CHAPTER 2

The Upper Limb

Questions

DIRECTIONS (Questions 1 through 83): Each of the (C) The acromion is superior to the glenoid
numbered items or incomplete statements in this cavity and projects anterolaterally.
section is followed by answers or by completions of (D) The scapula is fastened securely to the
the statement. Select the ONE lettered answer or thoracic cage at the scapulothoracic joint.
completion that is BEST in each case. (E) The acromioclavicular joint represents the
true shoulder joint.
1. Which of the following is NOT true regarding
the clavicle? 4. Which of the following is NOT included in the
(A) Its medial end is enlarged where it condyle of the humerus?
attaches to the sternum. (A) radial, coronoid, and olecranon fossae
(B) Its lateral end is flat where it articulates (B) epicondyles
with the humerus.
(C) trochlea
(C) The medial two-thirds of the shaft are
(D) capitulum
convex anteriorly.
(E) greater tubercle
(D) The clavicle transmits shock from the
upper limb to the axial skeleton.
5. Which of the following is NOT true in respect
(E) The clavicle is a “long bone” that has no to the ulna and radius?
medullary cavity.
(A) The brachialis attaches to the tuberosity of
2. The trapezius attaches to which of the follow- the ulna.
ing regions of the clavicle? (B) The ulnar styloid process is much larger
than the radial styloid process and
(A) lateral one-third of the clavicle
extends farther distally.
(B) conoid tubercle
(C) The head of the ulna lies distally, whereas
(C) subclavian groove the head of the radius articulates with the
(D) trapezoid line humerus.
(E) quadrangular tubercle (D) The ulna is medial to the radius in the
anatomical position.
3. Which of the following is true in respect to the (E) The bodies of these bones are firmly bound
scapula? together by the interosseous membrane.
(A) The spine of the scapula continues later-
ally as the coracoid process.
(B) The lateral surface of the scapula forms
the glenoid cavity.

11
12 2: The Upper Limb

6. Which of the following is true regarding the (D) subclavius

carpus? (E) serratus anterior
(A) The scaphoid articulates proximally with
the ulna and has a tubercle. 11. Which of the following best describes the action
of the pectoralis minor?
(B) The lunate articulates with the ulna and is
broader anteriorly than posteriorly. (A) stabilizes scapula by drawing it inferiorly
(C) The triquetrum articulates proximally and anteriorly against thoracic wall
with the articular disc of the distal (B) anchors and depresses clavicle
radioulnar joint. (C) adducts and medially rotates humerus
(D) The pisiform lies on the palmar surface of (D) rotates scapula
the trapezium. (E) flexes humerus
(E) It is composed of seven bones.
12. Which of the following muscles attaches to the
7. Which of the following describes the correct coracoid process of the scapula?
order of the distal row of carpals from lateral to
medial? (A) pectoralis minor
(B) triceps brachii
(A) triquetrum, trapezoid, capitate, hamate
(C) brachialis
(B) trapezoid, trapezium, capitate, hamate
(D) pectoralis major
(C) trapezium, trapezoid, capitate, hamate
(E) subclavius
(D) trapezium, triquetrum, capitate, hamate
(E) scaphoid, lunate, triquetrum, pisiform 13. All of the following are medial rotators of the
arm EXCEPT
8. Which of the following is actually a lateral cuta-
neous branch of an intercostal nerve, innervat- (A) latissimus dorsi
ing the skin of the medial surface of the arm? (B) teres major
(C) subscapularis
(A) intercostobrachial nerve
(D) infraspinatus
(B) superior lateral cutaneous nerve of the arm
(E) anterior part of deltoid
(C) inferior lateral cutaneous nerve of the arm
(D) medial cutaneous nerve of the arm 14. What muscles are necessary to raise the arm
(E) lateral pectoral nerve above the shoulder?

