis brevis, 1st and 2nd lumbricals. Adductor pollicis is supplied by the ulnar nerve.

 

 

 

Ref: Neurology, Marco Mumenthaler, Heinrich Mattle, 4th Edition, Page 749-783; Snell’s Clinical Anatomy, 7th Edition, Page 482,483.

 


Q. 5

 

TRUE/FALSE statements about carpal tunnel syndrome are:

 

 

 

1. Occurs in pregnancy

 

2. Affects medial three and half fingers

 

3. Associated with hypothyroidism

 

4. Froment sign positive

5. Median nerve involvement is present

 A

1,2,3 true & 4,5 false

 B

1,3,5 true & 2,4 false

 C

1,2,3,4 true & 5 false

 D

1,2,3,5 true & 4 false

Q. 5

 

TRUE/FALSE statements about carpal tunnel syndrome are:

 

 

 

1. Occurs in pregnancy

 

2. Affects medial three and half fingers

 

3. Associated with hypothyroidism

 

4. Froment sign positive

5. Median nerve involvement is present

 A

1,2,3 true & 4,5 false

 B

1,3,5 true & 2,4 false

 C

1,2,3,4 true & 5 false

 D

1,2,3,5 true & 4 false

Ans. B

Explanation:

Carpal tunnel syndrome is caused by the compression of the median nerve at wrist and is most common type of nerve entrapment syndrome.

 This is usually due to excessive use of the hands and occupational exposure to repeated trauma.

Infiltration of the transverse carpal ligament with amyloid (as occur in multiple myeloma) or thickening of connective tissue in rheumatoid arthritis, acromegaly, amyloidosis, mucopolysaccharidosis and hypothyroidism are less common cause of the syndrome.

It is not uncommon for the condition to make its appearance during pregnancy.

The syndrome is essentially a sensory one; the loss or impairment of superficial sensations affect the palmar aspect of the thumb. Index and middle fingers (especially the index finger) and may or may not split the ring finger. So the lateral three and half fingers are involved (not medial 3 1/2 fingers). The paresthesia are characteristically worsen during night.

 

 

 

Froment sign is seen in ulnar nerve injuries not in median nerve injuries.

Ref: Apley’s 8/e, Page 247-48; Harrison 17/e, Page 2153-54, 2231, 47; Maheshwari 3/e, Page 56.

 


Q. 6

Which of the following carpal bone fracture causes median nerve involvement?

 A

Scaphoid

 B

Lunate

 C

Trapezium

 D

Trapezoid

Q. 6

Which of the following carpal bone fracture causes median nerve involvement?

 A

Scaphoid

 B

Lunate

 C

Trapezium

 D

Trapezoid

Ans. B

Explanation:

Perilunate dislocation

 

 

Among all of the lunate dislocation, perilunate dislocation is most common. The most common type of perilunate instability is transscaphoid perilunate fracture dislocation. Median nerve is most commonly involved nerve. The most commonly used method of closed reduction is tavernier’s maneuver.

 

 

 

Ref: Rockwood & Green’s fracture in Adults 6/e, Page 864-82.

 


Q. 7

Carpel tunnel syndrome is due to compression of:

 A

Radial nerve

 B

Ulnar nerve

 C

Palmer branch of the Ulnar nerve

 D

Median nerve

Q. 7

Carpel tunnel syndrome is due to compression of:

 A

Radial nerve

 B

Ulnar nerve

 C

Palmer branch of the Ulnar nerve

 D

Median nerve

Ans. D

Explanation:

Carpel tunnel syndrome is due to compression ofmedian nerve.

Ref: Harrison’s Internal Medicine, 14th Edition, Page 2467; Essential Orthopedics By J Maheswari, 2nd Edition, Page 257


Q. 8

A 50 year old handicraft lady presented with numbness and weakness of the right hand. On examination, there was atrophy of the thenar eminence and and hypoaesthesia in the area. Compression of which of the following nerve could explain the presentation?

 A

Ulnar Nerve

 B

Radial Nerve

 C

Axillary Nerve

 D

Median Nerve

Q. 8

A 50 year old handicraft lady presented with numbness and weakness of the right hand. On examination, there was atrophy of the thenar eminence and and hypoaesthesia in the area. Compression of which of the following nerve could explain the presentation?

 A

Ulnar Nerve

 B

Radial Nerve

 C

Axillary Nerve

 D

Median Nerve

Ans. D

Explanation:

Median nerve innervates the thenar muscles and the skin over it. The likely condition is  Carpal Tunnel Syndrome.


Q. 9

Median Nerve supplies all of the structures, EXCEPT?

 A

Opponens pollicis

 B

Adductor pollicis

 C

Flexor pollicis brevis

 D

Abductor pollicis brevis

Q. 9

Median Nerve supplies all of the structures, EXCEPT?

 A

Opponens pollicis

 B

Adductor pollicis

 C

Flexor pollicis brevis

 D

Abductor pollicis brevis

Ans. B

Explanation:

The median nerve enters the hand through the carpal tunnel, deep to the flexor retinaculum along with the tendons of flexor digitorum superficialis, flexor digitorum profundus, and flexor pollicis longus.

From there it sends off several branches:
 
1. Recurrent branch to muscles of the thenar compartment (the recurrent branch is also called “the million dollar nerve”). Here it provides motor innervation to opponens pollicis, abductor pollicis brevis and flexor pollicis brevis.
 
2. Digital cutaneous branches to common palmar digital branch and proper palmar digital branch of the median nerve which supply the:
 
a) Lateral (radial) three and a half digits on the palmar side
 
b) Index, middle and ring finger on dorsum of the hand
 
3. The median nerve supplies motor innervation to the first and second Lumbricals of the hand.

 


Q. 10

A 12 year old, presents with a severely damaged nail on his index finger, after accidentally crushing the finger while closing a door. A decision is made to excise the injured nail. In preparation for the procedure, the physician would most likely anesthetize a branch of which of the following nerves?

 A

Anterior interosseous nerve

 B

Median nerve

 C

Musculocutaneous nerve

 D

Radial nerve

Q. 10

A 12 year old, presents with a severely damaged nail on his index finger, after accidentally crushing the finger while closing a door. A decision is made to excise the injured nail. In preparation for the procedure, the physician would most likely anesthetize a branch of which of the following nerves?

 A

Anterior interosseous nerve

 B

Median nerve

 C

Musculocutaneous nerve

 D

Radial nerve

Ans. B

Explanation:

The median nerve supplies the surface of the lateral palm, the palmar surface of the first three digits and the distal dorsal surface of the index and middle fingers (including the nail beds). Therefore, prior to performing surgery in this area, it is essential to anesthetize a branch of this nerve (possibly a proper digital branch) to eliminate pain sensation around the nail bed of the index finger.

