Grays practice questions

2. c) Extension at the knee. Quadriceps femoris extends the leg (rectus femoris and the vastus muscles) and helps flex the hip (rectus femoris). It is innervated by the femoral nerve, which is made from the contributions of L2, 3, and 4 in the lumbar plexus. If a patient could not adduct at the hip, the adductor muscles might be damaged. These are supplied by the obturator nerve, which also comes from L2, 3, and 4 in the lumbar plexus. If a patient could not extend at the hip or flex the leg, the hamstring muscles might be damaged. These muscles are supplied by the tibial nerve, a branch of the sciatic nerve. If a patient could not rotate the knee medially, popliteus might be injured. This muscle, which is innervated by the tibial nerve, allows the knee to twist and unlock from a fully extended position, as in erect stance.

2. Which movement would fail in case of paralysis of the quadriceps femoris muscle? a) Adduction at the hip b) Extension at the hip c) Extension at the knee d) Flexion at the knee e) Medial rotation at the knee

22. d) Teres major Teres major is not part of the rotator cuff. It does not insert on the greater or lesser tubercle of the humerus--instead, it inserts on the crest of the lesser tubercle of the humerus, which is distal to the lesser tubercle. It is innervated by the lower subscapular nerve and it is a medial rotator of the arm. The other four muscles comprise the rotator cuff--they all insert on the greater or lesser tubercles of the humerus. Supraspinatus inserts into the upper facet of the greater tubercle of the humerus and into the capsule of the shoulder joint. Infraspinatus inserts into the middle facet of the greater tubercle of the humerus and into the capsule of the shoulder joint. Teres minor inserts into the lower facet of the greater tubercle of the humerus and into the capsule of the shoulder joint. Subscapularis inserts onto the lesser tubercle of the humerus.

22. The rotator cuff is composed of all of the following muscles except: a) Infraspinatus b) Subscapularis c) Supraspinatus d) Teres major e) Teres minor

23. b) Flexor digitorum profundus The median and ulnar nerve both innervate flexor digitorum profundus. Flexor carpi ulnaris is innervated by the ulnar nerve only. Flexor digitorum superficialis and flexor pollicis longus are innervated by the median nerve. Pronator quadratus is innervated by the anterior interosseus nerve, which is a branch of the median nerve.

23. What muscle is innervated by branches of both the median and ulnar nerves? a) Flexor carpi ulnaris b) Flexor digitorum profundus c) Flexor digitorum superficialis d) Flexor pollicis longus e) Pronator quadratus

31. b) Abduction of the arm AND c) Lateral rotation of the arm The suprascapular nerve innervates the supraspinous and infraspinous muscles. The supraspinous muscle is responsible for beginning abduction of the arm, up to approximately 15° before the deltoid muscle can begin assisting. The infraspinous muscle attaches at the greater tuberosity of the humerus and the infraspinous fossa of the scapula and laterally rotates the arm.

31. A severed suprascapular nerve would cause a patient problems conducting what action(s)? a) Supination b) Abduction of the arm c) Lateral rotation of the arm d) Protraction of the arm e) Adduction of the arm

35. d) Ulnar nerve The flexor carpi ulnaris attaches at the thumb and causes flexion. The flexor carpi ulnaris muscle is in the anterior compartment of the forearm and is innervated by the ulnar nerve.

35. A medial cut of the arm preventing flexion of the 5th metacarpal would mean what nerve is cut? a) Tibial nerve b) Musculocutaneous nerve c) Medial pectoral nerve d) Ulnar nerve e) Radial nerve

b) swing

48. When you start to jog from a walking pace, your _________ phase becomes longer. a) Stance b) Swing c) Striking d) Pushing

49. b) External iliac; Inguinal ligament The femoral artery is a continuation of the external iliac, and the inguinal ligament is the landmark where it changes names.

49. The __________ artery becomes the femoral artery when it crosses which landmark? a) Internal iliac; Piriformis b) External iliac; Inguinal ligament c) Profunda femoris; Gracilis muscle d) External iliac; Piriformis

54. a) Abduction after 15 degrees The rotator cuff muscles (SITS) have a couple different functions. The supraspinatus also helps to abduct the arm, but only for the first 15 degrees. The infraspinatus helps to laterally rotate the arm. The teres minor helps to laterally rotate and adduct the arm. The subscapularis, which is the only one that is attached to the lesser tubercle, helps to medially rotate the humerus. Abduction of the humerus after 15 degrees is caused by the deltoid.

54. Which is NOT an action that would be produced by one of the rotator cuff muscles? a) Abduction after 15 degrees b) Medial rotation c) Lateral rotation d) Adduction

56. True. The tibial nerve is responsible for muscle innervation in the posterior compartment of the leg. This nerve continues down the leg and provides sensory innervation to the skin around the heel of the foot.

56. (T/F) The tibial nerve is responsible for sensory innervation to the posterior, superficial portion of the foot.

61. The superficial fibular nerve innervates the lateral compartment of the leg, so the patient would suffer from a loss of eversion.

61. A patient with a severed superficial fibular nerve would cause a patient issues performing what action?

59. False. The pectoralis major is innervated by both the lateral and medial pectoral nerve. The lateral pectoral nerve branches off of the lateral cord, whereas the medial pectoral nerve branches off of the medial cord of the brachial plexus.

59. (T/F) The two nerves that innervate the pectoralis major muscle are both direct branches off of the same cords.

1. c) Ulnar nerve The ulnar nerve innervates the medial 1.5 digits on the palmar surface of the hand, and 2.5 digits on the dorsal side. So, this is the nerve responsible for innervating the tip of the little finger. The radial nerve innervates the dorsal side of the lateral 2.5 digits, but does not innervate the tips of these fingers. The median nerve, which innervates the palmar side of the lateral 3.5 digits, also innervates the fingertips of these 3.5 fingers. The musculocutaneous nerve does not provide cutaneous innervation to the skin, but its branch, the lateral antebrachial cutaneous nerve, innervates the lateral skin of the forearm. The medial antebrachial cutaneous nerve innervates the medial skin of the forearm - this nerve is a direct branch of the medial cord of the brachial plexus.