9. Which of the following is NOT a branch of the (A) first the supraspinatus, next the deltoid,
radial nerve? and then the serratus anterior
(B) first the deltoid, next the supraspinatus,
(A) posterior cutaneous nerve of the arm and then the serratus anterior
(B)posterior cutaneous nerve of the forearm (C) first the supraspinatus, next the serratus
(C) inferior lateral cutaneous nerve of the arm anterior, and then the deltoid
(D) superior lateral cutaneous nerve of the (D) first the serratus anterior, next the deltoid,
arm and then the supraspinatus
(E) posterior interosseous nerve (E) first the deltoid, next the serratus anterior,
and then supraspinatus
10. Which of the following is NOT an anterior tho-
racoappendicular muscle? 15. Which of the following is innervated by the
(A) pectoralis major dorsal scapular nerve?
(B) pectoralis minor (A) serratus anterior
(C) deltoid (B) rhomboid major and minor
 Questions: 6–23 13

(C) erector spinae (C) teres major

(D) subscapularis (D) subscapularis
(E) supraspinatus (E) levator scapulae

16. Which of the following is an extrinsic shoulder 21. Which of the following is NOT contained in the
muscle? axilla?
(A) deltoid (A) axillary blood vessels
(B) teres major (B) lymph nodes
(C) levator scapulae (C) trunks and divisions of the brachial
(D) teres minor plexus
(E) supraspinatus (D) axillary nerve
(E) lymph nodes
17. Which of the following is true in respect to the
trapezius? 22. Which of the following is most correct?
(A) It is innervated by the dorsal scapular (A) The subscapular artery arises from the
nerve. third part of the axillary artery and
(B) Its superior fibers retract the scapula. contributes to blood supply of muscles
(C) Its middle fibers elevate the scapula. near the scapula and humerus.
(D) Its inferior fibers retract the scapula. (B) The second part of the axillary artery typi-
cally contains two branches—the thora-
(E) Its superior and inferior fibers act together
coacromial artery and the superior
in rotating the scapula on the thoracic
thoracic artery.
wall.
(C) The first part of the axillary artery lies
18. A patient is asked to place the hands posteriorly posterior to the pectoralis minor.
on the hips and to push the elbows posteriorly (D) The thoracoacromial artery supplies the
against resistance. Which muscle is being tested? pectoral muscles, axillary lymph nodes,
and most importantly the lateral part of
(A) levator scapulae the mammary gland in women.
(B) rhomboid (E) The lateral thoracic artery divides into
(C) trapezius four branches, the acromial, deltoid, pec-
(D) latissimus dorsi toral, and clavicular.
(E) serratus anterior
23. Which of the following is NOT correct?
19. Which rotator cuff muscle does NOT rotate the (A) The brachial plexus is formed by the union
humerus? of the ventral rami of C5 through T1.
(A) supraspinatus (B) The roots of the brachial plexus and the
(B) infraspinatus subclavian artery pass through the gap
(C) teres minor between the anterior and middle scalene
muscles.
(D) subscapularis
(C) Gray rami contribute sympathetic fibers
(E) teres major
to each root.
20. The axillary nerve innervates which of the fol- (D) Each of the three trunks of the brachial
lowing muscles? plexus divide into anterior and posterior
divisions.
(A) coracobrachialis (E) The cords of the brachial plexus surround
(B) teres minor the brachial artery.
14 2: The Upper Limb

24. Which of the following is NOT a supraclavicu- (D) It is primarily innervated by the musculo-
lar branch of the brachial plexus? cutaneous nerve, but some of its lateral
part is innervated by a branch of the
(A) dorsal scapular nerve
radial nerve.
(B) lateral pectoral nerve
(E) It crosses two joints.
(C) long thoracic nerve
(D) nerve to the subclavius 29. A patient is asked to abduct the arm 90 degrees
(E) suprascapular nerve and then to extend the flexed forearm against
resistance. Which muscle is being tested?
25. Which of the following is true regarding the
(A) triceps brachii
quadrangular space?
(B) brachialis
(A) It is bounded superiorly by the teres (C) coracobrachialis
major.
(D) biceps brachii
(B) It is bounded inferiorly by the subscapu-
(E) supinator
laris and teres minor.
(C) It is bounded medially by the humerus 30. The deep artery of the arm accompanies which
and laterally by the long head of the of the following before passing around the
triceps. body of the humerus?
(D) It contains the posterior circumflex
humeral artery and the axillary nerve. (A) radial nerve
(E) Brachial plexus herniations occur here. (B) musculocutaneous nerve
(C) median nerve
26. Which of the following is NOT innervated by (D) ulnar nerve
the suprascapular nerve? (E) axillary nerve
(A) supraspinatus
31. Which muscle assists in extension of the fore-
(B) infraspinatus
arm, resists abduction of the ulna during prona-
(C) glenohumeral joint tion of the forearm, and tenses the capsule of
(D) skin over superior part of scapula the elbow joint so that it is not pinched when
(E) shoulder joint the joint is extended?
(A) anconeus
27. Which of the following is NOT a branch of the
posterior cord of the brachial plexus? (B) triceps brachii
(C) coracobrachialis
(A) upper and lower subscapular nerves
(D) brachialis
(B) thoracodorsal nerve
(E) biceps brachii
(C) axillary nerve
(D) radial nerve 32. Which of the following is a branch of the brachial
(E) long thoracic nerve artery?
(A) anterior and posterior circumflex humeral
28. Which of the following is NOT true in respect
arteries
to the brachialis?
(B) deltoid artery
(A) Its origin is the distal half of the anterior (C) superior and inferior ulnar collateral
surface of the humerus. arteries
(B) Its insertion is the coronoid process and (D) thoracoacromial artery
tuberosity of the ulna.
(E) anterior and posterior ulnar recurrent
(C) It flexes the forearm in all positions. arteries
 Questions: 24–42 15