Neither the anterior interosseous nor the musculocutaneous nerves supplies the hand. The anterior interosseous nerve supplies the flexor pollicis longus, the lateral half of flexor digitorum profundus, and pronator quadratus.
The musculocutaneous nerve supplies the coracobrachialis, biceps, and most of the brachialis muscle, then becomes the lateral cutaneous nerve of the forearm.
 
The radial nerve supplies skin on the radial side of the dorsal surface of the hand, but not the fingertips.

 


Q. 11

All of the following muscles of pollex are supplied by median nerve, EXCEPT?

 A

Adductor pollicis

 B

Opponens pollicis

 C

Abductor pollicis brevis

 D

Flexor pollicis brevis

Q. 11

All of the following muscles of pollex are supplied by median nerve, EXCEPT?

 A

Adductor pollicis

 B

Opponens pollicis

 C

Abductor pollicis brevis

 D

Flexor pollicis brevis

Ans. A

Explanation:

Pollex means Thumb, which means strong in latin. There are four short muscles of thumb (pollex), they are abductor pollicis brevis, opponens pollicis, flexor pollicis brevis and adductor pollicisThe first three of these muscles form the thenar eminence. All these muscles are supplied by median nerve except for adductor pollicis which is innervated by ulnar nerve.


Q. 12

If median nerve is injured at the wrist, then loss of function of all of the following muscles will take place, EXCEPT?

 A

Lumbrical muscles to the Index finger

 B

Lumbrical muscles to the middle finger

 C

Muscles of the thenar eminence

 D

Abductor pollicis

Q. 12

If median nerve is injured at the wrist, then loss of function of all of the following muscles will take place, EXCEPT?

 A

Lumbrical muscles to the Index finger

 B

Lumbrical muscles to the middle finger

 C

Muscles of the thenar eminence

 D

Abductor pollicis

Ans. D

Explanation:

Median nerve (C6–T1): Provides most of the innervation to the anterior forearm, excluding one and one half muscles, the flexor carpi ulnaris and the ulnar half of the flexor digitorum profundus muscle, which are innervated by the ulnar nerve. The median nerve continues into the hand to innervate the thenar eminence and lumbricals 1 and 2. It provides cutaneous innervation to the medial palmar side of the hand and the palmar surface of digits 1 through 3 and half of digit 4.


Q. 13

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

 A

Musculocutaneous nerve

 B

Median nerve

 C

Ulnar nerve

 D

Radial nerve

Q. 13

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

 A

Musculocutaneous nerve

 B

Median nerve

 C

Ulnar nerve

 D

Radial nerve

Ans. B

Explanation:

Carpal tunnel syndrome is caused by swelling of the flexor digitorum superficialis, profundus, and flexor pollicis longus tendons, resulting in pressure on the median nerve. Repetitive motions of the fingers and wrist, hormonal changes, and vibration can be causes of tendon swelling. It results in tingling, numbness, and pain in the cutaneous distribution of the median nerve (lateral side). In more severe cases, atrophy of the thenar eminence may be present.

Q. 14

A patient has a tiny (0.2 cm), but exquisitely painful tumor under the nail of her index finger. Prior to surgery to remove it, local anesthetic block to a branch of which of the following nerves would be most likely to achieve adequate anesthesia?

 A

Axillary nerve

 B

Median nerve

 C

Musculocutaneous nerve

 D

Radial nerve

Q. 14

A patient has a tiny (0.2 cm), but exquisitely painful tumor under the nail of her index finger. Prior to surgery to remove it, local anesthetic block to a branch of which of the following nerves would be most likely to achieve adequate anesthesia?

 A

Axillary nerve

 B

Median nerve

 C

Musculocutaneous nerve

 D

Radial nerve

Ans. B

Explanation:

The tumor in question is probably a glomus tumor, which is a benign tumor notorious for producing pain far out of proportion to its small size. The question is a little tricky (but important clinically for obvious reasons) because it turns out that the most distal aspect of the dorsal skin of the fingers, including the nail beds, is innervated by the palmar digital nerves rather than the dorsal digital nerves. Specifically, the median nerve through its palmar digital nerves supplies the nail beds of the thumb, index finger, middle finger, and half of the ring finger.
The axillary nerve  musculocutaneous nerve , and radial nerves do not supply the nail beds.

Q. 15

A 16 years old girl failed in her final examination. Disgusted with life , she cut across the front of wrist at the flexor retinaculum . She was rushed to hospital and the surgeon noticed that the cut was superficial. All the following structures would have been damaged by this cut EXCEPT?

 A

Ulnar nerve

 B

Median nerve

 C

Palmar cutaneous branch of median nerve

 D

Superficial branch of radial artery

Q. 15

A 16 years old girl failed in her final examination. Disgusted with life , she cut across the front of wrist at the flexor retinaculum . She was rushed to hospital and the surgeon noticed that the cut was superficial. All the following structures would have been damaged by this cut EXCEPT?

 A

Ulnar nerve

 B

Median nerve

 C

Palmar cutaneous branch of median nerve

 D

Superficial branch of radial artery

Ans. B

Explanation:

Median nerve lies deep to the flexor retinaculum and is not damaged by cuts which are superficial. 
 
Structures crossing superficial to flexor retinaculum are:

From medial to lateral:
  • Superficial branch of ulnar nerve and ulnar artery
  • Tendon of palmaris longus
  • Palmar cutaneous branch of median nerve
  • Origin of the thenar muscles
Structures passing deep to flexor retinaculum are:
  • Median nerve
  • Tendons of flexor digitorum superficialis
  • Tendon of flexor digitorum profundus
  • Tendon of flexor pollicis longus
  • Ulnar bursa and radial bursa

Q. 16

True about peripheral nerve injury in upper limb :

 A

Radial nerve injury cause anaesthesia over anatomical snuff box

 B

Index finger anesthesia is caused by median nerve injury

 C

Ulnar nerve injury cause claw hand

 D

All

Q. 16

True about peripheral nerve injury in upper limb :

 A

Radial nerve injury cause anaesthesia over anatomical snuff box

 B

Index finger anesthesia is caused by median nerve injury

 C

Ulnar nerve injury cause claw hand

 D

All

Ans. D

Explanation:

A i.e. Radial nerve injury cause anaesthesia over anatomical snuff box; C i.e. Ulnar nerve injury cause claw hand; B i.e. Index finger anesthesia is caused by median nerve injury 


Q. 17

True regarding median nerve is/are

 A

Deep to pronator teres heads

 B

Lateral & medial cords

 C

Lateral to axillary artery in axilla

 D

All

Q. 17

True regarding median nerve is/are

 A

Deep to pronator teres heads

 B

Lateral & medial cords

 C

Lateral to axillary artery in axilla

 D

All

Ans. D

Explanation:

All Correct – A,B, C, 


Q. 18

If median nerve is injured at the wrist then loss of function of all of the following will take place except:

 A

Lumbrical muscles to the Index finger.