1. After trying to throw a curve ball, a pitcher lost sensation from the tip of the little finger. This indicates injury to which nerve? a) Radial b) Median c) Ulnar d) Musculocutaneous e) Medial antebrachial cutaneous

10. c) Lateral; piriformis A good way to answer this question is to look for a muscle that is a lateral rotator of the thigh and then make sure that the compartment that it is listed with is correct. Piriformis laterally rotates the thigh; it is a member of the lateral compartment which includes other muscles that laterally rotate the thigh, like obturator internus and the superior and inferior gemellus muscles. So, this is the best answer. Tensor fasciae latae is in the lateral compartment, but it's a medial rotator of the thigh, so this is not a correct answer. Rectus femoris is one of the quadriceps muscles, found in the anterior compartment of the thigh. This compartment extends the knee and flexes the hip, but these muscles do not rotate the thigh. Biceps femoris is a muscle in the posterior compartment--it's a hamstring muscle that extends the hip and flexes the knee.

10. The medial thigh muscles rotate the femur medially, counterbalanced by muscles of the _____________ thigh, including the ___________ muscle, which rotates the femur laterally. a) Lateral; tensor fasciae latae b) Anterior; rectus femoris c) Lateral; piriformis d) Posterior; biceps femoris e) Posterior; quadriceps femoris

3. e) Pectineus Pectineus is a muscle of the medial compartment of the thigh. Most of the muscles in this compartment are adductors and medial rotators, innervated by the obturator nerve. However, pectineus is the exception of the medial compartment--it's innervated by the femoral nerve, and it's a hip flexor. So, damage to the obturator nerve would not affect pectineus! Adductor brevis, adductor longus, and gracilis are muscles of the medial compartment which adduct and medially rotate the thigh--they are all innervated by the obturator nerve. Obturator externus is also innervated by the obturator nerve--it is a lateral rotator found in the medial compartment of the thigh.

3. An obturator hernia that compresses the obturator nerve in the obturator canal may affect the function of all of the following muscles EXCEPT: a) Adductor brevis b) Adductor longus c) Gracilis d) Obturator externus e) Pectineus

11. d) Flexion of the leg The ischial tuberosity is the origin of the hamstrings muscles, so fracturing this bone would disrupt this origin. The hamstrings are important for flexing the leg and extending the thigh; this means that these motions would be impaired following the fracture. Gluteus minimus and medius are important abductors of the hip. These muscles both take origin from the ilium. So, a fracture to the ilium might impair abduction of the hip, although these muscles are more commonly impaired by damage to the superior gluteal nerve. The tibialis anterior, in the anterior compartment of the leg, is responsible for dorsiflexion of the foot. It originates on the lateral condyle of the tibia, so breaking off the lateral condyle of the tibia might impair dorsiflexion. The quadriceps, in the anterior compartment of the thigh, are responsible for extending the leg. Rectus femoris takes origin from the anterior inferior iliac spine, while the vastus muscles originate from the body of the femur. Finally, the muscles responsible for flexing the hip are pectineus, iliopsoas, sartorius, and rectus femoris. Pectineus originates from the pecten pubis, iliopsoas originates on the lumbar vertebrae and the iliac fossa, and sartorius originates on the anterior superior iliac spine.

11. Because of its muscle attachments, a fracture to the ischial tuberosity would affect which movement of the lower limb? a) Abduction of the thigh b) Dorsiflexion of the foot c) Extension of the leg d) Flexion of the leg e) Flexion of the thigh

12. a) Calcaneal Gastrocnemius and soleus insert on the calcaneus via the calcaneal tendon, a tendon of the lower calf which is the thickest and strongest tendon of the body. These muscles are important plantar flexors of the foot, so it is likely that the tendon connected to these muscles has been damaged. The other tendons/muscles listed and their actions are as follows: Fibularis teritus: everts the foot; flexor digitorum longus: flexes toes 2-5; flexor hallucis longus: flexes toe 1; tibialis anterior: inverts and dorsiflexes the foot. Since none of these actions is disrupted, the other tendons are probably fine.

12. A patient complains of localized pain in a swollen lower calf and cannot strongly plantar flex his foot. What tendon may have ruptured? a) Calcaneal b) Fibularis tertius c) Flexor digitorum longus d) Flexor hallucis longus e) Tibialis anterior

13. d) Ulnar artery The ulnar artery is the main source of blood to the superficial palmar arterial arch; the arch is completed on the radial side by the superficial palmar branch of the radial artery. The radial artery is the main source of blood to the deep palmar arterial arch, which is completed on the ulnar side by the deep branch of the ulnar artery.

13. The main source of blood to the superficial palmar arterial arch is the: a) Deep branch of the ulnar artery b) Radial artery c) Superficial palmar branch of the radial artery d) Ulnar artery

14. a) Median nerve Carpal tunnel syndrome is caused by a compression of the median nerve within the carpal tunnel. The carpal tunnel is a canal on the anterior side of the wrist. It is made of the carpal bones which are covered by the flexor retinaculum. It contains the tendon of flexor pollicis longus, the tendons of flexor digitorum superficialis and profundus, and the median nerve. If the sheath over the common flexor tendons, the ulnar bursa, becomes inflamed, this can compress the median nerve in the canal, leading to pain and weakness in the hand. None of the other structures mentioned in the question are contained in the carpal tunnel, so they would not be compressed in that space.

