Upper Limb
Arm tending to lie in medial rotation
1. A 21-year-old patient has a lesion of the upper trunk of the brachial plexus (Erb- Duchenne paralysis). Which of the following is the most likely diagnosis? (A) Paralysis of the rhomboid major (B) Inability to elevate the arm above the horizontal (C) Arm tending to lie in medial rotation (D) Loss of sensation on the medial side of the arm (E) Inability to adduct the thumb
Median Nerve
1. Physical examination of a 40-year-old man injured in an automobile accident indicates that he has suffered nerve damage affecting his left upper limb. The patient exhibits significant weakness when pronating his left forearm and flexing his left wrist. What nerve is most likely damaged? (A) Median nerve (B) Ulnar nerve (C) Superficial branch of the radial nerve (D) Deep branch of the radial nerve (E) Musculocutaneous nerve
Median nerve
10. A 35-year-old man walks in with a stab wound to the most medial side of the proximal portion of the cubital fossa. Which of the following structures would most likely be damaged? (A) Biceps brachii tendon (B) Radial nerve (C) Brachial artery (D) Radial recurrent artery (E) Median nerve
Profunda brachii artery
10. The given anteroposterior (AP) X-ray depicts a humeral shaft fracture in a 22-year-old man. Given the location of the fracture, which of the following structures is most likely damaged? (A) Posterior circumflex humeral artery (B) Ulnar nerve (C) Axillary nerve (D) Profunda brachii artery (E) Median nerve
Anterior interosseous nerve
11. A 23-year-old man was injured in a motor vehicle accident and X-rays confirmed a displaced distal radius fracture in his left forearm. Upon examination, the patient exhibits weakened pronation, weakened flexion of the index and middle fingers at the distal interphalangeal joints, and weakened flexion of the interphalangeal joint of the thumb. When asked to make the "okay" sign (make a circle with the thumb and index finger), the patient is unable to make a round circle, producing a "col- lapsed circle" on the affected hand (see photo). No areas of sen- sory loss are detected. Which nerve is most likely damaged? (A) Deep branch of the radial nerve (B) Superficial branch of the radial nerve (C) Anterior interosseous nerve (D) Median nerve, proximal to the carpal tunnel (E) Recurrent branch of the median nerve
Ape hand
11. The police bring in a murder suspect who has been in a gunfight with a police officer. The suspect was struck by a bullet in the arm; his median nerve has been damaged. Which of the following symptoms is likely produced by this nerve damage? (A) Waiter's tip hand (B) Claw hand (C) Wrist drop (D) Ape hand (E) Flattening of the hypothenar eminence
Abduction of the index finger
12. A 23-year-old medical student complains of loss of sensation in the skin on the medial edge of her left hand, including the entire fifth digit. The associated motor deficit probably involves weakness in which of the following? (A) Pronation (B) Abduction of the wrist (C) Extension of the wrist (D) Abduction of the index finger (E) Flexion of the interphalangeal joints of the index finger
palmar interosseous
12. An automobile body shop worker has his middle finger crushed while working on a transmission. Which of the following muscles is most likely to retain function? (A) Extensor digitorum (B) Flexor digitorum profundus (C) Palmar interosseous (D) Dorsal interosseous (E) Lumbrical
Radial artery
13. A 14-year-old boy falls on his outstretched hand and has a fracture of the scaphoid bone. The fracture is most likely accompanied by a rupture of which of the following arteries? (A) Brachial artery (B) Ulnar artery (C) Deep palmar arterial arch (D) Radial artery (E) Princeps pollicis artery
Accessory nerve
13. A dermatologist performed a biopsy on a suspicious mole on the right side of the posterior neck of a 57-year-old male construction worker. Pathology confirmed a malignant melanoma, so the physician excised a substantial amount of tissue surrounding the mole. After the procedure, the patient experienced difficulty elevating his right shoulder and lifting his right arm over his head. No sensory deficits were seen. What nerve was most likely damaged in this patient? (A) Accessory nerve (B) Axillary nerve (C) Dorsal scapular nerve (D) Long thoracic nerve (E) Thoracodorsal nerve
Radial and axillary
14. A 12-year-old boy walks in; he fell out of a tree and fractured the upper portion of his humerus. Which of the following nerves are intimately related to the humerus and are most likely to be injured by such a fracture? (A) Axillary and musculocutaneous (B) Radial and ulnar (C) Radial and axillary (D) Median and musculocutaneous (E) Median and ulnar
Superficial branch of the radial nerve
15. A 36-year-old man broke a window with his fist to rescue his child from a house fire. The man sustained a laceration to the lateral aspect of his right forearm, but he only showed a sensory deficit (numbness and paresthesia) to the dorsolateral aspect of his hand (as denoted by the shaded area within the given photo). What nerve was most likely damaged? (A) Dorsal cutaneous branch of the ulnar nerve (B) Lateral cutaneous nerve of the forearm (C) Posterior cutaneous nerve of the forearm (D) Deep branch of the radial nerve (E) Superficial branch of the radial nerve
Ulnar artery and ulnar nerve
15. A man injures his wrist on broken glass. Which of the following structures entering the palm superficial to the flexor retinaculum may be damaged? (A) Ulnar nerve and median nerve (B) Median nerve and flexor digitorum profundus (C) Median nerve and flexor pollicis longus (D) Ulnar artery and ulnar nerve (E) Ulnar nerve and flexor digitorum superficialis
Opponens pollicis
16. A patient with Bennett's fracture (a fracture of the base of the first metacarpal bone) experiences an impaired thumb movement. Which of the following intrinsic muscles of the thumb is most likely injured? (A) Abductor pollicis brevis (B) Flexor pollicis brevis (superficial head) (C) Opponens pollicis (D) Adductor pollicis (E) Flexor pollicis brevis (deep head)
Intercostobrachial nerve
16. An anesthesiologist administers an anesthetic solution into the axillary sheath of a 19-year-old college baseball player in preparation for repair of the ulnar collateral ligament of the elbow. After 5 minutes, the patient experiences numbness and paresthesia distal to the middle aspect of the arm; however, the medial aspect of the arm and elbow remain sensitive to pain. What nerve provides sensory innervation to the sensitive area and was not blocked by the anesthetic solution? (A) Long thoracic nerve (B) Median nerve (C) Medial cutaneous nerve of the arm (D) Intercostobrachial nerve (E) Ulnar nerve
Axillary nerve