 B

Lumbrical muscles to the middle finger

 C

Muscles of the thenar eminence

 D

Adductor pollicis

Q. 18

If median nerve is injured at the wrist then loss of function of all of the following will take place except:

 A

Lumbrical muscles to the Index finger.

 B

Lumbrical muscles to the middle finger

 C

Muscles of the thenar eminence

 D

Adductor pollicis

Ans. D

Explanation:

D i.e. Adductor pollicis


Q. 19

Median nerve injury at wrist, is commonly tested by:

 A

Contraction of abductor pollicis brevis

 B

Contraction of flexor pollicis brevis

 C

Loss of sensation on palm

 D

Loss of sensation on ring finger

Q. 19

Median nerve injury at wrist, is commonly tested by:

 A

Contraction of abductor pollicis brevis

 B

Contraction of flexor pollicis brevis

 C

Loss of sensation on palm

 D

Loss of sensation on ring finger

Ans. A

Explanation:

Injury or compression of median nerve at wrist (eg carpel tunnel syndrome) can be tested by

1.      Pen test for loss of action of Abductor pollicis brevis

2.      Ape thumb deformity Q (adducted posture of thumb)

3.      Loss of opposition & abduction of thumb Q (d/ t wasting of thenar muscles)

4.      Sensory loss – lateral 31/2 of digits & 2/3 palm (autonomous zone is tip of index & tniddle finger)

Abductor pollicis longus is supplied by posterior interosseous nerve (br. of radial nerve)Q; so abduction of thumb is not completely lost.


Q. 20

Muscle supplied by median nerve:

 A

Opponens pollicis

 B

Abductor pollicis brevis

 C

Flexor pollicis brevis

 D

All

Q. 20

Muscle supplied by median nerve:

 A

Opponens pollicis

 B

Abductor pollicis brevis

 C

Flexor pollicis brevis

 D

All

Ans. D

Explanation:

A, B, C,  i.e. Opponens pollicis, Abductor pollicis brevis, Flexor pollicis brevis, & First lumbricals


Q. 21

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

 A

Musculocutaneous nerve

 B

Median nerve

 C

Ulnar nerve

 D

Radial nerve

Q. 21

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

 A

Musculocutaneous nerve

 B

Median nerve

 C

Ulnar nerve

 D

Radial nerve

Ans. B

Explanation:

B i.e. Median Nerve


Q. 22

Ape thumb deformity is seen in involvement of :

 A

Median nerve

 B

Ulnar nerve

 C

Radial nerve

 D

Axillary nerve

Q. 22

Ape thumb deformity is seen in involvement of :

 A

Median nerve

 B

Ulnar nerve

 C

Radial nerve

 D

Axillary nerve

Ans. A

Explanation:

A i.e. Medial Nerve 


Q. 23

Which complication may arise after supra-condylar fracture?

 A

Median nerve injury

 B

Damage to brainchild artery

 C

Cubitus varus

 D

All of the above

Q. 23

Which complication may arise after supra-condylar fracture?

 A

Median nerve injury

 B

Damage to brainchild artery

 C

Cubitus varus

 D

All of the above

Ans. D

Explanation:

D i.e. All of the above 


Q. 24

In supra condylar fracture of humerus, the nerve most commonly injured is

 A

Radial nerve

 B

Ulnar nerve

 C

Median nerve

 D

Auxiliary nerve

Q. 24

In supra condylar fracture of humerus, the nerve most commonly injured is

 A

Radial nerve

 B

Ulnar nerve

 C

Median nerve

 D

Auxiliary nerve

Ans. C

Explanation:

C i.e. Median nerve

  • Anterior interosseous nerve is the most commonly injured nerve with loss of motor- power to flexor pollicis longus & deep flexor to the index finger in extension type supracondylar fractureQ
  • Over all involvement of peripheral nerve in fracture supracondylar humerus is AIN > median nerve > radial nerve > ulnar nerveQ

Q. 25

The most common nerve involvement is dislocation of Lunate is

 A

Median nerve

 B

Anterior interosseus

 C

Posterior interosseus

 D

Median nerve

Q. 25

The most common nerve involvement is dislocation of Lunate is

 A

Median nerve

 B

Anterior interosseus

 C

Posterior interosseus

 D

Median nerve

Ans. A

Explanation:

A i.e. Median nerve


Q. 26

Which carpal bone fracture causes median nerve involvement?

 A

Scaphoid

 B

Lunate

 C

Trapezium

 D

Trapezoid

Q. 26

Which carpal bone fracture causes median nerve involvement?

 A

Scaphoid

 B

Lunate

 C

Trapezium

 D

Trapezoid

Ans. B

Explanation:

B i.e. Lunate


Q. 27

Labourers nerve is another name for which nerve:

 A

Median nerve

 B

Radial nerve

 C

Ulnar nerve

 D

Axillary nerve

Q. 27

Labourers nerve is another name for which nerve:

 A

Median nerve

 B

Radial nerve

 C

Ulnar nerve

 D

Axillary nerve

Ans. A

Explanation:

The median nerve controls the coarse movements of the hands, as it supplies most of the long muscles of the front of the forearm a nd therefore called the ‘labourer’s nerve’.

The median nerve is formed from parts of the medial and lateral cords of the brachial plexus

The median nerve is the only nerve that passes through the carpal tunnel.

Innervation

  • Upper Arm

No motor innervation.

  • Forearm

It innervates most of the flexors in the forearm except flexor carpi ulnaris and the medial two digits of flexor digitorum profundus, which are supplied by the ulnar nerve.

Unbranched, the median nerve supplies the following muscles:

  • Pronator teres
  • Flexor carpi radialis
  • Palmaris longus
  • Flexor digitorum superficialis muscle.

The anterior interosseus branch supplies the following muscles:

  • Lateral (radial) half of flexor digitorum profundus muscle
  • Flexor pollicics longus muscle
  • Pronator quadratus Hand.

In the hand, the median nerve supplies motor innervation to the 1st and 2nd lumbricals and the muscles of the thenar eminence of the hand by a recurrent thenar branch.

The rest of the intrinsic muscles of the hand are supplied by the ulnar nerve.