14. The signs and symptoms of carpal tunnel syndrome may vary among patients, but they always result from compression of what structure in the carpal canal? a) Median nerve b) Radial artery c) Superficial radial nerve d) Ulnar artery e) Ulnar nerve

15. b) Gluteus maximus Gluteus maximus is the most important muscle for powerfully extending the thigh. This is the muscle that is used for forceful extension at the hip joint, which is what you need to go up the stairs or to jump powerfully. That's why gluteus maximus is the answer. Semitendinosus is the other muscle mentioned which extends the thigh--it's one of the hamstrings muscles in the posterior compartment of the thigh. However, semitendinosus flexes the leg, and there is no weakness with this motion. Also, you should remember that gluteus maximus is the key muscle for very forceful extension--not semitendinosus. Adductor magnus adducts and medially rotates the thigh, while gluteus medius abducts and medially rotates the thigh. Iliopsoas is a hip flexor. There is no weakness in any of these movements, so you should know that these muscles are not injured.

15. An elderly patient complains of difficulty in walking up stairs. Tests by her doctor reveal weakness in extension at her hip, but no change in hip flexion, or flexion or extension of the knee. Based upon these results, what muscle is most likely not functioning properly. a) Adductor magnus b) Gluteus maximus c) Gluteus medius d) Iliopsoas e) Semitendinosus

16. d) Tibialis anterior Tibialis anterior is the major dorsiflexer of the foot--if it is damaged, you will observe foot drop. It is found in the anterior compartment and is innervated by the deep fibular nerve. This patient probably damaged her common fibular nerve in the accident. This nerve wraps around the neck of the fibula before giving off its two branches: the deep fibular nerve and the superficial fibular nerve. You might hypothesize that this patient would also have a loss of cutaneous sensation on the distal third of the anterior leg and the dorsum of the foot, since those are the areas that receive cutaneous innervation from the superficial fibular nerve. None of the other muscles listed are dorsiflexers. Fibularis longus and brevis evert and plantarflex the foot; tibialis posterior plantarflexes and inverts the foot; popliteus flexes and rotates the leg medially so that the knee can unlock.

16. Your patient was struck by a car's bumper as she crossed the street, and her fibular neck is broken. After the bone has healed, she has "foot drop", i. e. she cannot dorsiflex her foot, and so it flops onto the ground during walking. Denervation (paralysis) of which of the following muscles would be associated with foot drop? a) Fibularis longus b) Tibialis posterior c) Fibularis brevis d) Tibialis anterior e) Popliteus

42. d) Extensor digitorum longus The skin between the first and second toe is innervated by the deep fibular nerve, which also innervates the anterior compartment of the leg. This compartment houses the extensors of the leg (for example, the extensor digitorum longus).

42. If a patient cannot feel pressure between their first and second toe, which muscle will most likely not have innervation? a) Rectus femoris b) Soleus c) Flexor hallucis longus d) Extensor digitorum longus

17. d) Foot drop Anterior compartment syndrome leads to foot drop due to the compression of the deep fibular nerve. Since the deep fibular nerve innervates tibialis anterior, an important dorsiflexer, injuring this nerve will impair dorsiflexion and cause the foot to drop. Numbness on the dorsum of the foot would suggest an injury to the superficial fibular nerve. An inability to evert the foot might also be due to an injury to the superficial fibular nerve, since that nerve supplies the lateral, everter compartment. Damage to the deep fibular nerve might also impair inversion since that is an action of tibialis anterior, but this would be a more subtle finding. Also, remember that tibialis posterior is also an inverter, so that muscle might be able to compensate for the injury to the anterior compartment. Finally, an inability to plantarflex the foot would stem from damage to the tibial nerve and the posterior compartment.

17. A player is kicked on the front of his leg during a soccer game, and a large bruise develops. A hematoma deep to the crural fascia can create extreme pressure within the anterior compartment of the leg, compressing structures within it. The most likely finding resulting from this anterior compartment syndrome is: a) Numbness on the dorsum of the foot b) Inability to evert the foot c) Inability to invert the foot d) Foot drop e) Inability to plantarflex the foot

18. e) Suprascapular nerve Let's take the observations one by one to break down this question. If the diaphragm is functioning normally, you know that the phrenic nerve is probably uninjured, which means that the C5 root has not been damaged. Since the scapula is not winged, there was no damage to the long thoracic nerve or the C5-7 nerve roots. Finally, since the patient cannot initiate abduction of the arm, you know that the suprascapular nerve is injured and supraspinatus has been denervated. But, the patient can abduct the arm once it is lifted to 45 degrees, so the deltoid muscle and the axillary nerve must be intact. Taking the answer choices one by one: The axillary nerve is ok, because deltoid is functioning. The posterior cord of the brachial plexus must also be intact, since this cord gives off the axillary nerve. The roots of the brachial plexus are ok, since the phrenic nerve and long thoracic nerve (which are derived from the roots) are still functioning. The superior trunk of the brachial plexus must also be undamaged, since this trunk contributes to the posterior cord which is intact. So, this means that the injury must be to the suprascapular nerve.

18. A person sustains a left brachial plexus injury in an auto accident. After initial recovery the following is observed: 1) the diaphragm functions normally, 2) there is no winging of the scapula, 3) abduction cannot be initiated, but if the arm is helped through the first 45 degrees of abduction, the patient can fully abduct the arm. From this amount of information and your knowledge of the formation of the brachial plexus where would you expect the injury to be: a) Axillary nerve b) Posterior cord c) Roots of plexus d) Superior trunk e) Suprascapular nerve

19. c) Long thoracic nerve An injury to the long thoracic nerve denervates serratus anterior, meaning that there will be no muscle protracting the scapula and counteracting trapezius and the rhomboids, powerful retractors of the scapula. This means that the scapula will be winged backwards, which is this patient's main symptom. The long thoracic nerve is derived from the nerve roots of C5-7. This nerve is particularly vulnerable to iatrogenic injury during surgical procedures, such as mastectomies, because it is located on the superficial side of serratus anterior. The accessory nerve innervates trapezius--an injury to this nerve might lead to an inability to raise the acromion of the shoulder. The lateral pectoral nerve is a small nerve that provides innervation to pectoralis major. The phrenic nerve innervates the diaphragm. The vagus nerve provides parasympathetic innervation to the thorax and much of the abdominal viscera. The patient's symptoms do not fit with an injury to any of these nerves.