17. A 17-year-old male football player suffers a shoulder injury and arrives at the ER 2 hours after the injury. The physician diagnoses a shoulder dislocation, and after administration of a local anesthetic solution, the doctor repositions the head of the humerus into the glenoid cavity of the scapula (reduction). No fractures are seen on X-rays. However, the patient displays weakness in abduction and external rotation at the shoulder. A loss of sensation is also noted at the superior and lateral aspects of the arm. What nerve was most likely damaged in this injury? (A) Axillary nerve (B) Median nerve (C) Ulnar nerve (D) Radial nerve (E) Musculocutaneous nerve
Lateral two lumbricals and opponens pollicis
17. A 27-year-old pianist with a known carpal tunnel syndrome experiences difficulty in finger movements. Which of the following intrinsic muscles of her hand is paralyzed? (A) Palmar interossei and adductor pollicis (B) Dorsal interossei and lateral two lumbricals (C) Lateral two lumbricals and opponens pollicis (D) Abductor pollicis brevis and palmar interossei (E) Medial two and lateral two lumbricals
Tendon of the flexor digitorum profundus
18. A 31-year-old roofer walks in with tenosynovitis resulting from a deep penetrated wound in the palm by a big nail. Examination indicates that he has an infection in the ulnar bursa. This infection most likely resulted in necrosis of which of the following tendons? (A) Tendon of the flexor carpi ulnaris (B) Tendon of the flexor pollicis longus (C) Tendon of the flexor digitorum profundus (D) Tendon of the flexor carpi radialis (E) Tendon of the palmaris longus
Musculocutaneous nerve
18. A physician tests the myotatic biceps reflex as shown. A normal response of involuntary contraction of the biceps brachii muscle is noted. This reflex confirms the integrity of what nerve? (A) Axillary nerve (B) Median nerve (C) Ulnar nerve (D) Radial nerve (E) Musculocutaneous nerve
Radial nerve
19. A 21-year-old male college student reports to the student health clinic on Monday morning, the day after the Super Bowl. He explains that he was intoxicated and lost consciousness with his upper limbs draped over the back of a couch. He complains of numbness and paresthesia over the dorsum of his hand on the radial side and is unable to support the weight of his left hand when the hand is placed in a pronated position (see photo). What nerve was most likely damaged in this individual? (A) Axillary nerve (B) Median nerve (C) Ulnar nerve (D) Radial nerve (E) Musculocutaneous nerve
Suprascapular and axillary
19. An 18-year-old boy involved in an automobile accident presents with arm that cannot abduct. His paralysis is caused by damage to which of the following nerves? (A) Suprascapular and axillary (B) Thoracodorsal and upper subscapular (C) Axillary and musculocutaneous (D) Radial and lower subscapular (E) Suprascapular and dorsal scapular
Upper trunk of the brachial plexus
2. A 50-year old man falls off a ladder while cleaning his windows, landing on the ground as seen in the given drawing. He does not seek medical aid, believing his general soreness will go away with time. However, after several months, he develops a postural deformity of his left upper limb that includes an adducted, medially rotated, and extended shoulder, extended elbow, and pronated forearm. The injury and subsequent condition reflect damage to what structure? (A) Upper trunk of the brachial plexus (B) Lower roots of the brachial plexus (C) Posterior divisions of the brachial plexus (D) Medial cord of the brachial plexus (E) Lateral root of the median nerve
Superior thoracic
2. A patient comes in with a gunshot wound and requires surgery in which his thoracoacromial trunk needs to be ligated. Which of the following arterial branches would maintain normal blood flow? (A) Acromial (B) Pectoral (C) Clavicular (D) Deltoid (E) Superior thoracic
Posterior humeral circumflex
20. A 17-year-old boy with a stab wound received multiple injuries on the upper part of the arm and required surgery. If the brachial artery were ligated at its origin, which of the following arteries would supply blood to the profunda brachii artery? (A) Lateral thoracic (B) Subscapular (C) Posterior humeral circumflex (D) Superior ulnar collateral (E) Radial recurrent
Lower trunk of the brachlal plexus
20. A 50-year female equestrian is thrown from a startled horse and dragged by the reins, which were wrapped around her left wrist, for some distance. At the ER, she is experiencing pain and paresthesia in the axilla and medial aspect of her upper limb. Despite being left-handed, she has marked weakness in the movements of her dominant hand, especially abduction and adduction of the fingers. What structure was most likely damaged in this woman? (A) Upper trunk of the brachial plexus (B) Lower trunk of the brachial plexus (C) Posterior cord of the brachial plexus (D) Lateral cord of the brachial plexus (E) Long thoracic nerve
Ulnar and radial
21. A 23-year-old woman who receives a deep cut to her ring finger by a kitchen knife is unable to move the metacarpophalangeal joint. Which of the following pairs of nerves was damaged? (A) Median and ulnar (B) Radial and median (C) Musculocutaneous and ulnar (D) Ulnar and radial (E) Radial and axillary
Meromelia
21. A child is born to a young woman who had utilized thalidomide to help relieve her morning sickness early in her pregnancy. The infant suffers the congenital defects shown here. She is missing the proximal segments of both upper and lower limbs. The hands and feet that are present are attached to the trunk of the body and resemble small seal's flippers. Which of the following is the correct term for this malformation? (A) Adysplasia (B) A duplication defect (C) Micromelia (D) Meromelia (E) Amelia
Biceps brachii
22. A 23-year-old competitive weight lifter goes to his physician complaining of pain in his proximal forearm. During his examination, the pain is exacerbated by flexion of the elbow and supination of the forearm against resistance. A lateral radiograph shows chronic microtrauma to the proximal radius, marked by the black arrows. Which of the following muscles attaches to, and most likely damaged, this osteological process? (A) Supinator (B) Brachialis (C) Pronator teres (D) Biceps brachii (E) Brachioradialis
Brachialis and supinator
22. A 27-year-old baseball player is hit on his forearm by a high-speed ball during the World Series, and the muscles that form the floor of the cubital fossa appear to be torn. Which of the following groups of muscles have lost their functions? (A) Brachioradialis and supinator (B) Brachialis and supinator (C) Pronator teres and supinator (D) Supinator and pronator quadratus (E) Brachialis and pronator teres
Dorsal root ganglion