Injury

  • Injury of this nerve at a level above elbow joint results in loss of pronation and a decrease in flexion of the hand at the wrist joint.
  • In the hand, thenar muscle are paralysed and atrophy with in time. Opposition and flexion movements of thumb are lost, and thumb and index finger are arrested in adduction and hyperextension position. This appearance is referred as ape hand deformity.

In addition, in palmar side of the hand sensation of lateral part of hand, first three fingers and lateral half of the f our t h finger and in dorsal side sensation of distal S! portion of first three fingers and lateral half of distal S! portionof fourth finger is lost.


Q. 28

Structure passing deep to flexor retinaculum at wrist:

 A

Ulnar nerve

 B

Median nerve

 C

Radial nerve

 D

Ulnar artery

Q. 28

Structure passing deep to flexor retinaculum at wrist:

 A

Ulnar nerve

 B

Median nerve

 C

Radial nerve

 D

Ulnar artery

Ans. B

Explanation:

The flexor retinaculum stretches across the front of the wrist and converts the concave anterior surface of the hand into an osteofascial tunnel, the carpal tunnel, for the passage of:

  • The median nerve
  • Flexor tendons of the thumb (flexor pollicis longus and fingers) (flexor digitorum superficialis and profundus).
  • Radial and the ulnar bursa

It is attached medially to the pisiform bone and the hook of the hamate and laterally to the tubercle of the scaphoid and the trapezium bones.

The attachment to the trapezium consists of superficial and deep parts and forms a synovial-lined tunnel for passage of the tendon of the flexor carpi radialis.

The lower border is attached to the palmar aponeurosis.


Q. 29

Humeral supracondylar fracture commonly results in which nerve injury:     

September 2007

 A

Musculocutaneous nerve

 B

Radial nerve

 C

Ulnar nerve

 D

Median nerve

Q. 29

Humeral supracondylar fracture commonly results in which nerve injury:     

September 2007

 A

Musculocutaneous nerve

 B

Radial nerve

 C

Ulnar nerve

 D

Median nerve

Ans. D

Explanation:

Ans. D: Median Nerve

Supracondylar humerus fracture:

  • Most common < 10 years, peak age 5-8 years
  • Constitutes 80% of all pediatric distal humerus fractures
  • 2:1 males to female ratio

Classificatio:

  • Extension type: Extension type accounts for 90-98% of all supracondylar fractures
  • Flexion type

Gartland Classification is commonly used to classify extension type of injuries:

I: Nondisplaced

IIA: displaced, posterior cortex intact; rotationally stable, intact posterior cortex acts like a hinge

IIB: displaced, posterior cortex intact; rotationally unstable

III: completely displaced, no cortical contact, most often a medial periosteal sleeve intact when medially displaced and vice-versa

Management:

i. Closed Reduction is done for type I and type II fractures. Closed reduction is not attempted in type III fractures. Assessing adequacy of reduction:

  • Jones view: hyperflexion shoot through elbow
  • Baumann’s Angle: comparison to uninjured side, difference of more than 5degrees is unacceptable
  • Anterior Humeral Line

Type III fracture:

  • Increased swelling and soft tissue injury
  • Proper neurovascular and compartment assessment
  • Closed reduction and percutaneous pinning is the management of choice, 2 pins may achieve stability

Neurologic Injury:

  • 5-19% of supracondylar farctures
  • More in type III supracondylar fractures
  • Median nerve 52% (especially posteromedial displacement)
  • Radial nerve: 28%
  • Most are neuropraxic injuries
  • Motor Recovery may take 7-12 weeks
  • Sensory recovery may take nearly 6 months

Q. 30

Nerve supply of nail bed of middle finger:

March 2013 (c)

 A

Radial nerve

 B

Ulnar nerve

 C

Median nerve

 D

Axillary nerve

Q. 30

Nerve supply of nail bed of middle finger:

March 2013 (c)

 A

Radial nerve

 B

Ulnar nerve

 C

Median nerve

 D

Axillary nerve

Ans. C

Explanation:

Ans. C i.e. Median nerve


Q. 31

Total claw hand is seen in the paralysis of:

September 2005

 A

Ulnar and median nerve

 B

Ulnar nerve

 C

Median nerve

 D

Radial nerve

Q. 31

Total claw hand is seen in the paralysis of:

September 2005

 A

Ulnar and median nerve

 B

Ulnar nerve

 C

Median nerve

 D

Radial nerve

Ans. A

Explanation:

Ans. A: Ulnar and median nerve

Claw hand deformity is manifested by flattening of the transverse metacarpal arch and longitudinal arches, with hyperextension of MCP joints and flexion of the PIP and DIP joints;

This deformity is produced by imbalance of the intrinsic & extrinsics:

i. Intrinsic muscles must be markedly weakened or paralyzed to produce claw deformity;

Long extensor muscles hyperextend the MCP joint, & long flexor muscles flex the PIP and DIP joints; weakness of the

long flexors (as in high palsy) actually decreases claw fingers;

In ulnar nerve palsy, only the medial two fingers develops clawing while all the four fingers develop clawing in combined median and ulnar nerve palsy.


Q. 32

Anterior interosseous nerve is a branch of‑

 A

Radial nerve

 B

Median nerve

 C

Ulnar nerve

 D

Axillary nerve

Q. 32

Anterior interosseous nerve is a branch of‑

 A

Radial nerve

 B

Median nerve

 C

Ulnar nerve

 D

Axillary nerve

Ans. B

Explanation:

Ans. is ‘b’ i.e., Median nerve

  • Anterior interosseous nerve is a branch of median nerve.
  • Anterior interosseous artery is a branch of ulnar artery.