19. During a motorcycle accident, an 18-year-old male landed on the right lateral side of his rib cage with his right upper limb abducted. In the hospital he was found to have "winging" of the right scapula. Which nerve was likely damaged in the accident? a) Accessory b) Lateral pectoral c) Long thoracic d) Phrenic e) Vagus

20. b) Abduction Injuries to the upper roots of the brachial plexus (C5 and C6) are the most common types of injuries. It affects especially the suprascapular, axillary, and musculocutaneous nerves, which causes paralysis of the rotator cuff muscles, biceps, brachialis, coracobrachialis, and deltoid. It also knocks out the upper and lower subscapular nerves, denervating subscapularis and teres major. It knocks out most of the lateral pectoral nerve, but the majority of pect major is innervated by medial pectoral nerve, so it is only weakened. After this injury, the upper limb hangs limply, medially rotated by an unopposed latissimus and pectoralis major muscles, and pronated due to a loss of biceps. So, the limb is constantly adducted and medially rotated. However, the limb can no longer be abducted because both supraspinatus, which initiates abduction, and deltoid, which allows for complete abduction, have been denervated. As far as extension and flexion go: Extension occurs through the actions of the triceps which is innervated by the radial nerve. This nerve should still be intact. Flexion of the arm is not totally lost if biceps brachii and coracobrachialis are denervated, because pectoralis major is not completely lost.

20. A man riding a motorcycle hit a wet spot in the road, lost control, and was thrown from his bike. He landed on the right side of his head and the tip of his shoulder, bending his head sharply to the left and stretching the right side of his neck. Subsequent neurological examination revealed that the roots of the 5th and 6th cervical nerves had been torn away from the spinal cord. Following the above injury, which of the movements of the arm at the shoulder would you expect to be totally lost? a) Adduction b) Abduction c) Flexion d) Extension e) Medial rotation

21. e) Posterior cord The axillary nerve and radial nerve are both terminal branches from the posterior cord. There are no nerves from the inferior trunk. The lateral cord gives off the musculocutaneous nerve and contributes a branch to the median nerve. The medial cord of the brachial plexus terminates with the ulnar nerve and a branch to the median nerve; it also gives off the medial pectoral nerve, the medial cutaneous nerve of the arm, and the medial cutaneous nerve of the forarm. The middle trunk of the brachial plexus has no direct branches. There is no superior cord of the brachial plexus--only a superior trunk! 22. Bad question, discard.

21. The axillary nerve arises directly from which part of the brachial plexus? a) Inferior trunk b) Lateral cord c) Medial cord d) Middle trunk e) Posterior cord f) Superior cord

58. True. The interosseous membrane is connective tissue that will become tight during supination and will stop the forearm from continuing to rotate. Excessive stretching would not inhibit supination but would rather allow for more supination than before.

58. (T/F) Excessive stretching of the interosseous membrane between the radius and the ulna would not inhibit the ability to fully supinate.

24. c) Musculocutaneous The musculocutaneous nerve innervates biceps brachii and coracobrachialis--muscles which flex the arm. Since this man cannot flex his arm, it appears that the musculocutaneous nerve has been damaged. He had also lost sensation over the lateral part of his forearm, indicating that the lateral antebrachial cutaneous nerve has been damaged. This nerve is a branch of the musculocutaneous nerve. The axillary nerve innervates deltoid and teres minor--an injury to this nerve would prevent the patient from abducting his arm. The median nerve innervates the muscles that permit flexion at the wrist and some muscles in the hand, especially of the thumb. The radial nerve innervates the extensors of the arm, elbow, wrist, and hand. The ulnar nerve innervates muscles of the hand, primarily. The listed symptoms do not match injuries to any of these other nerves.

24. While putting metal panels on the roof of a barn, one of the panels slips out of the hands of the man on the roof. During an attempt to catch the panel, a worker below is struck by its sharp edge. The panel hits across the anterior surface of his right arm at midlength and the impact severs all of the tissue to the bone. When examined in the emergency room it is noted that the patient can only weakly flex his elbow and the lateral side of his forearm is numb. In addition to the muscles, which nerve is injured? a) Axillary b) Median c) Musculocutaneous d) Radial e) Ulnar

25. a) Iliofemoral The iliofemoral ligament is a Y-shaped ligament extending from the anterior inferior iliac spine to the anterior surface of the intertrochanteric line of the femur. It prevents hyperextension of the hip joint during standing by screwing the femoral head into the acetabulum. (The ischiofemoral ligament also helps to prevent hyperextension of the hip joint by screwing the femoral head into the acetabulum.) Ligamentum capitis femoris attaches the head of the femur to the acetabular fossa. The pubofemoral ligament connects the pubic portion of the rim of the bony acetabulum to the medial surface of the femoral neck. It prevents overabduction of the hip joint. The ischiofemoral ligament limits abduction.

25. Which ligament limits extension at the hip joint? a) Iliofemoral b) Ligamentum capitis femorus c) Pubofemoral d) Ischiofemoral

26. a) Anterior cruciate ligament The doctor is performing the drawer test on this football player. The drawer test is a test designed to evaluate the integrity of the anterior and posterior cruciate ligaments. It involves firmly grasping the leg with both hands just below the knee, with the thumbs on the tibial tuberosity. With the knee flexed, the examiner pushes and pulls the leg in a line parallel to the long axis of the femur. If the leg moves too far anteriorly, this indicates a ruptured anterior cruciate ligament. If the leg moves too far posteriorly, the posterior cruciate ligament is probably ruptured. In this case, the leg is moving anteriorly, so the anterior cruciate ligament must be injured--which is what happened in this case. ACL tears often result from a blow to the lateral side of the knee; a blow to the medial side of the knee may signal an injury to the lateral collateral ligament. In ACL injuries, there are three structures that are commonly torn: the anterior cruciate ligament, the medial collateral ligament, and the medial meniscus. Remember, the MCL and the medial meniscus are attached, so an injury to the MCL will usually disupt the medial meniscus, too. This constellation of injuries is sometimes referred to as "the terrible triad." (Although these injuries tend to happen together, the anterior drawer test is specifically evaluating the integrity of the ACL, and you can't just assume that all of the structures are damaged after a positive anterior drawer test.)