23. A 23-year-old man complains of numbness on the medial side of the arm following a stab wound in the axilla. On examination, he is diagnosed with an injury of his medial brachial cutaneous nerve. In which of the following structures are the cell bodies of the damaged nerve involved in numbness located? (A) Sympathetic chain ganglion (B) Dorsal root ganglion (C) Anterior horn of the spinal cord (D) Lateral horn of the spinal cord (E) Posterior horn of the spinal cord
Latissimus dorsi
23. A 65-year-old man is brought to the emergency room after being attacked in his office by a disgruntled co-worker. The attacker reportedly used a long, narrow-bladed letter-opener to inflict multiple stab wounds to the man's back. Physical examination shows a puncture wound in the posterior axillary fold. The patient presents with weakness in extension, adduction, and medial rotation of his arm. Which of the following muscles is most likely cut in this injury? (A) Pectoralis minor (B) Latissimus dorsi (C) Levator scapulae (D) Serratus anterior (E) Teres minor
Radial and musculocutaneous (suppinator by radial, biceps brachii by musculocutaneous)
24. A 38-year-old homebuilder was involved in an accident and is unable to supinate his forearm. Which of the following nerves are most likely damaged? (A) Suprascapular and axillary (B) Musculocutaneous and median (C) Axillary and radial (D) Radial and musculocutaneous (E) Median and ulnar
Axillary nerve
24. Physical examination of a 45-year-old man who had been stabbed in the back of the shoulder shows a deep wound penetrating into the quadrangular space of the shoulder, causing bleeding from the severed blood vessels there. Which of the following neural structures is most likely damaged as well? (A) Musculocutaneous nerve (B) Lateral cord of the brachial plexus (C) Radial nerve (D) Axillary nerve (E) Medial cutaneous nerve of the arm
Ulnar
25. A 31-year-old patient complains of sensory loss over the anterior and posterior surfaces of the medial third of the hand and the medial one and one-half fingers. He is diagnosed by a physician as having "funny bone" symptoms. Which of the following nerves is injured? (A) Axillary (B) Radial (C) Median (D) Ulnar (E) Musculocutaneous
The second part of the axillary artery lies deep to the muscle
25. The pectoralis minor muscle is an important landmark in identifying and describing neighboring structures in the chest and axillary regions. Which of the following relationships of the pectoralis minor is correct? (A) The lateral cord of the brachial plexus lies lateral to the muscle (B) The clavipectoral triangle lies lateral to the muscle (C) The anterior axillary lymph nodes lie along the medial border of the muscle (D) The lateral wall of the axillary fossa includes the muscle (E) The second part of the axillary artery lies deep to the muscle
Flexor digitorum profundus and pronator quadratus
26. A patient with a deep stab wound in the middle of the forearm has impaired movement of the thumb. Examination indicates a lesion of the anterior interosseous nerve. Which of the following muscles is paralyzed? (A) Flexor pollicis longus and brevis (B) Flexor pollicis longus and opponens pollicis (C) Flexor digitorum profundus and pronator quadratus (D) Flexor digitorum profundus and superficialis (E) Flexor pollicis brevis and pronator quadratus
Teres minor
26. Lateral rotation of the arm is an important mechanical component of "bringing the arm back" when preparing to throw an object. What muscle acts to produce lateral rotation of the arm? (A) Supraspinatus (B) Teres major (C) Latissimus dorsi (D) Subscapularis (E) Teres minor
Loss of sensation over the distal part of the second digit
27. A 29-year-old patient comes in; he cannot flex the distal interphalangeal (DIP) joint of the index finger. His physician determines that he has nerve damage from a supracondylar fracture. Which of the following conditions is also a symptom of this nerve damage? (A) Inability to flex the DIP joint of the ring finger (B) Atrophy of the hypothenar eminence (C) Loss of sensation over the distal part of the second digit (D) Paralysis of all the thumb muscles (E) Loss of supination
Axillary artery
27. The lateral cord of the brachial plexus is named because it lies immediately lateral to which of the following structures? (A) Long head of the biceps brachii muscle (B) Axillary artery (C) Subclavian vein (D) Surgical neck of the humerus (E) Pectoralis minor muscle
Median nerve
28. "Pronator teres syndrome" is a condition in which one of the following nerves is excessively compressed where it passes between the two heads of the pronator teres muscle. Which of the following nerves is entrapped? (A) Deep branch of radial nerve (B) Median Nerve (C) Deep branch of ulnar nerve (D) Superficial branch of ulnar nerve (E) Musculocutaneous nerve
Two medial lumbricals (the ulnar nerve is in the tunnel and innervates the two medial lumbricals)
28. A 27-year-old man with cubital tunnel syndrome complains of numbness and tingling in the ring and little finger and back and sides of his hand because of damage to a nerve in the tunnel at the elbow. Which of the following muscles is most likely to be paralyzed? (A) Flexor digitorum superficialis (B) Opponens pollicis (C) Two medial lumbricals (D) Pronator teres (E) Supinator
Flattened thenar eminence
29. A secretary comes in to your office complaining of pain in her wrists from typing all day. You determine that she likely has carpal tunnel syndrome. Which of the following conditions would help you determine the diagnosis? (A) Inability to adduct the little finger (B) Inability to flex the DIP joint of the ring finger (C) Flattened thenar eminence (D) Loss of skin sensation of the medial one and one-half fingers (E) Atrophied adductor pollicis muscle
Lateral to the tendon of the flexor carpi radialis
29. The pulse of the radial artery is readily palpable where the vessel passes which of the following structures? (A) Across the anterior aspect of the lateral epicondyle of the humerus (B) Between the tendons of the palmaris longus and flexor carpi ulnaris (C) Lateral to the tendon of the flexor carpi radialis (D) Superficial to the tendons of the extensor pollicis brevis and abductor pollicis longus (E) Superficial to the carpal tunnel
Scaphoid
3. A 21-year-old man goes to his college campus health clinic complaining of soreness in his left wrist after falling on an outstretched hand during a basketball game the previous day. He is supporting his left wrist and indicates that the pain worsens with movement and is minimized with inactivity. There is no loss of feeling in his hand, nor does he have trouble grasping or holding objects. The physician exacerbates the wrist pain by applying pressure to the base of the thumb in the anatomical snuffbox (see photo). Radiographic imaging will confirm a break of which carpal bone? (A) Capitate (B) Scaphoid (C) Hamate (D) Trapezium (E) Pisiform