Q. 33

Inability to pronate forearm is due to injury to which nerve ‑

 A

Ulnar

 B

Radial

 C

Median nerve

 D

Musculocutaneous

Q. 33

Inability to pronate forearm is due to injury to which nerve ‑

 A

Ulnar

 B

Radial

 C

Median nerve

 D

Musculocutaneous

Ans. C

Explanation:

Ans. is ‘c’ i.e., Median nerve

  • Pronation of the forearm is by two muscles pronator teres and pronator quadratus. These two muscles are supplied by median nerve. Thus injury to median nerve produces inability to pronate forearm.
  • The median nerve is also called labourer’s nerve. The median nerve arises by two roots, one from the lateral cord (C5,6,7) and the other from the medial cord (C8, T1). The various muscles supplied by median nerve are : ‑

1) In the forearm

  • All the flexor muscles of the forearm, except the flexor carpi ulnaris and the medial half of flexor digitorum profundus to the ulnar two fingers. These muscles are : –
  1. Pronater teres
  2. Flexor digitorum superficialis
  3. Flexor pollicis longus
  4. Flexor carpi radialis
  5. Flexor digitorum profundus (lateral half)
  6. Pronator quadratus
  7. Pulmaris longus

2) In hand

  • Median nerve supplies : –
  1. Thenar muscles (except adductor pollicis) – Flexor pollicis brevis, opponens pollicis and abductor pollicis brevis. Adductor pollicis is supplied by ulnar nerve.
  2. First two lumbricals

Q. 34

Nerve supply of opponens pollicis ‑

 A

Superficial branch of ulnar nerve

 B

Deep branch of ulnar nerve

 C

Median nerve

 D

Posterior interosseous nerve

Q. 34

Nerve supply of opponens pollicis ‑

 A

Superficial branch of ulnar nerve

 B

Deep branch of ulnar nerve

 C

Median nerve

 D

Posterior interosseous nerve

Ans. C

Explanation:

Hand muscles supplied by median nerve are :-

i) Thenar muscles (except adductor pollicis) :- Flexor pollicis brevis, opponens pollicis and abductor pollicis brevis. Adductor pollicis is supplied by ulnar nerve.

ii) First two lumbricals.

Hand muscles supplied by ulnar nerve are :‑

1) Superficial terminal branch : It supplies palmaris brevis and skin of palmar surface of medial 1% fingers.

2) Deep terminal branch : It supplies adductor pollicis, all interossei, medial two (3rd & 4th)lumbricals and all hypothenar muscles except palmaris brevis (i.e. abductor digiti minimi, flexor digiti minimi, opponens digiti minimi).


Q. 35

Nerve supply of pronator teres ‑

 A

Ulnar nerve

 B

Median nerve

 C

Posterior interosseous

 D

Radial nerve

Q. 35

Nerve supply of pronator teres ‑

 A

Ulnar nerve

 B

Median nerve

 C

Posterior interosseous

 D

Radial nerve

Ans. B

Explanation:

 Median nerve


Q. 36

Median nerve lesion at the wrist causes all of the following.except ‑

 A

Thenar atrophy

 B

Weakness of Adductor pollicis

 C

Weaknes of 1st and 2nd lumbricals

 D

Weakness of Flexor pollicis brevis

Q. 36

Median nerve lesion at the wrist causes all of the following.except ‑

 A

Thenar atrophy

 B

Weakness of Adductor pollicis

 C

Weaknes of 1st and 2nd lumbricals

 D

Weakness of Flexor pollicis brevis

Ans. B

Explanation:

Ans. is ‘b’ i.e., Weakness of Adductor pollicis

Adductor pollicis is supplied by ulnar nerve.



Brachial Plexus nerve block

Brachial Plexus nerve block

Q. 1

Interscalene approach to brachial plexus block does not provide optimal surgical anaesthesia in the area of distribution of which of the following nerve?

 A

Musculocutaneous nerve

 B

Ulnar nerve

 C

Radial nerve

 D

Median nerve

Q. 1

Interscalene approach to brachial plexus block does not provide optimal surgical anaesthesia in the area of distribution of which of the following nerve?

 A

Musculocutaneous nerve

 B

Ulnar nerve

 C

Radial nerve

 D

Median nerve

Ans. B

Explanation:

The roots of the brachial plexus are found in the interscalene groove

(defined by the anterior and middle scalene muscles)deep to the sternocleidomastoid.

Interscalene block is used to provide anesthesia or analgesia for shoulder surgery

as it targets the proximal roots of the plexus (C4-C7).

The more distal roots of the plexus such as ulnar nerve (C8-T1) is usually spared.

 
Ref: Atlas of Ultrasound-Guided Procedures in Interventional Pain Management By Samer N. Narouze, Page 229 : Miller’s Anesthesia, 6th Edition, Pages 1687, 1689

Q. 2

A 25 year old male with roadside accident underwent debridement and reduction of fractured both bones right forearm under axillary block.

On the second postoperative day the patient complained of persistent numbness and paresthesia in the right forearm and the hand. The commonest cause of this neurological dysfunction could be all of the following except :

 A

Crush injury to the hand and lacerated nerves

 B

A tight cast or dressing

 C

Systemic toxicity of local anaesthetics

 D

Tourniquet pressure

Q. 2

A 25 year old male with roadside accident underwent debridement and reduction of fractured both bones right forearm under axillary block.

On the second postoperative day the patient complained of persistent numbness and paresthesia in the right forearm and the hand. The commonest cause of this neurological dysfunction could be all of the following except :

 A

Crush injury to the hand and lacerated nerves

 B

A tight cast or dressing

 C

Systemic toxicity of local anaesthetics

 D

Tourniquet pressure

Ans. C

Explanation:

C i.e. Systemic toxicity of Local Anaesthetics

  • Systemic toxicity of LA include – CNS toxicity, cardiovascular system, methemoglobinemia & Allergies.

CNS is particularly vulnerable to toxicity & is the site of premonitory signs of overdose in awake patients. Cortical inhibitory pathways are most susceptible resulting in excitatory motor phenomenon in initial stages of LA toxicity.

  • Hypercapnia, respiratory & metabolic acidosis exacerbates CNS toxicityQ. Increased PaCO2 increases cerebral blood flow delivering greater dose of LA more rapidly to brain. And decreased intracellular pH favours formation of non diffusable cationic (protonated) form of LA, which is trapped within neuron. Finally plasma protein binding of LA is decreased in acidic environment resulting in increased availability of free drug for diffusion into brain.
  • But the involvement of the peripheral nerve is characterized by parathesies, numbness, hypaesthesia, pain and neurological dysfunction.
  • So, this patient is having peripheral nerve injury. It could have happened d/t:

– Open (crush) injury 1/ t laceration of nerves. As the patient underwent debriment, so he is a case of open injury.

Nerve injury during debriment.

Nerve injury during reduction & manipulation.

Tourniquet pressure palsy

Nerve injury d/t tight bandage or cast.


Q. 3

Pneumothorax is a complication of

 A

Axillary block

 B

Brachial plexus block

 C

Epidural block

 D

High Spinal block

Q. 3

Pneumothorax is a complication of

 A

Axillary block

 B

Brachial plexus block

 C

Epidural block

 D

High Spinal block

Ans. B

Explanation:

B i.e. Brachial Plexus block

Brachial plexus block with interscalene approach provides most intense anesthesia in C5-C7 dermatomes and least intense in C8-T1 (ulnar nerve) area.