26. During the Orange Bowl, the national championship football game between Florida State and a team from a land-locked state, a player is blocked from behind during a kick-off return, injuring his medial collateral ligament. The team doctor tests his knee by pulling anteriorly on the leg with the knee flexed. If the leg translates (moves) forward significantly, this indicates damage to which structure? a) Anterior cruciate ligament b) Lateral collateral ligament c) Medial meniscus d) Medial collateral ligament e) Posterior cruciate ligament

27. a) Annular A "pulled elbow" is a condition where the head of the radius has been pulled inferiorly, out of the annular ligament. It most commonly occurs in young children whose hand or forearm is suddenly yanked for some reason. Since the head of the radius is largely cartilage until about puberty, it is easily pulled from the socket formed by the annular ligament and radial notch of the ulna. You should be familar with this case history! The glenoid labrum is a fibrocartilage extension of the glenoid fossa--it makes the shoulder socket deeper. The interosseous ligament or membrane is a fibrous membrane that connects the interosseous borders located on the shafts of the radius and the ulna. Forces from the hand pass through the radius and are transferred to the ulna through the interosseous membrane. The radial collateral ligaments and ulnar collateral ligaments are found at the elbow and wrist--they stabilize the articular capsules of the wrist and elbow on the ulnar and radial sides.

27. A father and child are about to step off a curb to cross a street when a car suddenly turns around the corner. In panic the father yanks on the child's arm to pull him out of the way of the car. Safe on the curb, the child screams in pain and holds his elbow. The diagnosis is "pulled elbow;" the head of the radius has been pulled out of the socket holding it against the radial notch of the ulna. In order for the head of the radius to be dislocated in this way, what ligament must be stretched or torn? a) Annular b) Glenoid labrum c) Interosseous d) Radial collateral e) Ulnar collateral

28. c) Separated shoulder A shoulder separation is the dislocation of the acromioclavicular joint. The injury often occurs from a hard fall on the shoulder with the impact taken by the acromion or from a fall on the outstretched upper limb. The injury is severe if the AC and the coracoclavicular ligaments are torn. A pulled elbow occurs when the head of the radius slips out of the annular ligament. This is a common injury in children whose forearms are pulled forcefully. A rotator cuff tear is damage to the tendon of one of the muscles in the rotator cuff. It can lead to rupture of one or more of the tendons of the muscles forming the rotator cuff. Acute tears may occur when the arm is violently pushed into abduction. A dislocated shoulder occurs when the humeral head slips out of the labrum; this often happens in the anterior direction. Finally, a Colles' fracture is a common fracture of the radius. The distal end of the radius is broken, and distal fragment is displaced dorsally and is often broken into pieces. The fracture results from forced dorsiflexion of the hand, usually as the result of trying to ease a fall by outstretching the upper limb.

28. It was determined that a football player tore his coracoclavicular ligament. This is an example of a: a) Pulled elbow b) Rotator cuff tear c) Separated shoulder d) Dislocated shoulder e) Colles' fracture

29. b) Plantar aponerosus Plantar aponeurosus is connective tissue that has attachment points on the inferior side of the foot, giving the foot its arch. Cutting of the plantar aponerosus would cause foot to spread out and become "flat".

29. A cut to what structure would cause the foot to become larger? a) Deep femoral nerve b) Plantar aponeurosis c) Achilles tendon d) Anterior talofibular ligament e) Lateral malleolus

30. e) Flexor hallucis longus- Tibial nerve. The big toe is the last part of the foot to leave the ground during the pushoff phase of the gait cycle. The pushing off movement of the foot is plantar flexion, which comes from muscles in the posterior compartment of the leg, which is innervated by the tibial nerve. The Flexor hallucis longus is the muscle that is associated with plantar flexion of the big toe and thus is the last muscle that is contracting during the pushoff phase.

30. Weakness during the final moment of the pushoff phase of the gait cycle would indicate problems with what muscle/nerve combination? a) Fibularis longus- Deep fibular nerve b) Extensor hallucis longus- Tibial nerve c) Tibialis anterior- Deep fibular nerve d) Flexor digitorum- Tibial nerve e) Flexor hallucis longus- Tibial nerve

32. a) Median cubital vein

32. A phlebotomist is responsible for obtaining blood from patients. Retrieving blood from a vessel on the medial border of the cubital fossa would be what blood vessel? a) Median cubital vein b) Radial artery c) Anterior cubital artery d) Ulnar vein e) Brachial vein

33. b) Extension The medial cord of the brachial plexus will branch into the ulnar nerve and the medial root of the median nerve, which will come together with the lateral root of the lateral cord. A cut to the medial cord means that the ulnar nerve is severed as well as a portion of the median nerve. The ulnar and median nerves innervate the anterior compartment of the forearm, which is composed of muscles responsible for flexion of the hand and the wrist. The radial nerve innervates the muscles of the posterior compartment of the forearm, which extend the hand at the wrist. The radial nerve is unaffected because is arises solely form the posterior cord of the brachial plexus.

33. If a patient has a cut to the medial cord of the brachial plexus, what movement of the hand is unaffected? a) Flexion b) Extension c) Supination d) Pronation e) Abduction

34. d) Extensor retinaculum The extensor retinaculum is connective tissue that is tightly attached on the dorsal side of the wrist that keeps the tendons in the posterior compartment from raising up off of the wrist when the muscle contracts.

34. A patient that experiences "bowstringing" (raising of the tendons) of the wrist when extending the hand and phalanges would mean what structure is cut or absent? a) Interosseous membrane b) Median nerve c) Flexor retinaculum d) Extensor retinaculum e) Radial nerve

36. c) Superior gluteal The Trendelenbug test is testing the action of the gluteus medius, which is innervated by the superior gluteal nerve.