33. Which of the following nerves supply NO 38. Which muscle does NOT cross the elbow joint?
branches to the arm?
(A) flexor pollicis longus
(A) musculocutaneous and median (B) pronator teres
(B) radial and ulnar (C) flexor carpi radialis
(C) median and ulnar (D) flexor carpi ulnaris
(D) median and radial (E) flexor digitorum superficialis
(E) musculocutaneous and radial
39. The ulnar nerve innervates which of the fol-
34. Which of the following nerves is correctly paired lowing muscles in the flexor compartment?
with its cutaneous branch?
(A) the medial part of the flexor digitorum
(A) median nerve and medial antebrachial superficialis
cutaneous nerve (B) flexor carpi radialis
(B) musculocutaneous nerve and lateral ante- (C) pronator quadratus
brachial cutaneous nerve (D) pronator teres
(C) ulnar nerve and posterior antebrachial (E) the medial part of flexor digitorum
cutaneous nerve profundus
(D) median nerve and medial brachial cuta-
neous nerve 40. The radial artery lies just lateral to the tendon of
(E) radial nerve and superior lateral brachial which muscle?
cutaneous nerve
(A) pronator teres
35. The cubital fossa does NOT contain which of the (B) flexor carpi radialis
following? (C) palmaris longus
(D) flexor carpi ulnaris
(A) terminal part of the brachial artery
(E) flexor digitorum superficialis
(B) deep accompanying veins of the arteries
(C) median nerve 41. The palmaris longus tendon is a useful guide to
(D) biceps brachii tendon which nerve at the wrist?
(E) ulnar nerve
(A) anterior interosseous nerve
36. A patient is unable to flex the arm and forearm. (B) posterior interosseous nerve
Where is the lesion likely to be? (C) median nerve
(D) ulnar nerve
(A) ventral rami of C3–C4
(E) radial nerve
(B) ventral rami of C5–C6–C7
(C) dorsal rami of C6–C7–C8 42. To pronate the forearm, which of the following
(D) ventral rami of C8–T1 must occur?
(E) dorsal rami of T1
(A) The pronator quadratus initiates prona-
tion, assisted later by the pronator teres.
37. The radial nerve innervates muscles in the exten-
sor compartment of the forearm, but it also in- (B) The pronator teres initiates pronation,
nervates the following flexor: assisted later by the pronator quadratus.
(C) The anconeus initiates pronation, assisted
(A) brachioradialis later by the pronator teres.
(B) pronator teres (D) The pronator quadratus initiates prona-
(C) palmaris longus tion, assisted later by the anconeus.
(D) pronator quadratus (E) The ulnar nerve must be used.
(E) palmaris longus
16 2: The Upper Limb