KLUMPKE’S PARALYSIS

KLUMPKE’S PARALYSIS

Q. 1

Klumpke’s paralysis from a brachial plexus injury involves which of the following nerve cords?

 A

C5, C6

 B

C6, C7

 C

C7, T1

 D

C8, T1

Q. 1

Klumpke’s paralysis from a brachial plexus injury involves which of the following nerve cords?

 A

C5, C6

 B

C6, C7

 C

C7, T1

 D

C8, T1

Ans. D

Explanation:

Klumpke’s paralysis is a form of paralysis involving the muscles of the forearm and hand, resulting from a brachial plexus injury in which the eighth cervical (C8) and first thoracic (T1) nerves are injured either before or after they have joined to form the lower trunk. 


Q. 2

Klumpke’s palsy is due to injury to the following nerves?

 A

Inferior trunk of the brachial plexus

 B

Superior trunk of the brachial plexus

 C

Subscapular nerve

 D

Ulnar nerve

Q. 2

Klumpke’s palsy is due to injury to the following nerves?

 A

Inferior trunk of the brachial plexus

 B

Superior trunk of the brachial plexus

 C

Subscapular nerve

 D

Ulnar nerve

Ans. A

Explanation:

The upper trunk (C5 and C6) is the most common area injured and results in the classic Erb palsy. Injury to the lower trunk (C7–T1) produces a Klumpke palsy. Klumpke palsy is characterized by good shoulder function but decreased or absent hand function. Brachial plexus injuries may also cause a Horner syndrome (unilateral miosis, ptosis, and facial anhidrosis) due to disruption of cervical sympathetic nerves.


Erb’s paralysis

Erb’s paralysis

Q. 1

Which of the following cords are associated with Erb’s Palsy?

 A

C5 – C6

 B

C6 – C7

 C

C8 – T1

 D

T1 – T2

Q. 1

Which of the following cords are associated with Erb’s Palsy?

 A

C5 – C6

 B

C6 – C7

 C

C8 – T1

 D

T1 – T2

Ans. A

Explanation:

A lesion at C5 – C6 causes the policeman’s tip deformity. Injury may be seen due to birth related injuries.  Erb’s point or the punctum nervosum is a site at the lateral root of the brachial plexus located 2–3 cm above the clavicle. Erb’s point is formed by the union of the C5 and C6 nerve roots, which later converge. At the nerve trunk, branches of suprascapular nerves and the nerve to the subclavius also merge. Injury to Erb’s point causes paralysis of the biceps, brachialis, and coracobrachialis. The effect is called “Erb’s palsy”.


Q. 2

In a patient with erb’s palsy, paralysis of which of the following muscles results in medial rotation of the arm?

 A

Supraspinatus and deltoid

 B

Teres major and biceps brachii

 C

Infraspinatus and teres minor

 D

Biceps brachii, brachialis and brachioradialis

Q. 2

In a patient with erb’s palsy, paralysis of which of the following muscles results in medial rotation of the arm?

 A

Supraspinatus and deltoid

 B

Teres major and biceps brachii

 C

Infraspinatus and teres minor

 D

Biceps brachii, brachialis and brachioradialis

Ans. C

Explanation:

In a patient with Erb’s palsy there is involvement of C5, 6 nerve root. In this condition, the arm is held in adduction and internal rotation at the shoulder, extension at the elbow, pronation of the forearm and flexion at the wrist. Paralysis of the teres minor and infraspinatus result in medial rotation of the arm. 
  • Paralysis of Biceps brachii, brachialis and brachioradialis result in extended forearm.
  • Paralysis of Supraspinatus and deltoid result in adducted arm.

Q. 3

A man with a history of fall presented with a deformity which is resembling ‘a waiter who waits for receiving his tip’. This posture is characteristically seen in?

 A

Erb’s paralysis

 B

Klumpke’s paralysis

 C

Radial nerve paralysis

 D

Ulnar nerve paralysis

Q. 3

A man with a history of fall presented with a deformity which is resembling ‘a waiter who waits for receiving his tip’. This posture is characteristically seen in?

 A

Erb’s paralysis

 B

Klumpke’s paralysis

 C

Radial nerve paralysis

 D

Ulnar nerve paralysis

Ans. A

Explanation:

The upper trunk (C5 and C6) of brachial plexus is the most common area injured and results in the classic Erb palsy. It has been described as the “waiter’s tip posture” and is characterized by shoulder weakness with internal rotation and adduction of the upper arm. The elbow is extended and the wrist flexed. There is good preservation of hand function.

Q. 4

Erb’s point is?

 A

C4, C5

 B

C5, C6

 C

C6, C7

 D

C7, C8, T1

Q. 4

Erb’s point is?

 A

C4, C5

 B

C5, C6

 C

C6, C7

 D

C7, C8, T1

Ans. B

Explanation:

Erb’s point is is a site at the lateral root of the brachial plexus located 2–3 cm above the clavicle.Erb’s point is formed by the union of the C5 and C6 nerve roots, which later converge. At the nerve trunk, branches of suprascapular nerves and the nerve to the subclavius also merge. The merged nerve divides into the anterior and posterior division of C5 and C6.

 


Q. 5

A 19 year old boy fell from the motorbike on his shoulder. The doctor diagnosed him as a case of Erb’s paralysis. All of the following signs and symptoms will be observed in this boy, EXCEPT?

 A

Loss of abduction at shoulder joint

 B

Loss of lateral rotation

 C

Loss of pronation at radioulnar joint

 D

Loss of flexion at elbow joint.

Q. 5

A 19 year old boy fell from the motorbike on his shoulder. The doctor diagnosed him as a case of Erb’s paralysis. All of the following signs and symptoms will be observed in this boy, EXCEPT?

 A

Loss of abduction at shoulder joint

 B

Loss of lateral rotation

 C

Loss of pronation at radioulnar joint

 D

Loss of flexion at elbow joint.

Ans. C

Explanation:

Due to Erb’s paralysis there is damage of biceps brachii and supinator due to which there is loss of pronation of forearm. It is associated with loss of abduction at shoulder joint, loss of lateral rotation and loss of flexion at elbow joint and is not associated with loss of pronation at radioulnar joint.

Erb’s paralysis occur from damage at the Erb’s point which is the meeting point of 6 nerves such as ventral rami of C5 and C6, suprascapular and nerve to subclavius of upper trunk and two divisions of upper trunk. Muscles paralysed are supraspinatus, deltoid, teres minor, infraspinatus, biceps brachii, brachialis, brachioradialis and supinator.