Roots
3. A 29-year-old man comes in with a stab wound, cannot raise his arm above horizontal, and exhibits a condition known as "winged scapula." Which of the following structures of the brachial plexus would most likely be damaged? (A) Medial cord (B) Posterior cord (C) Lower trunk (D) Roots (E) Upper trunk
Radial artery
30. A 74-year-old man complains of pain in his right hand and fingers when he works with his hands for a while. Thorough testing reveals insufficient blood flow into the deep palmar arch. Occlusion of which of the following arteries is the most likely cause of this condition? (A) Posterior interosseous artery (B) Ulnar artery (C) Anterior interosseous artery (D) Radial artery (E) Inferior ulnar collateral artery
Ulnar nerve
30. A man is unable to hold typing paper between his index and middle fingers. Which of the following nerves was likely injured? (A) Radial nerve (B) Median nerve (C) Ulnar nerve (D) Musculocutaneous nerve (E) Axillary nerve
Cephalic vein
31. In both the upper and lower limbs, the superficial veins begin in a dorsal cutaneous arch that drains into medial and lateral cutaneous veins aligned mainly along the first and fifth digit sides of the limb. Which of the following veins in the upper limb is the equivalent of the great saphenous vein in the lower limb? (A) Radial vein (B) Ulnar vein (C) Brachial vein (D) Basilic vein (E) Cephalic vein
Triquetrum
31. The victim of an automobile accident has a destructive injury of the proximal row of carpal bones. Which of the following bones is most likely damaged? (A) Capitate (B) Hamate (C) Trapezium (D) Triquetrum (E) Trapezoid
Teres major
32. A patient has a torn rotator cuff of the shoulder joint as the result of an automobile accident. Which of the following muscle tendons is intact and has normal function? (A) Supraspinatus (B) Subscapularis (C) Teres major (D) Teres minor (E) Infraspinatus
Posterior circumflex humeral artery
32. The given X-ray reveals a fracture of the proximal humerus, indicated by the black arrow. Given the location of the fracture, what artery is most likely damaged in this patient? (A) Posterior circumflex humeral artery (B) Brachial artery (C) Deep brachial (profunda brachii) artery (D) Subscapul arartery (E) Superior ulnar collateral artery
A marked decrease in the blood flow in the princeps pollicis artery
33. A patient complains of having pain with repeated movements of his thumb (claudication). His physician performs the Allen test and finds an insufficiency of the radial artery. Which of the following conditions would be a result of the radial artery stenosis? (A) A marked decrease in the blood flow in the superficial palmar arterial arch (B) Decreased pulsation in the artery passing superficial to the flexor retinaculum (C) Ischemia of the entire extensor muscles of the forearm (D) A marked decrease in the blood flow in the princeps pollicis artery (E) A low blood pressure in the anterior interosseous artery
Flexor carpi radialis (that's the one you can see on yourself)
33. During an attempted suicide, a depressed young woman slashes the front of her wrist with a razor blade. However, she cuts only to the depth of the superficial aspect of the flexor retinaculum before passing out at the sight of her own blood. Which of the following muscle tendons may be severed? (A) Flexor digitorum superficialis (B) Brachioradialis (C) Flexor pollicis longus (D) Abductor pollicis longus (E) Flexor carpi radialis
Fracture of the fifth metacarpal bone
34. A 17-year-old man has pain and moderate swelling over the dorsomedial aspect and in the hypothenar area of his right hand after punching a locker over a dispute with his girlfriend. What is the most likely finding on an X-ray of his hand? (A) Dislocation of the fifth metacarpophalangeal joint (B) Fracture of the triquetral bone (C) Fracture of the proximal phalanx of the ring finger (D) Fracture of the proximal phalanx of the little finger (E) Fracture of the fifth metacarpal bone
Dorsal scapular artery
34. A patient bleeding from the shoulder secondary to a knife wound is in fair condition because there is vascular anastomosis around the shoulder. Which of the following arteries is most likely a direct branch of the subclavian artery that is involved in the anastomosis? (A) Dorsal scapular artery (B) Thoracoacromial artery (C) Circumflex scapular artery (D) Transverse cervical artery (E) Suprascapular artery
Supraspinatus tendonitis
35. A right-handed 21-year-old college student visits his physician because of pain in his right shoulder that developed after starting a summer job on a construction crew 2 weeks ago. He explains that on his job site he regularly lifts heavy construction materials over his head. During physical examination, the patient experiences sharp pain in the range of 80 to 150 degrees of abduction at the glenohumeral joint. What is the most likely diagnosis? (A) Infraspinatus tendonitis (B) Supraspinatus tendonitis (C) Acromioclavicular (AC) joint arthritis (D) Degenerative arthritis of the shoulder (E) Broken clavicle
Dimpling of the overlying skin
35. During a breast examination of a 56-year-old woman, the physician found a palpable mass in her breast. Which of the following characteristics of breast cancer and its diagnosis is correct? (A) Elevated nipple (B) Polymastia (C) Shortening of the clavipectoral fascia (D) Dimpling of the overlying skin (E) Enlargement of the breast
Ulnar nerve at the elbow
36. A 56-year-old woman was stopped at a light when her car was rear-ended by another car. She had her right arm on the steering wheel, and the impact caused forced flexion at her elbow. Several months later, she comes to her physician complaining of numbness and a "pins and needles" sensation in her right little finger when she talks on the phone, rests her head on her right hand at work, or spends most of her day typing at work. She also notices the quality of her typing and her ability to play the violin have diminished. Which nerve is compressed at what location? (A) Ulnar nerve in the elbow (B) Ulnar nerve in the wrist (C) Median nerve in the wrist (D) Median nerve in the elbow (E) Median nerve in the axilla
Lack of sweating on the lateral side of the forearm
36. A patient with a stab wound receives a laceration of the musculocutaneous nerve. Which of the following conditions is most likely to have occurred? (A) Lack of sweating on the lateral side of the forearm (B) Inability to extend the forearm (C) Paralysis of brachioradialis muscle (D) Loss of tactile sensation on the arm (E) Constriction of blood vessels on the hand
Pectoralis major
37. A 20-year-old man fell from the parallel bar during the Olympic trial. A neurologic examination reveals that he has a lesion of the lateral cord of the brachial plexus. Which of the following muscles is most likely weakened by this injury? (A) Subscapularis (B) Teres major (C) Latissimus dorsi (D) Teres minor (E) Pectoralis major