36. The Trendelenburg test will reveal any defects or lesions to which nerve? a) Gluteus medius b) Obturator c) Superior gluteal d) Inferior gluteal

37. b) Adduct; Metatarsals Plantar interossei help to adduct (PAD), whereas dorsal interossei help to abduct (DAB) the toes. They are both located in between the metatarsals.

37. The plantar interossei help us to _________ our toes and are between our _________. a) Adduct; 1st Phalanges b) Adduct; Metatarsals c) Abduct; 1st Phalanges d) Abduct; Metatarsals

38. d) Skin on the lateral part of the leg The superficial fibular nerve innervates muscles of the lateral compartment, as well as provides cutaneous sensory innervation to the dorsal surface of the foot (except for where the deep fibular nerve innervates in between the first two toes). The skin on the lateral part of the leg is innervated by the sural nerve.

38. Which of the following is not innervated by the superficial fibular nerve? a) Fibularis brevis b) Fibularis longus a) Skin on the dorsal surface of the foot b) Skin on the lateral part of the leg

39. c) Inferior gluteal N The patient is obviously having trouble standing up, which would normally recruit the gluteus maximus to help us do so. If the gluteus maximus is not working, it is mostly likely because the inferior gluteal nerve is injured or damaged.

39. You notice that a patient is having to rock back and use her arms to stand up from her chair. Which nerve do you think might be damaged? a) Obturator N b) Deep fibular N c) Inferior gluteal N d) Femoral N

4. c) Obturator With "scissor gait" there is overactive adduction of the thigh. So, you need to identify which nerve innervates the adductor compartment. And that nerve is the obturator nerve. The obturator nerve innervates the medial compartment of the thigh, including adductor longus, magnus, and brevis. If the obturator nerve was firing too much, the leg would be constantly adducting, causing the scissor gait. The femoral nerve innervates the quadriceps muscles, which extend the leg at the knee. The inferior gluteal nerve innervates gluteus maximus, which is important for powerful extension of the thigh. The tibial nerve innervates the hamstrings, which flex the knee and extend the thigh. The tibial nerve also innervates the muscles of the posterior compartment of the leg, which plantarflex the foot.

4. "Scissor gait" is a condition in which one limb crosses in front of the other during stepping as a result of powerful hip adduction caused by continuous, unwanted nerve activity. What is the nerve involved in this condition? a) Femoral b) Inferior gluteal c) Obturator d) Tibial

40. b) Tibionavicular All of these ligaments are stabilizers of the ankle joint, but there are two major groups. One group prevents inversion and one prevents eversion. In this situation, the woman is landing on the lateral part of her foot, which would be causing excessive inversion. Some of the ligaments on that lateral portion of the ankle joint that prevent inversion are calcaneofibular, anterior tibiofibular, and posterior talofibular. The tibionavilcular ligament prevents excessive eversion since it is located on the medial side of the ankle joint. Note: break down each ligament name to think about where each one connects, so you can surmise if it is on the medial or lateral surface. For example, tibionavicular would be attached to the tibia and navicular, so you know that since both of those bones are medially located, this ligament would prevent eversion.

40. While performing a gymnastics routine, a young woman lands on her lateral side of her foot, causing excessive inversion. Which of the following ligaments will NOT help stabilize her ankle joint in this situation? a) Calcaneofibular b) Tibionavicular c) Anterior tibiofibular d) Posterior talofibular

41. c) Dorsum; Anterior Tibial

41. The dorsalis pedis supplies the ______ of the foot and is a continuation of the _____________ artery. a) Plantar surface; Posterior Tibial b) Plantar surface; Fibular c) Dorsum; Anterior Tibial d) Dorsum; Posterior Tibial

43. b) PCL Since the player is being pushed in the thigh region, and the force is pushing it anteriorly. This would mean that we are looking for the ligament that is preventing posterior translation of the tibia, which would be the PCL. The ACL prevents anterior translation of the tibia.

43. If a football player is pushed from behind, in the thigh region, while his feet are firmly planted on the ground. Which ligament would possibly be torn if the force is great enough? a) ACL b) PCL c) MCL d) LCL

44. b) Her iliofemoral ligament is very tight. The iliofemoral ligament prevents excessive extension of the femur at the hip (think about where it would be located to see the function). The pubofemoral ligament prevents excessive abduction of the femur. Neither the quadriceps femoris, nor the piriformis helps extend the leg either.

44. A ballet dancer complains that her arabesque (leg extended behind her) cannot get any higher. What is most likely her problem? a) She needs to strengthen her quadriceps femoris muscles. b) Her iliofemoral ligament is very tight. c) Her pubofemoral ligament is very tight. d) She needs to strengthen her piriformis.

45. a) Gluteus medius Your lateral rotators include the piriformis, superior gamellus, inferior gamellus, and quadratus femoris. The gluteus medius does not function in this way; it actually helps to slightly rotate the femur medially.

45. The same ballet dancer has amazing turn out (can laterally rotate her hip joint very well). Which muscle would NOT help her attain this? a) Gluteus medius b) Superior gamellus c) Quadratus femoris d) Piriformis

46. e) All of the above The head of the femur has three main arterial suppliers- the medial circumflex artery, the lateral circumflex artery, and the acetabular branch of the obturator artery. Both circumflex arteries are branches off of the profunda femoris, which is a branch off of the external iliac artery. The obturator artery is a branch off of the internal iliac artery. Thus, all of these would compromise the blood flow to the head of the femur

46. A blockage of which of the following arteries will reduce blood flow to the head of the femur? a) Profunda femoris b) Obturator artery c) Internal iliac d) A & B e) All of the above

47. d) Ischial tuberosity All of the hamstring muscles (semitendinosus, semimembranosus, and biceps brachii) attach to the ischial tuberosity of the hip bone.