 

Position

Paralysis of

Overaction of 

Adduction of arm

Supraspinatus and deltoid

Adductors of the shoulder

Medial rotation of the arm

Teres minor and infraspinatus

Medial rotators of the shoulder

Extension of forearm

Biceps brachii, brachialis and brachioradialis

Extensors of elbow

Pronation of forearm

Biceps brachii and supinator

Pronators of forearm


Q. 6

Erb’s point is

 A

Posterior primary rami of C6-C7

 B

Anterior primary rami of C5-C6

 C

Posterior primary rami of Cs-T1

 D

Posterior primary rami of C2-C8

Q. 6

Erb’s point is

 A

Posterior primary rami of C6-C7

 B

Anterior primary rami of C5-C6

 C

Posterior primary rami of Cs-T1

 D

Posterior primary rami of C2-C8

Ans. B

Explanation:

B. i.e. Anterior primary rami of C5– C6


Q. 7

A 19 year old boy fell from the motar bike on his shoulder. The doctor diagnosed him a case of Erbs paralysis. The following signs and symptoms will be observed except:

 A

Loss of abduction at shoulder joint

 B

Loss of abduction at shoulder joint

 C

Loss of pronation at radioulnar joint.

 D

Loss of flexion at elbow joint.

Q. 7

A 19 year old boy fell from the motar bike on his shoulder. The doctor diagnosed him a case of Erbs paralysis. The following signs and symptoms will be observed except:

 A

Loss of abduction at shoulder joint

 B

Loss of abduction at shoulder joint

 C

Loss of pronation at radioulnar joint.

 D

Loss of flexion at elbow joint.

Ans. C

Explanation:

C ie Loss of pronation at radio ulnar joint


Q. 8

Which of the following deformity is evident in case of erbs palsy?

 A

Policeman tip deformity

 B

Winging of scapula

 C

Claw hand

 D

Wrist drop

Q. 8

Which of the following deformity is evident in case of erbs palsy?

 A

Policeman tip deformity

 B

Winging of scapula

 C

Claw hand

 D

Wrist drop

Ans. A

Explanation:

Ans. is ‘a’ i.e., Policeman tip deformity



Ulnar nerve

ULNAR NERVE

Q. 1 M.C. nerve used for monitoring during anaesthesia
 A >Ulnar nerve
 B >Facial nerve
 C Radial nerve
 D Median nerve
Q. 1 M.C. nerve used for monitoring during anaesthesia
 A >Ulnar nerve
 B >Facial nerve
 C Radial nerve
 D Median nerve
Ans. A

Explanation:

Ulnar nerve [Ref. Ajai yadav Anaesthesia p 46, Miller’s anaesthesia 6th/e p 289]

  • Most common nerve used for monitoring during anaesthesia is ulnar nerve.
  • Ulnar nerve supplies adductor pollicis, and this muscle is most commonly observed during perioperative period.
  • Adductor pollicis muscle is monitored for neuromuscular blockade. If adductor pollicis is showing no activity it means laryngeal muscles have already been blocked and intubation can be performed.
  • At the reversal, if there is activity in adductor pollicis it means that diaphragmatic activity has already returned and the patient will be able to maintain tidal volume even after extubation.

Also know

  • The muscle to show earliest reversal is orbicularis occuli, supplied by the facial nerve.
  • Common peroneal nerve can also be used for monitoring.

Q. 2

The fourth dorsal interosseous muscle is innervated by?

 A

Recurrent (motor) branch of the median nerve

 B

Deep branch of the ulnar nerve

 C

Dorsal branch of the ulnar nerve

 D

Superficial branch of the radial nerve

Q. 2

The fourth dorsal interosseous muscle is innervated by?

 A

Recurrent (motor) branch of the median nerve

 B

Deep branch of the ulnar nerve

 C

Dorsal branch of the ulnar nerve

 D

Superficial branch of the radial nerve

Ans. B

Explanation:

 
The deep branch of the ulnar nerve innervates the intrinsic muscles of the hand (with the exception of the thenar compartment). This includes the dorsal interosseous muscles, the palmar interosseous muscles, the two lumbrical muscles on the medial side of the hand, and the muscles to the 5th digit (digiti minimi). The dorsal branch of the ulnar nerve innervates the skin of the dorsal surface of the medial 1.5 digits and the skin of the medial side of the back of the hand.

The recurrent motor branch of the median nerve innervates the thenar compartment. The superficial branch of the radial nerve provides sensory innervation to the skin on the radial side of the dorsum of the hand, including the radial 3.5 digits. Finally, the superficial branch of the ulnar nerve innervates the skin of the palmar surface of the medial 1.5 digits as well as the skin of the medial side of the front of the hand. 


Q. 3

Which of the following structure is NOT a content of the cubital fossa?

 A

Brachial artery

 B

Ulnar nerve

 C

Radial nerve

 D

Median nerve

Q. 3

Which of the following structure is NOT a content of the cubital fossa?

 A

Brachial artery

 B

Ulnar nerve

 C

Radial nerve

 D

Median nerve

Ans. B

Explanation:

The cubital fossa is a triangular intermuscular space seen as a shallow surface depression in front of the elbow. The contents of the cubital fossa are tendon of biceps brachii, brachial artery, median nerve and radial nerve. Radial nerve is present in the superolateral aspect of the fossa under cover of brachioradialis.
 
Boundaries of cubital fossa:
  • Base is formed by an imaginary line passing through the medial and lateral epicondyle of humerus.
  • Medial boundary is formed by lateral margin of pronator teres muscle.
  • Lateral boundary is formed by medial margin of brachioradialis muscle.
  • Apex is located at the crossing of pronator teres and brachioradialis muscle.
  • Floor consist of brachialis in the upper part and supinator in the lower part.

Q. 4

Martin-Gruber connections are

 A

Median and axillary nerve

 B

Axillary & radial nerves

 C

Radial & ulnar nerve

 D

Median & ulnar nerve

Q. 4

Martin-Gruber connections are

 A

Median and axillary nerve

 B

Axillary & radial nerves

 C

Radial & ulnar nerve

 D

Median & ulnar nerve

Ans. D

Explanation:

D i.e. Median & ulnar nerve 


Q. 5

Regarding cervical rib, which statement is correct ‑

 A

It always connects to the scalene tubercle by a fibrous band

 B

It passes through the apex of the supraclavicular triangle

 C

It causes pressure on the ulnar nerve

 D

All

 

Q. 5

Regarding cervical rib, which statement is correct ‑

 A

It always connects to the scalene tubercle by a fibrous band

 B

It passes through the apex of the supraclavicular triangle

 C

It causes pressure on the ulnar nerve

 D

All

 

Ans. C

Explanation:

Ans is i.e., ‘c’ i.e. It causes pressure on the ulnar nerve 


Q. 6

Nerve supply to hypothenar muscles is from :

 A

Ulnar nerve

 B

Median nerve

 C

Radial nerve

 D

Musculocutaneous nerve

Q. 6

Nerve supply to hypothenar muscles is from :

 A

Ulnar nerve

 B

Median nerve

 C

Radial nerve

 D

Musculocutaneous nerve

Ans. A

Explanation:

The muscles of hypothenar eminence are:

  • Opponens digiti minimi
  • Flexor digiti minimi
  • Abductor digiti minimi
  • Palmar brevis

The intrinsic muscles of hand can be remembered using the mnemonic, “A OF A OF A (P)” for, Abductor pollicis longus, Opponens pollicis, Flexor pollicis brevis, Adductor pollicis (thenar muslces) and Opponens digiti minimi, Flexor digiti minimi, Abductor digiti minimi and Palmar brevis (Hypothenar muscles)

They are all supplied by the deep branch of the ulnar nerve.