Flexor digitorum superficialis
37. As part of a physical examination to evaluate intrinsic hand muscle function, a physician holds three fingers in the extended position, and instructs the patient to flex the proximal interphalangeal joint of the free finger, as shown. Which of the following muscles is the doctor specifically testing? (A) Flexor digitorum profundus (FDP) (B) Extensor digitorum (C) Second lumbrical (D) Dorsal interosseous (E) Flexor digitorum superficialis (FDS)
Dorsal interossei
38. A 24-year-old carpenter suffers a crush injury of his entire little finger. Which of the following muscles is most likely to be spared? (A) Flexor digitorum profundus (B) Extensor digitorum (C) Palmar interossei (D) Dorsal interossei (E) Lumbricals
Brachialis muscle
38. Because of repeated bad needle sticks, a heroin addict develops an infected abscess in the floor of the cubital fossa. Which of the following structures is the abscess most likely to invade first? (A) Brachioradialis muscle (B) Pronator teres muscle (C) Brachialis muscle (D) Head of the radius (E) Olecranon fossa of the humerus
Inferior dislocation of the head of the humerus
39. A 7-year-old boy falls from a tree house and is brought to the emergency department of a local hospital. On examination, he has weakness in rotating his arm laterally because of an injury of a nerve. Which of the following conditions is most likely to cause a loss of this nerve function? (A) Injury to the lateral cord of the brachial plexus (B) Fracture of the anatomic neck of the humerus (C) Knife wound on the teres major muscle (D) Inferior dislocation of the head of the humerus (E) A tumor in the triangular space in the shoulder region
Adduction of the arm
39. The traditional radical mastectomy includes removal of the pectoralis major muscle. Which of the following movements is most affected postoperatively by this surgical procedure? (A) Adduction of the arm (B) Abduction of the arm (C) Extension of the arm (D) Lateral rotation of the arm (E) Depression of the arm
Palmar interosseous
4. A 16-year-old patient has weakness flexing the metacarpophalangeal joint of the ring finger and is unable to adduct the same finger. Which of the following muscles is most likely paralyzed? (A) Flexor digitorum profundus (B) Extensor digitorum (C) Lumbrical (D) Dorsal interosseous (E) Palmar interosseous
Supraspinatus
4. As a result of chronic stress associated with an intense high school weight-lifting program, a 15-year-old boy suffers an avulsion fracture of the greater tubercle of the humerus. In the ER, he displays difficulty initiating abduction of the upper limb. Which of the following muscles was involved in this fracture? (A) Supraspinatus (B) Long head of biceps brachii (C) Long head of triceps (D) Subscapularis (E) Infraspinatus
Anterior (pectoral) nodes
40. A 49-year-old woman is diagnosed as having a large lump in her right breast. Lymph from the cancerous breast drains primarily into which of the following nodes? (A) Apical nodes (B) Anterior (pectoral) nodes (C) Parasternal (internal thoracic) nodes (D) Supraclavicular nodes (E) Nodes of the anterior abdominal wall
Second part of the axillary artery
40. The lateral thoracic artery provides the main blood supply to the lateral side of the chest wall, including much of the breast. To deter excessive blood loss during a surgical procedure involving the breast, a surgeon can clamp the lateral thoracic artery near its origin. Which of the following arteries gives rise to this artery? (A) First part of the axillary artery (B) Second part of the axillary artery (C) Third part of the axillary artery (D) Third part of the subclavian artery (E) First part of the brachial artery
Preganglionic sympathetic axons
41. A 17-year-old boy fell from his motorcycle and complains of numbness of the lateral part of the arm. Examination reveals that the axillary nerve is severed. Which of the following types of axons is most likely spared? (A) Postganglionic sympathetic axons (B) Somatic afferent axons (C) Preganglionic sympathetic axons (D) General somatic efferent axons (E) General visceral afferent axons
Thoracodorsal nerve
41. Following a radical mastectomy procedure, a surgeon plans to conduct a breast reconstruction utilizing a latissimus dorsi muscle flap. What nerve will the surgeon need to keep intact during the surgical dissection of the chest wall to prevent atrophy of the muscle flap? (A) Long thoracic nerve (B) Intercostobrachial nerve (C) Medial pectoral nerve (D) Thoracodorsal nerve (E) Axillary nerve
Radial artery
42. A construction worker suffers a destructive injury of the structures related to the anatomic snuffbox. Which of the following structures would most likely be damaged? (A) Triquetral bone (B) Trapezoid bone (C) Extensor indicis tendon (D) Abductor pollicis brevis tendon (E) Radial artery
Suspensory ligaments
42. An 80-year-old woman comes to the physician because of a lump in her right breast. Physical examination shows a 2-cm mass in the right breast with dimpling of the overlying skin and peau d'orange (edema of the breast with the skin assuming the appearance of an orange peel). Examination of a biopsy specimen confirms a diagnosis of carcinoma. Involvement of what structure is the most likely cause of this patient's skin dimpling? (A) Clavipectoral fascia (B) Suspensory ligaments (C) Lactiferous ducts (D) Retromammary space (E) Pectoralis major
Subscapularis muscle
43. A rock climber falls on his shoulder, resulting in a chipping off of the lesser tubercle of the humerus. Which of the following structures would most likely have structural and functional damage? (A) Supraspinatus muscle (B) Infraspinatus muscle (C) Subscapularis muscle (D) Teres minor muscle (E) Coracohumeral ligament
Deep branch of ulnar nerve (flexion of metacarpophalangeal joint is interossei muscles which are innervated by the deep branch of the ulnar nerve)
43. As part of a physical examination to evaluate intrinsic hand muscle function, a physician asks the patient to assume the Z-position (seen in photo) with his hand, which involves flexion of the metacarpophalangeal joints and extension of the interphalangeal joints of the fingers. Which of the following nerves is being tested in assuming this position? (A) Deep branch of radial nerve (B) Superficial branch of radial nerve (C) Recurrent branch of median nerve (D) Deep branch of ulnar nerve (E) Superficial branch of ulnar nerve
Recurrent branch of median nerve