43. The extensor carpi radialis longus tendon is 47. Which of the following is true in respect to the
crossed by which two muscles? anatomical snuff box?
(A) abductor pollicis longus and extensor pol- (A) It is bounded anteriorly by the tendons of
licis longus the extensor pollicis longus.
(B) extensor indicis and extensor digitorum (B) It is bounded posteriorly by the tendons
(C) extensor digitorum and extensor pollicis of the abductor pollicis longus and exten-
brevis sor pollicis brevis.
(D) abductor pollicis longus and extensor pol- (C) The radial artery lies in the floor of the
licis brevis snuff box.
(E) extensor indicis and extensor carpi radi- (D) The scaphoid and triquetrum can be pal-
alis brevis pated within the snuff box.
(E) The snuff box is visible when the thumb is
44. Which of the following is true in respect to the fully flexed.
supinator?
48. Which of the following does NOT abduct the
(A) It is innervated by the ulnar nerve.
hand at the wrist joint?
(B) It supinates the forearm by rotating the
ulna. (A) flexor carpi radialis
(C) It forms the floor of the cubital fossa along (B) extensor carpi radialis longus
with the brachioradialis. (C) extensor carpi radialis brevis
(D) It supinates the forearm when the forearm (D) abductor pollicis longus
is already flexed. (E) palmaris longus
(E) It rotates the radius to turn the palm ante-
riorly. 49. Which of the following is derived from the
radial artery?
45. Which of the following does NOT take an ori-
(A) dorsal and palmar carpal arteries
gin from the lateral epicondyle of the humerus?
(B) common interosseous artery
(A) extensor carpi radialis brevis (C) anterior interosseous artery
(B) extensor carpi ulnaris (D) poster interosseous artery
(C) abductor pollicis longus (E) ulnar recurrent artery
(D) supinator
(E) extensor digiti minimi 50. The median nerve does which of the following?
(A) innervates the elbow joint with articular
46. Which of the following is correctly paired with
branches
its nerve?
(B) innervates the medial half of the flexor
(A) flexor pollicis longus and anterior digitorum profundus
interosseous nerve (C) innervates the hypothenar muscles
(B) flexor digitorum profundus and anterior (D) innervates lumbricals 3 and 4
interosseous nerve
(E) innervates the skin of the dorsum of the
(C) extensor carpi radialis longus and poste- hand
rior interosseous nerve
(D) brachioradialis and posterior interosseous 51. The ulnar nerve does NOT do which of the fol-
nerve lowing?
(E) abductor pollicis longus and anterior
(A) innervate the elbow joint with articular
interosseous nerve
branches
(B) innervate the flexor carpi ulnaris
 Questions: 43–59 17

(C) innervate the skin on the lateral part of (B) adductor pollicis
the palm and dorsum of the hand (C) flexor pollicis brevis
(D) innervate the adductor pollicis (D) opponens pollicis
(E) innervate the dorsal and palmar interossei (E) The recurrent branch of the median nerve
innervates all of the above.
52. The radial nerve does NOT do which of the fol-
lowing? 56. Which of the following muscles is correctly
(A) give a superficial branch that innervates matched with the accompanying description?
the dorsum of the hand (A) lumbricals 1 and 2 . . . bipennate
(B) innervate the brachioradialis and extensor (B) lumbricals 3 and 4 . . . unipennate
carpi radialis longus (C) dorsal interossei 1–4 . . . bipennate
(C) give a deep branch that innervates the (D) palmar interossei 1–3 . . . bipennate
extensor carpi radialis brevis and
(E) deltoid . . . bipennate
supinator
(D) give a posterior interosseous branch that 57. The deep branch of the ulnar does NOT inner-
innervates all remaining extensor muscles vate which of the following?
in the posterior compartment of the fore-
arm (A) abductor digiti minimi
(E) innervate the glenohumeral joint (B) flexor digiti minimi brevis
(C) lumbricals 1 and 2
53. Which of the following is NOT true in respect (D) dorsal interossei 3 and 4
to the flexor pollicis brevis? (E) palmar interossei 1 and 2
(A) It is located medial to the abductor polli-
cis brevis. 58. The carpal tunnel does NOT contain which of
(B) It flexes the thumb at the carpometacarpal the following?
joint. (A) median nerve
(C) It flexes the thumb at the metacarpopha- (B) four tendons of the flexor digitorum
langeal joint. superficialis
(D) Its tendon typically contains a sesamoid (C) four tendons of the flexor digitorum pro-
bone. fundus
(E) It is innervated by C5–C6. (D) the tendon of the flexor pollicis longus
(E) ulnar nerve
54. Which of the following is true in respect to the
palmaris brevis? 59. The sternoclavicular joint . . .
(A) It aids the palmaris longus in tightening (A) . . . is a saddle-type synovial joint but
the palmar aponeurosis. functions as a ball-and-socket joint.
(B) It is innervated by the median nerve. (B) . . . is supplied by lateral thoracic and
(C) It is in the hypothenar compartment. thoracoacromial arteries.
(D) It covers and protects the radial artery. (C) . . . is innervated by the lateral and medial
(E) It wrinkles the skin of the hypothenar pectoral nerves.
eminence and deepens the hollow of the (D) . . . is the articulation of the clavicle and
palm. gladiolus of the sternum.
(E) . . . dislocates easily.
55. The recurrent branch of the median nerve does
NOT innervate which of the following?
(A) abductor pollicis brevis
18 2: The Upper Limb