Q. 7

Identify the Nerev as marked A in the Image ?

 A

Radial Nerve

 B

Ulnar Nerve

 C

 Brachioradialis

 D

None of the Above

Q. 7

Identify the Nerev as marked A in the Image ?

 A

Radial Nerve

 B

Ulnar Nerve

 C

 Brachioradialis

 D

None of the Above

Ans. B

Explanation:

Ulnar Nerve In Arm


Q. 8

All are contents of cubital fossa except ‑

 A

Median nerve

 B

Biceps tendon

 C

Brachial artery

 D

Ulnar nerve

Q. 8

All are contents of cubital fossa except ‑

 A

Median nerve

 B

Biceps tendon

 C

Brachial artery

 D

Ulnar nerve

Ans. D

Explanation:

 Ulnar nerve


Q. 9

Structure not passing through carpal tunnel ‑

 A

Ulnar nerve

 B

Median nerve

 C

Tendons of FDP

 D

Tendons of FDS

Q. 9

Structure not passing through carpal tunnel ‑

 A

Ulnar nerve

 B

Median nerve

 C

Tendons of FDP

 D

Tendons of FDS

Ans. A

Explanation:

Ans. is ‘A’ i.e., Ulnar nerve

Ten structures pass through the carpal tunnel, most of them flexor tendons(not the muscles themselves):

  • flexor digitorum profundus (four tendons)
  • flexor digitorum superficialis (four tendons)
  • flexor pollicis longus (one tendon)
  • Median nerve between tendons of flexor digitorum profundus and flexor digitorum superficialis

Q. 10

Deep branch of ulnar nerve supplies all except ‑

 A

Adductor pollicis

 B

Abductor digiti minimi

 C

Flexor digiti minimi

 D

Opponens pollicis

Q. 10

Deep branch of ulnar nerve supplies all except ‑

 A

Adductor pollicis

 B

Abductor digiti minimi

 C

Flexor digiti minimi

 D

Opponens pollicis

Ans. D

Explanation:

Various branches of ulnar nerve are :‑

A) In arm : No branch.

B) In forearm : There are following branches :‑

1)  Muscular : In proximal part of forearm it supplies flexor carpi ulnaris and medial half of flexor digitorum profundus.

2)  Cutaneous : There are two cutaneous branches in forearm:-

i)   Palmar cutaneous branch : Supplies skin over the hypothenar eminence.

ii)  Dorsal (posterior) cutaneous branch : Supplies skin over medial 1/3 of dorsum of hand and dorsal surface of medial 11/2 fingers.

C) In hand : Ulnar nerve enters the palm by passing superficial to flexor retunuculum and divides into two terminal branches :‑

1)   Superficial terminal branch : It supplies palmaris brevis and skin of palmar surface of medial 11/2 fingers.

2)  Deep terminal branch : It supplies adductor pollicis, all interossei, medial two (3″1 & 4th)lumbricals and all hypothenar muscles except palmaris brevis (i.e. abductor digiti minimi, flexor digiti minimi, opponens digiti minimi).


Q. 11

Ulnar nerve supplies all except ‑

 A

FCU

 B

1st lumbrical

 C

4th lumbrical

 D

Dorsal interossei

Q. 11

Ulnar nerve supplies all except ‑

 A

FCU

 B

1st lumbrical

 C

4th lumbrical

 D

Dorsal interossei

Ans. B

Explanation:

 1st lumbrical


Q. 12

Which of the following nerve does not have root valve C5, C6,C7 

 A

Lateral pectoral nerve

 B

Musculocutaneous nerve

 C

Lateral root of median nerve

 D

Ulnar nerve

Q. 12

Which of the following nerve does not have root valve C5, C6,C7 

 A

Lateral pectoral nerve

 B

Musculocutaneous nerve

 C

Lateral root of median nerve

 D

Ulnar nerve

Ans. D

Explanation:

Ulnar nerve does not have root valve C5, C6,C7 .


Q. 13

All are seen in carpal tunnel except ‑

 A

Median nerve

 B

Ulnar nerve

 C

FPL

 D

FDP

Q. 13

All are seen in carpal tunnel except ‑

 A

Median nerve

 B

Ulnar nerve

 C

FPL

 D

FDP

Ans. B

Explanation:

Ans. is ‘b’ i.e., Ulnar nerve

Contents of carpal tunnel are 1 nerve and 9 tendons :-

i) Median nerve

ii) 4 tendons of flexor digitorum profunds.

iii) 4 tendons of flexor digitorum superficialis.

iv) 1 tendon of flexor pollicis longus.


Q. 14

All are contents of cubital fossa except ‑

 A

Median nerve

 B

Biceps tendon

 C

Brachial artery

 D

Ulnar nerve

Q. 14

All are contents of cubital fossa except ‑

 A

Median nerve

 B

Biceps tendon

 C

Brachial artery

 D

Ulnar nerve

Ans. D

Explanation:

Ans. is ‘d’ i.e., Ulnar nerve

Contents of cubital fossa

  • Median nerve
  • Brachial artery termination and begining of radial and ulnar arteriesQ.
  • Biceps tendon
  • Radial nerve and Radial collateral artery

Q. 15

Adductor pollicis is supplied by ‑

 A

Median nerve

 B

Radial nerve

 C

Superficial branch of ulnar nerve

 D

Deep branch of ulnar nerve

Q. 15

Adductor pollicis is supplied by ‑

 A

Median nerve

 B

Radial nerve

 C

Superficial branch of ulnar nerve

 D

Deep branch of ulnar nerve

Ans. D

Explanation:

Ans. is `d’ i.e., Deep branch of ulnar nerve



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