44. A 10-year-old boy was running across a parking lot when he tripped and received lacerations on the base of his thumb from a broken glass bottle. On examination, his thumb was unable to oppose to his fingers, and the thumb also showed weakness when abducting and flexing. No sensory deficits were reported. What nerve was most likely severed? (A) Deep branch of radial nerve (B) Superficial branch of radial nerve (C) Recurrent branch of median nerve (D) Deep branch of ulnar nerve (E) Superficial branch of ulnar nerve
Radial and musculocutaneous nerves (supinator by the radial and biceps brachii by the musculocutaneous)
44. A 22-year-old female Macarena dancer fell from the stage and complains of elbow pain and inability to supinate her forearm. Which of the following nerves are most likely injured from this accident? (A) Median and ulnar nerves (B) Axillary and radial nerves (C) Radial and musculocutaneous nerves (D) Ulnar and axillary nerves (E) Musculocutaneous and median nerves
Anterior axillary lymph nodes
45. A 48-year-old woman is diagnosed with a malignant tumor in the superolateral quadrant of the right breast, including the axillary tail. If it metastasizes, this cancer will most likely spread first to which of the following locations? (A) Lateral axillary lymph nodes (B) Anterior axillary lymph nodes (C) Deep cervical lymph nodes (D) Parasternal lymph nodes (E) Contralateral breast lymph nodes
Weakness extending the wrist and fingers
46. A 48-year-old woman falls on an icy sidewalk and lands on her right elbow. She suffers a midshaft humeral fracture, as seen on the given X-ray. The attending physician wants to assess whether the nerve residing in the spiral groove of the humerus is damaged. What sign or symptom would confirm damage to this nerve? (A) Numbness on the lateral (radial) aspect of the forearm (B) Numbness of the medial aspect of the upper arm (C) Numbness over the superolateral aspect of the upper arm (D) Weakness extending the wrist and fingers (E) Weakness in grip strength
Pectoralis minor
47. Organization of the axillary lymph nodes into Levels I, II, and III for breast cancer treatment is based on the location of the nodes relative to which of the following muscles? (A) Pectoralis minor (B) Pectoralis major (C) Latissimus dorsi (D) Serratus anterior (E) Subscapularis
Scaphoid
48. A 37-year-old factory worker fractures multiple bones distal to the elbow when his hand and forearm are crushed by equipment dropped by a faulty hydraulic lift. Which of the following bones, if fractured, would most likely develop avascular necrosis? (A) Distal radius (B) Midshaft ulna (C) Fifth metacarpal (D) Lunate (E) Scaphoid
Dorsal interosseous muscles
49. As part of a physical examination to evaluate muscle function in the hand, a physician holds the four fingers (digits 2 through 5) and asks the patient to spread their fingers, as shown below. What muscle(s) is/are the doctor testing? (A) Lumbrical muscles (B) Palmar interosseous muscles (C) Dorsal interosseous muscles (D) Flexor digitorum superficialis (E) Flexor digitorum profundus
Fracture of the coracoid process
5. A 27-year-old patient presents with an inability to draw the scapula forward and downward because of paralysis of the pectoralis minor. Which of the following would most likely be a cause of his condition? (A) Fracture of the clavicle (B) Injury to the posterior cord of the brachial plexus (C) Fracture of the coracoid process (D) Axillary nerve injury (E) Defects in the posterior wall of the axilla
Inability to adduct the thumb (because you're all the way at the pisiform so it must be ulnar)
5. During an attempted suicide, a depressed young woman slashes her wrist with a straight razor. She cuts just proximal to the pisiform bone to the depth of the superficial aspect of the flexor retinaculum before passing out at the sight of her own blood. As a result of this wound, she may suffer a neuromuscular deficit that results in which of the following? (A) Weakness in pronation (B) Inability to abduct the thumb (C) Weakness in flexion of the thumb (D) Weakness in opposition of the thumb (E) Inability to adduct the thumb
Ulnar nerve in the wrist
50. A 52-year-old retired professional cyclist, who still rides his bike 400 miles per week, comes to his physician complaining of hand problems. The physician notes hyperextension of the ring and little fingers at the metacarpophalangeal joints and flexion at the interphalangeal joints within the same fingers (see photo). During examination, the patient has no weakness in flexion or adduction of the wrist. What nerve is compressed at what location? (A) Ulnar nerve in the elbow (B) Ulnar nerve in the wrist (C) Median nerve in the wrist (D) Median nerve in the elbow (E) Median nerve in the axilla
Anular ligament of radius
51. A 3-year-old girl is brought to the emergency room holding her right arm with the elbow flexed and the forearm pronated. She refuses to move her arm and complains her elbow "hurts a lot." Her mother reports they were holding hands and running in the park when the child tripped. The mother pulled on the child's hand to prevent her from hitting the ground. Given the nature of this injury and the age of the patient, what structure is most likely damaged? (A) Interosseous membrane of forearm (B) Quadrate ligament (C) Radial collateral ligament of elbow (D) Ulnar collateral ligament of elbow (E) Anular ligament of radius
Loss of sensory fibers from the second intercostal nerve
6. A 22-year-old patient received a stab wound in the chest that injured the intercostobrachial nerve. Which of the following conditions results from the described lesion of the nerve? (A) Inability to move the ribs (B) Loss of tactile sensation on the lateral aspect of the arm (C) Absence of sweating on the posterior aspect of the arm (D) Loss of sensory fibers from the second intercostal nerve (E) Damage to the sympathetic preganglionic fibers
Flexor digitorum profundus
6. As part of a physical examination to evaluate muscle function in the hand, a physician holds the proximal interphalangeal joint of his patient's index finger in the extended position and instructs him to try to flex the distal interphalangeal joint, as shown below. Which of the following muscles is the doctor testing? (A) Flexor digitorum profundus (FDP) (B) Extensor indicis (C) First lumbrical (D) First dorsal interosseous (E) Flexor digitorum superficialis (FDS)
Infraspinitus (suprascapular nerve to the infraspinitus runs beneath the superior transverse ligament)
63. If the structure indicated by the letter A is calcified, which of the following muscles is most likely paralyzed? (A) Deltoid (B) Teres major (C) Teres minor (D) Infraspinatus (E) Subscapularis
Posterior humoral circumflex artery
64. If the structure indicated by the letter B is fractured, which of the following structures is most likely injured? (A) Musculocutaneous nerve (B) Radial nerve (C) Deep brachial artery (D) Posterior humeral circumflex artery (E) Scapular circumflex artery
