Tutorial 2 2

Tutorial No 2
Dr. Salma Malik

MBBS
Scenario
• A 30-year-old female visits the orthopedic clinic
complaining of severe pain in her right wrist and hand.
She reports that her right hand is weak.
History
• The patient is a medical illustrator who makes extensive
use of a computerized drawing tablet. Her right hand is
dominant. She reports that her wrist and hand pain was
exacerbated during and after her first pregnancy.
Physical examination
• Numbness, paresthesia, and pain along the lateral palm
and lateral 3½ fingers
• Mild atrophy of the thenar muscle group, with a weak
grip compared to the left hand
• Positive Tinel sign and Phalen wrist flexion maneuver
Discussion
1. Describe boundaries of the cubital fossa and its
content
2. What are the content of the cubital tunnel.
3. What are the content of the carpal tunnel
4. Describe the distribution of the median
and ulnar nerves.
5. Explain the anatomical basis for the signs
and symptoms associated with this case
1. A 54-year-old male is brought to the emergency department
after a motor vehicle accident. Physical examination reveals
some sensory loss from the upper limb and radiologic imaging
confirms herniation of the C5-C6 intervertebral disc. Which
nerve carries sensory fibers from the affected dermatome?
A. Deep branch of ulnar

B. Lateral cutaneous nerve of forearm
C. Long thoracic
D. Medial cutaneous nerve of forearm
E. None of the above
• Answer B. The intervertebral disc herniation affects
the C6 spinal nerve and its dermatome. This dermatome
is located along the lateral aspect of the forearm, which
is supplied by the lateral cutaneous nerve of the
forearm (the terminal branch of the musculocutaneous
nerve).
2. Which actions would also be likely impaired by this
injury?
A. Elbow flexion and thumb opposition

B. Shoulder abduction and wrist adduction
C. Shoulder abduction and elbow flexion
D. Shoulder abduction and shoulder elevation
• Answer C. Motor fibers from the C6 spinal cord enter
nerves that supply muscles that control shoulder
abduction (deltoid and rotator cuff muscles) and
elbow flexion (biceps brachii and brachialis).
3. A 44-year-old woman is diagnosed with breast cancer.
Following mastectomy and dissection of axillary lymph
nodes, the patient is unable to raise her arm over her head.
Which nerve is most likely damaged?
A. Long thoracic
B. Pectoral branch of thoraco-acromial
C. Suprascapular
D. Thoracodorsal
• Answer A. The long thoracic nerve supplies the
serratus anterior muscle, which is necessary for the
upward rotation of the scapula when raising the
abducted arm above the head.
4. Which clinical sign would not be associated with injury
of the ulnar nerve due to fracture of the medial
epicondyle?
A. Hypesthesia from proximal part of the medial half of

the palm
B. Hypesthesia from the middle finger
C. Hypesthesia from the ring finger
D. Weakened flexion of digits 4 and 5
E. Weakened flexion of the wrist
• Answer B. This injury affects the ulnar nerve. The
lateral half of the palm is supplied by the median
nerve and is, therefore, not affected in this injury.
5. A 35-year-old male patient visits the orthopedics clinic
complaining of weakness of his upper limb. Physical
examination suggests involvement of the posterior cord of
the brachial plexus. Which action would not be affected?
A. Elbow extension
B. Elbow flexion
C. Pronation
D. Shoulder abduction
E. Wrist extension
• Answer C. Nerves derived from the posterior cord supply
muscles of the shoulder (e.g., axillary nerve— deltoid muscle;
thoracodorsal nerve—latissimus dorsi), and the arm and forearm
(radial nerve—all
extensors, brachioradialis, supinator, and the snuffbox muscles).
Therefore, posterior cord injury would affect extensor functions,
thumb abduction (abductor pollicis longus—a snuffbox muscle),
and elbow flexion (brachioradialis). The primary pronators
(teres and quadratus) would not be affected by this injury
because they are supplied by the median nerve, which receives
contributions from the medial and lateral
cords.
6. A 52-year-old male undergoes rotator cuff surgery to
repair the supraspinatus muscle. During the
procedure,the suprascapular artery is identified. Which
other vessels contribute to scapular collateral circulation.
A. Circumflex scapular and posterior circumflex