47. Where do your hamstring muscles attach proximally? a) Linea aspera b) ASIS c) Obturator foramen d) Ischial tuberosity

5. a) Femoral The quadriceps muscles, innervated by the femoral nerve, are the most important leg extensors. Rectus femoris, a component of the quads, is also a hip flexor. So, the patient's deficits, as well as the clinical history of an abscess in the femoral triangle, are consistent with an injury to the femoral nerve. The inferior gluteal nerve innervates gluteus maximus. If this nerve or muscle was injured, the patient would have trouble extending his leg powerfully. The obturator nerve innervates the adductor compartment; a defect with this nerve would result in impaired adduction. The sciatic nerve does not innervate any muscles itself. However, it has two branches, the common fibular and tibial nerves, which innervate the posterior (hamstring) compartment of the thigh and all of the muscles of the leg and foot. Clearly, an injury to the sciatic nerve would lead to a huge motor impairment. Finally, the superior gluteal nerve innervates gluteus medius and minimus and tensor fasciae latae. If this nerve is injured, a patient will exhibit Trendelenburg's sign, which means that when the patient stands on the injured leg only, the pelvis will drop on the unsupported side. This indicates that the gluteus medius and minimus on the supported side are not functional.

5. A patient with a tuberculous abscess (localized collection of pus) on the iliopsoas muscle in the femoral triangle presented impaired flexion of the thigh and extension of the leg. Which of the following nerves was likely involved? a) Femoral b) Inferior gluteal c) Obturator d) Sciatic e) Superior gluteal

50. d) Subscapularis The posterior head of the deltoid helps to laterally rotate and extend the humerus. All of the rotator cuff muscles (remember, SITS) EXCEPT the subscapularis help to laterally rotate the humerus as well. The subscapularis, since it is on the anterior surface of the scapula and attaches to the lesser tubercle of the humerus, will help medially rotate the humerus.

50. A patient injured the posterior head of his deltoid muscle on his right arm. After recovery, he starts working with a physical therapist to strengthen muscles that would help him compensate for the decreased strength in his injured muscle. Which muscle would NOT help him compensate for the injury? a) Supraspinatus b) Teres minor c) Infraspinatus d) Subscapularis

51. c) 3rd part

51. Which part of the axillary artery gives rise to a branch that supplies the latissimus dorsi with oxygenated blood? a) 1st part b) 2nd part c) 3rd part d) 4th part

52. c) Medial

52. The ulnar nerve is a direct branch off of the _______________ chord of the brachial plexus. a) Anterior b) Posterior c) Medial d) Lateral

53. b) Ulnar nerve The upper/superior trunk gives nerves to both the posterior and lateral cords. These cords give rise to the musculocutaneous nerve, radial nerve, axillary nerve, and median nerve. The ulnar nerve (which comes from the medial cord) does not get any nerves from the superior trunk and would therefore not be damaged.

53. If the upper/superior trunk of the brachial plexus was severed accidentally during surgery, all of the following nerves would potentially lose working neurons EXCEPT the a) Median nerve b) Ulnar nerve c) Axillary nerve d) Musculocutaneous nerve

55. c) MCP; Flexor digitorum superficialis The knuckle joint is called the MCP joint (metacarpophalangeal). The flexor digitorum superficialis, located in the anterior compartment of the forearm, helps to flex this joint and the PIP. The DIP can be flexed with the flexor digitorum profundus, but would not be useful in waving.

55. Your niece is having trouble waving goodbye. Which joint is this affecting and what muscle is most likely damaged? a) DIP; Flexor digitorum profundus b) PIP; Flexor carpi ulnaris c) MCP; Flexor digitorum superficialis d) Wrist; Pronator teres

57. False. While the coracohumeral and glenohumeral ligaments are responsible for the stabilization of the glenohumeral joint, it is the muscles that surround the joint that provide most of the stability for this joint.

57. (T/F) The coracohumeral and glenohumeral ligaments are the chief stabilizers of the glenohumeral joint.

6. e) Superior gluteal nerve The superior gluteal nerve supplies gluteus minimus and medius--two muscles that are important abductors of the hip--as well as tensor fasciae latae. These muscles stabilize the pelvis when walking. The gluteus medius and minimus work in such a way that when you are standing on your right leg only, the muscles on the right side are supporting the left side of the pelvis. When you are standing on your left leg only, the muscles of the left side are supporting the right side of the pelvis. If a patient exhibits a characteristic hip drop on the uninjured side (in this case, the left side) while standing on the injured side (right), this is called Trendelenburg's sign. It occurs when the superior gluteal nerve--the nerve supply to the abductors of the thigh--is disrupted due to injury or disease. Nerve to piriformis and nerve to obturator internus allow those muscles to laterally rotate the thigh. However, if one of these muscles was denervated, the other might be able to compensate and prevent a significant loss of function. The sciatic nerve has no direct muscular branches; however, its two branches, common fibular and tibial nerves, innervate the posterior compartment of the thigh and all the muscles of the leg. A disruption to the sciatic nerve would lead to a significant motor deficit. The femoral nerve innervates the quadriceps. If this nerve were damaged, a patient would present with an inability to extend the knee.

6. During recovery from a gunshot wound of the right pelvis, the patient notices a lurch in his gait. When he lifts his left foot off of the ground, his pelvis dips down on the left side. The nerve that appears to have been injured is the: a) Nerve to piriformis b) Nerve to obturator internus c) Sciatic nerve d) Femoral nerve e) Superior gluteal nerve

60. C,5 Musculocutaneous nerve A,2 Axillary nerve D,3 Ulnar nerve E,1 Radial nerve B,4 Median nerve

60. Given the terminal branches of the brachial plexus, match the muscle that it innervates and the action it helps provide. ______________ Musculocutaneous nerve A. Deltoid 1. Extension at the elbow ______________ Axillary nerve B. Flexor digitorum superficialis 2. Abduction of humerus after 15 ______________ Ulnar nerve C. Brachialis 3. Adduction of the fingers ______________ Radial nerve D. Palmar interossei 4. Flexion at the wrist ______________ Median nerve E. Triceps brachii 5. Flexion at the elbow

62. Tibial nerve/plantar fexion. The tibial nerve is responsible for the motor innervation of the interosseous muscles of the foot as well as the posterior compartment of the leg, which is responsible for plantar flexion of the foot.