B
65. Destruction of this area would most likely cause weakness of supination and flexion of the forearm.
E
66. Destruction of this area would most likely cause weakness of pronation of the forearm and flexion of the wrist joints.
D
67. A lesion of the radial nerve would most likely cause paralysis of muscles that are attached to this area.
Flexor carpi ulnaris
68. Destruction of the structure indicated by the letter E most likely causes weakness of which of the following muscles? (A) Flexor carpi radialis (B) Palmaris longus (C) Flexor carpi ulnaris (D) Brachioradialis (E) Flexor digitorum superficialis
B
69. If the floor of the anatomic snuffbox and origin of the abductor pollicis brevis are damaged, which of the following bones is most likely to be involved? (A) A (B) B (C) C (D) D (E) E
Loss of wrist extension leading to wrist drop
7. A 16 year-old boy fell from a motorcycle, and his radial nerve was severely damaged because of a fracture of the midshaft of the humerus. Which of the following conditions would most likely result from this accident? (A) Loss of wrist extension leading to wrist drop (B) Weakness in pronating the forearm (C) Sensory loss over the ventral aspect of the base of the thumb (D) Inability to oppose the thumb (E) Inability to abduct the fingers
Torn coracoclavicular ligament
7. A 17-year-old boy comes to the emergency room after a hard fall onto the lateral aspect of his left shoulder during a high school basketball game. He complains of generalized pain during shoulder motion. On physical examination, the distal end of the clavicle is prominent and distinctly palpable. Radiological findings confirm the diagnosis of a severe (grade 3) shoulder separation. Which of the following features is a component of this condition? (A) Dislocated head of the humerus (B) Torn coracoclavicular ligament (C) Fractured clavicle (D) Dislocated sternal end of the clavicle (E) Torn anterior glenohumeral (GH) ligament
D
70. The patient is unable to abduct her middle finger because of paralysis of this structure.
A
71. A lesion of the median nerve causes paralysis of this structure.
G (PALMAR interossei adduct the fingers)
72. The patient is unable to adduct her little finger because of paralysis of this structure.
E
73. Atrophy of this structure impairs extension of both the metacarpophalangeal and interphalangeal joints.
Flexor digitorum superficialis
8. A patient comes in complaining that she cannot flex her proximal interphalangeal joints. Which of the following muscles appear(s) to be paralyzed on further examination of her finger? (A) Palmar interossei (B) Dorsal interossei (C) Flexor digitorum profundus (D) Flexor digitorum superficialis (E) Lumbricals
Long thoracic nerve
8. An 18-year-old boy is cut severely on the lateral wall of his right chest during a knife fight. Following healing, his scapula moves away from the thoracic wall when he leans on his right hand, giving the appearance indicated in the given photo. Which of the following nerves is likely damaged? (A) Axillary nerve (B) Thoracodorsal nerve (C) Long thoracic nerve (D) Dorsal scapular nerve (E) Suprascapular nerve
Latissimus dorsi
9. A 21-year-old woman walks in with a shoulder and arm injury after falling during horseback riding. Examination indicates that she cannot adduct her arm because of paralysis of which of the following muscles? (A) Teres minor (B) Supraspinatus (C) Latissimus dorsi (D) Infraspinatus (E) Serratus anterior
Hamate
9. On his downswing, an amateur golfer strikes the hard earth with his club and feels pain in his right wrist. During a subsequent physical examination, he complains of wrist pain that is exacerbated by gripping, displays point tenderness in his medial wrist, and complains of numbness and weakness in his pinky finger (fifth digit). What carpal bone, identified by the white arrow on the given X-ray, is most likely fractured in this patient? (A) Capitate (B) Hamate (C) Lunate (D) Pisiform (E) Scaphoid
Axillary
A 10-year-old boy falls off his bike, has difficulty in moving his shoulder, and is brought to an emergency department. His radiogram and angiogram reveal fracture of the surgical neck of his humerus and bleeding from the point of the fracture. 51. Which of the following nerves is most likely injured as a result of this accident? (A) Musculocutaneous (B) Axillary (C) Radial (D) Median (E) Ulnar
Anterior horn of the spinal cord
A 10-year-old boy falls off his bike, has difficulty in moving his shoulder, and is brought to an emergency department. His radiogram and angiogram reveal fracture of the surgical neck of his humerus and bleeding from the point of the fracture. 52. Following this accident, the damaged nerve causes difficulty in abduction, extension, and lateral rotation of his arm. Cell bodies of the injured nerve involved in movement of his arm are located in which of the following structures? (A) Dorsal root ganglion (B) Sympathetic chain ganglion (C) Anterior horn of the spinal cord (D) Lateral horn of the spinal cord (E) Posterior horn of the spinal cord
Dorsal root ganglia
A 10-year-old boy falls off his bike, has difficulty in moving his shoulder, and is brought to an emergency department. His radiogram and angiogram reveal fracture of the surgical neck of his humerus and bleeding from the point of the fracture. 53. The damaged nerve causes numbness of the lateral side of the arm. Cell bodies of the injured nerve fibers involved in sensory loss are located in which of the following structures? (A) Anterior horn of the spinal cord (B) Posterior horn of the spinal cord (C) Lateral horn of the spinal cord (D) Dorsal root ganglia (E) Sympathetic chain ganglia
Posterior humoral circumflex
A 10-year-old boy falls off his bike, has difficulty in moving his shoulder, and is brought to an emergency department. His radiogram and angiogram reveal fracture of the surgical neck of his humerus and bleeding from the point of the fracture. 54. This accident most likely leads to damage of which of the following arteries? (A) Axillary (B) Deep brachial (C) Posterior humeral circumflex (D) Superior ulnar collateral (E) Scapular circumflex
Teres minor and deltoid