humeral
B. Dorsal scapular and circumflex scapular
C. Thoracodorsal and dorsal scapular
D. Lateral thoracic and circumflex scapular
• Answer B. Collateral circulation around the scapula is
formed by the anastomoses between the suprascapular
artery (commonly a branch of the thyrocervical trunk),
the dorsal scapular artery (usually a branch of the
subclavian), and the circumflex scapular artery (a
branch of the subscapular, the largest branch of the
axillary artery). Small, dorsal branches of posterior
intercostal arteries also anastomose with the dorsal
scapular
and, thereby, contribute to this circulation.
7. During anatomy lab dissection, a medical student
accidentally receives a superficial laceration on the anterior
aspect of his wrist. Physical examination in the emergency
department reveals no loss of function of intrinsic hand
muscles, but the skin on lateral aspect
of his palm is numb. Which nerve has been severed?
A. Lateral cutaneous nerve of the forearm

B. Palmar branch of median
C. Palmar branch of radial
D. Recurrent branch of median
E. Superficial branch of ulnar
• Answer B. Palmar branches of the median and ulnar
nerves supply the proximal portion of the palm. The
palmar branches arise in the distal forearm and course
in subcutaneous tissue to reach the palm. Therefore,
these nerves do not pass through the carpal tunnel or
ulnar canal (Guyon) and are at risk for injury with
superficial laceration. In this patient, the skin of the
thenar eminence (i.e., lateral palm) is involved,
indicating that the palmar branch of median nerve is
damaged.
8. Intravenous lines are often placed in subcutaneous
veins on the posterolateral aspect of the hand?
Which nerve would be stimulated in this location?
A. Deep branch of radial

B. Deep branch of ulnar
C. Lateral cutaneous nerve of forearm
D. Superficial branch of radial
E. Superficial branch of ulnar
• Answer D. Skin on the posterior aspect of the hand is
supplied by the three nerves, and the posterolateral
aspect is supplied by the superficial branch of radial
nerve. The posteromedial aspect is supplied by the
ulnar nerve, and the distal phalanges of the lateral
3½ fingers is supplied by the median nerve
9. A 12-year-old boy is brought to the emergency department
after a collision while playing baseball. He complains of
extreme pain over his right clavicle, which is obviously
deformed. Radiologic imaging confirms a right midclavicular
fracture. Which vein is especially vulnerable to injury as a
result of the fracture?
A. Subclavian
B. Brachiocephalic
C. External jugular
D. Internal jugular
E. Brachial
• Answer A. As the subclavian vein arches over the
first rib, it lies posterior and inferior to the clavicle. The
vein is partially protected by the subclavius muscle,
which attaches to the inferior surface of the clavicle.
Clavicular fracture may compress the vein between the
clavicle and first rib, or cause its rupture due to the
fascial connections between the vein, the subclavius
muscle, and the clavicle.
10. A 33-year-old female comes to the orthopedics clinic
complaining of weakness in her right (dominant) hand. During
physical examination, you ask her to hold a piece of paper
tightly between adjacent surfaces of the index and middle
fingers. You find, however, that it is easy, compared with her lef
hand, to pull the paper from between her fingers. Which
muscles are involved?
A. First dorsal and first palmar interosseous

B. First dorsal and second palmar interosseous
C. First lumbrical and second dorsal interosseous
D. First palmar and second dorsal interosseous
• Answer D. The finger movements involved in this test
are abduction of the middle finger and adduction of the
index finger (the reference line for abduction/adduction
of fingers 2-5 passes through the middle finger). In this
patient, you detect weakened
actions of the first palmar interosseous (adduction of
the index finger) and second dorsal interosseous
(abduction of the middle finger). A mnemonic for the
actions of the interosseous muscles
of the hand is DAB (dorsal abducts) and PAD (palmar
adducts).

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Tutorial No 2

Dr. Salma Malik

A. Deep branch of ulnar

A. Elbow flexion and thumb opposition

A. Hypesthesia from proximal part of the medial half of

A. Circumflex scapular and posterior circumflex

A. Lateral cutaneous nerve of the forearm

A. Deep branch of radial

A. First dorsal and first palmar interosseous

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