62. The inability to abduct and adduct the phalanges of the foot would indicate damage to what nerve located in the popliteal region? What other movements would be affected?

63. No. The Adductor magnus is innervated by both the sciatic nerve as well as the obturator nerve, so a loss of innervation coming from the sciatic nerve would not cause complete loss of function.

63. Would damage to the branch of the sciatic nerve that innervates the medial compartment of the thigh cause complete loss of function to the adductor magnus?

64. C5. The dorsal scapular nerve is a nerve that branches from the C5 nerve root that innervates the rhomboid muscles and the levator scapulae, which are mainly responsible in elevation of the scapula.

64. A cut to what nerve root would cause issues with elevation of the scapula?

65. The upper and lower scapular nerves innervate the subscapularis muscle, which is responsible for medial rotation. Damage to the medial and lateral pectoral nerves would also cause problems during medial rotation as these nerves innervate the pectoralis muscles.

65. Inability to medially rotate the arm would indicate damage to what nerve?

66. The pectoralis major is innervated by the medial and lateral pectoral nerves. However, the main innervation of the pectoralis major comes from the lateral pectoral nerve, which arises from the lateral cord of the brachial plexus.

66. A patient comes in to the ER and examination shows the patient is unable to flex the pectoralis major. What main nerve of the pectoralis major is affected and from what part of the brachial plexus does this nerve arise?

67. No, the flexor digitorum profundus is a deep forearm muscle that doesn't cross the elbow and thus is not able to assist in flexion at the elbow.

67. Would the flexor digitorum profundus assist in flexion at the elbow?

68. B)- Annular ligament. The annular ligament attaches on the medial and lateral side of the ulna and wraps around the radius, allowing for rotational movement but not allowing the radius to unattach to the ulna.

68. If the radius becomes unattached to the ulna at the elbow joint, what structure would you expect to be cut? a) Glenohumoral ligament b) Annular ligament c) Interosseous membrane d) Flexor retinaculum

69. The lateral chord of the brachial plexus gives off terminal branches to the musculocutaneous nerve as well as part of the nerve fibers to the median nerve. With the musculocutaneous nerve being completely damaged, anterior muscles of the arm would not function properly (flexion at the elbow). The patient would also lose some sensation to the forearm as the musculocutaneous nerve also provides sensory innervation to the lateral most side of the forearm. The patient would also lose partial function of the forearm, so the patient would experience trouble flexing the digits (including the thumb), pronation, and also sensory loss to digits 1-3 and the lateral side of digit 4. Remember that the patient won't experience complete loss of these functions as the median nerve receives partial innervation from the medial chord of the brachial plexus as well.

69. An abrasion to the lateral chord of the brachial plexus (just distal to the lateral pectoral nerve) would cause what problems to the patient?

7. b) Obturator internus Obturator internus leaves the pelvis by passing through the lesser sciatic foramen. It eventually inserts on the greater trochanter of the femur and helps to laterally rotate and abduct the thigh. Piriformis leaves the pelvis through the greater sciatic foramen and also inserts of the greater trochanter of the femur. It helps with the same movements as obturator internus--lateral rotation and abduction of the thigh. The other muscles listed act at the hip, but they are not related to the greater or lesser sciatic foramen. Gluteus minimus originates on the ilium and inserts on the greater trochanter of the femur--it abducts and medially rotates the thigh. Quadratus femoris is a lateral rotator of the thigh which originates on the ischial tuberosity and inserts on the quadrate line. Superior gemellus is another lateral rotator of the thigh which inserts with obturator internus on the obturator tendon.

7. What muscle passes through the lesser sciatic foramen? a) Gluteus minimus b) Obturator internus c) Piriformis d) Quadratus femoris e) Superior gemellus

8. d) Quadriceps femoris If a knee is continually collapsing into flexion, it means that there is something wrong with the knee extenders--the quadriceps muscles. This makes sense given the clinical history--the injury to the left femoral triangle probably damaged the femoral nerve which innervates the quads. Sartorius is also a flexor of the hip and knee which is innervated by the femoral nerve. However, it is a much weaker muscle and damage to this muscle would not be as debilitating as damage to the quadriceps. Adductor magnus is innervated by the obturator nerve, except for the part inserting on adductor tubercle, which is innervated by tibial nerve. An injury to this muscle or nerve would result in impaired adduction of the thigh. Biceps femoris is a hamstring muscle of the posterior compartment which extends the hip and flexes the knee. Its long head is innervated by the tibial nerve and its short head is innervated by the common fibular nerve. Gluteus maximus is the muscle for powerful extension of the hip--it is innervated by the inferior gluteal nerve.

8. Following a penetrating injury to the left femoral triangle, a patient related that walking was virtually impossible because at every step the left knee collapsed into flexion. This history suggests paralysis of which muscle? a) Adductor magnus b) Biceps femoris c) Gluteus maximus d) Quadriceps femoris e) Sartorius

9. e) Superior gluteal The superior gluteal nerve supplies gluteus minimus and medius--two muscles that are important abductors of the hip--and tensor fasciae latae. These muscles stabilize the pelvis when walking. They work in such a way that when you are standing on your right leg only, the muscles on the right side are holding the left side of the pelvis level. When you are standing on your left leg only, the muscles of the left side are supporting the right side of the pelvis. So, if a patient exhibits this characteristic hip drop on the uninjured side while standing on the injured side, this is called Trendelenburg sign. It demonstrates that the superior gluteal nerve was injured and the gluteus minimus and medius can no longer support the hip.

9. After suffering a deep stab wound in the medial upper quadrant of the right buttock, an emergency room patient found walking to be very difficult. The basic problem was that, during stepping, her left hip sagged down as soon as the left foot was lifted off the ground to swing forward. What nerve was damaged? a) Femoral b) Inferior gluteal c) Obturator d) Pudendal e) Superior gluteal