A 10-year-old boy falls off his bike, has difficulty in moving his shoulder, and is brought to an emergency department. His radiogram and angiogram reveal fracture of the surgical neck of his humerus and bleeding from the point of the fracture. 55. Following this accident, the boy has weakness in rotating his arm laterally. Which of the following muscles are paralyzed? (A) Teres major and teres minor (B) Teres minor and deltoid (C) Infraspinatus and deltoid (D) Supraspinatus and subscapularis (E) Teres minor and infraspinatus
Radial nerve
A 17-year-old boy is injured in an automobile accident. He has a fracture of the shaft of the humerus. 58. Which of the following nerves is most likely damaged? (A) Axillary nerve (B) Radial nerve (C) Musculocutaneous nerve (D) Median nerve (E) Ulnar nerve
Sympathetic chain ganglion
A 17-year-old boy is injured in an automobile accident. He has a fracture of the shaft of the humerus. 59. As a result of this fracture, the patient shows lack of sweating on the back of the arm and forearm. Cell bodies of the damaged nerve fibers involved in sweating are located in which of the following structures? (A) Anterior horn of the spinal cord (B) Posterior horn of the spinal cord (C) Lateral horn of the spinal cord (D) Sympathetic chain ganglion (E) Dorsal root ganglion
Area of the anatomic snuffbox
A 17-year-old boy is injured in an automobile accident. He has a fracture of the shaft of the humerus. 60. Following this accident, the patient has no cutaneous sensation in which of the following areas? (A) Medial aspect of the arm (B) Lateral aspect of the forearm (C) Palmar aspect of the second and third digits (D) Area of the anatomic snuffbox (E) Medial one and one-half fingers
Profunda brachii artery
A 17-year-old boy is injured in an automobile accident. He has a fracture of the shaft of the humerus. 61. Which of the following arteries may be damaged? (A) Brachial artery (B) Posterior humeral circumflex artery (C) Profunda brachii artery (D) Radial artery (E) Radial recurrent artery
Biceps brachii (radial nerve is lesioned, so supinator and brachioradialis don't work)
A 17-year-old boy is injured in an automobile accident. He has a fracture of the shaft of the humerus. 62. After this accident, supination is still possible through contraction of which of the following muscles? (A) Supinator (B) Pronator teres (C) Brachioradialis (D) Biceps brachii (E) Supraspinatus
Ulnar
A 21-year-old man injures his right arm in an automobile accident. Radiographic examination reveals a fracture of the medial epicondyle of the humerus. 48. Which of the following nerves is most likely injured as a result of this accident? (A) Axillary (B) Musculocutaneous (C) Radial (D) Median (E) Ulnar
Adductor pollicis
A 21-year-old man injures his right arm in an automobile accident. Radiographic examination reveals a fracture of the medial epicondyle of the humerus. 49. Which of the following muscles is most likely paralyzed as a result of this accident? (A) Extensor pollicis brevis (B) Abductor pollicis longus (C) Abductor pollicis brevis (D) Adductor pollicis (E) Opponens pollicis
Adduct his index finger (adduction = palmar interossei = deep ulnar)
A 21-year-old man injures his right arm in an automobile accident. Radiographic examination reveals a fracture of the medial epicondyle of the humerus. 50. After this injury, the patient is unable to do which of the following? (A) Flex the proximal interphalangeal joint of his ring finger (B) Flex the DIP joint of his index finger (C) Feel sensation on his middle finger (D) Abduct his thumb (E) Adduct his index finger
Deltoid muscle and gravity
A 37-year-old female patient has a fracture of the clavicle. The junction of the middle and lateral thirds of the bone exhibits overriding of the medial and lateral fragments. The arm is rotated medially, but it is not rotated laterally. 45. The lateral portion of the fractured clavicle is displaced downward by which of the following? (A) Deltoid and trapezius muscles (B) Pectoralis major and deltoid muscles (C) Pectoralis minor muscle and gravity (D) Trapezius and pectoralis minor muscles (E) Deltoid muscle and gravity
Sternocleidomastoid (pulls the medial part up)
A 37-year-old female patient has a fracture of the clavicle. The junction of the middle and lateral thirds of the bone exhibits overriding of the medial and lateral fragments. The arm is rotated medially, but it is not rotated laterally. 46. Which of the following muscles causes upward displacement of the medial fragment? (A) Pectoralis major (B) Deltoid (C) Trapezius (D) Sternocleidomastoid (E) Scalenus anterior
A fatal hemorrhage from the brachiocephalic vein
A 37-year-old female patient has a fracture of the clavicle. The junction of the middle and lateral thirds of the bone exhibits overriding of the medial and lateral fragments. The arm is rotated medially, but it is not rotated laterally. 47. Which of the following conditions is most likely to occur secondary to the fractured clavicle? (A) A fatal hemorrhage from the brachiocephalic vein (B) Thrombosis of the subclavian vein, causing a pulmonary embolism (C) Thrombosis of the subclavian artery, causing an embolism in the ascending aorta (D) Damage to the upper trunk of the brachial plexus (E) Damage to the long thoracic nerve, causing the winged scapula
Brachial
A 64-year-old man with a history of liver cirrhosis has been examined for hepatitis A, B, and C viruses. In an attempt to obtain a blood sample from the patient's median cubital vein, a registered nurse inadvertently procures arterial blood. 56. The blood most likely comes from which of the following arteries? (A) Brachial (B) Radial (C) Ulnar (D) Common interosseous (E) Superior ulnar collateral
Median
A 64-year-old man with a history of liver cirrhosis has been examined for hepatitis A, B, and C viruses. In an attempt to obtain a blood sample from the patient's median cubital vein, a registered nurse inadvertently procures arterial blood. 57. During the procedure, the needle hits a nerve medial to the artery. Which of the following nerves is most likely damaged? (A) Radial (B) Median (C) Ulnar (D) Lateral antebrachial (E) Medial antebrachial