60. Which of the following is true in respect to the (A) proximal and distal radioulnar joints . . .
acromioclavicular joint? condyloid type of synovial joint
(A) It is a saddle-type synovial joint. (B) radiocarpal joint . . . pivot type of synovial
joint
(B) It is strengthened by the coracohumeral
and transverse humeral ligaments. (C) intercarpal joints . . . plane type of syn-
ovial joints
(C) It is supplied by the lateral thoracic
arteries. (D) metacarpophalangeal joints . . . hinge type
of synovial joints
(D) It is innervated by the nerve to the sub-
clavius. (E) interphalangeal joints . . . condyloid type
of synovial joints
(E) When dislocated, it is often referred to as
a “separated shoulder.”
65. All carpometacarpal and intermetacarpal joints
are plane types of synovial joints EXCEPT for
61. Which of the following flexes the arm at the
glenohumeral joint? (A) the carpometacarpal joint of the thumb.
(A) deltoid (posterior part) (B) the carpometacarpal joint of the fifth
metacarpal.
(B) pectoralis major
(C) the carpometacarpal joint of the third
(C) latissimus dorsi
metacarpal.
(D) subscapularis
(D) the intermetacarpal joint of the 4th and
(E) infraspinatus 5th metacarpals.
(E) the intermetacarpal joint of the 1st and
62. In respect to movement of the arm at the gleno-
2nd metacarpals.
humeral joint, which of the following move-
ments is correctly paired with its prime mover?
66. Which of the following is NOT true in respect
(A) extension . . . deltoid (posterior part) to the clavicle?
(B) abduction . . . pectoralis major and latis- (A) The clavicle varies more in shape than
simus dorsi most other long bones.
(C) adduction . . . deltoid (B) The clavicle can be pierced by a branch of
(D) medial rotation . . . infraspinatus the supraclavicular nerve.
(E) lateral rotation . . . subscapularis (C) The clavicle is thicker and more curved in
manual workers.
63. Which of the following is true in respect to the (D) The right clavicle is stronger than the left
elbow joint? and is usually shorter.
(A) It is a plane type of synovial joint. (E) The clavicle is a compact bone.
(B) It is strengthened by the radial and ulnar
cruciate ligaments. 67. Fractures of the scapula typically involve
(C) It is supplied by the cephalic and basilic (A) the acromion.
arteries. (B) the coracoid process.
(D) It is innervated by the median and axil- (C) the spine.
lary nerves.
(D) the inferior angle.
(E) It is surrounded by the intratendinous ole-
(E) the suprascapular notch.
cranon bursa, the subtendinous olecranon
bursa, and the subcutaneous olecranon
68. Which of the following parts of the humerus is
bursa.
matched correctly with the nerve with which it
is in direct contact?
64. Which of the following joints is paired correctly
with its type?
 Questions: 60–76 19

(A) distal end of humerus . . . radial nerve (A) The teres major atrophies.
(B) surgical neck . . . musculocutaneous nerve (B) The rounded contour of the shoulder dis-
(C) radial groove . . . musculocutaneous nerve appears.
(D) medial epicondyle . . . ulnar nerve (C) A loss of sensation may occur in the
(E) scapular notch . . . suprascapular nerve lateral forearm.
(D) The patient may lose the ability to adduct
69. “Winging” of the scapula is most likely caused the arm.
by which of the following? (E) The patient may exhibit “wrist-drop.”
(A) a lesion to the long thoracic nerve
74. Which of the following is true regarding rotator
(B) a lesion to the thoracodorsal nerve cuff injuries?
(C) injury to the suprascapular nerve
(A) Injury or disease may damage the rotator
(D) damage to the dorsal scapular nerve
cuff, causing instability of the acromio-
(E) damage to the upper and lower subscapu- clavicular joint.
lar nerves
(B) The supraspinatus tendon is the most
commonly torn part of the rotator cuff.
70. Which of the following is correct regarding the
triangle of auscultation? (C) The teres major takes the longest to reha-
bilitate of the rotator cuff muscles.
(A) Its borders are the latissimus dorsi, (D) The injuries occur when the muscles pull
scapula, and trapezius. away from their origin on the acromion.
(B) It is a good location to hear heart murmurs. (E) Acute tears are common in young persons.
(C) The 8th and 9th ribs and the 8th inter-
costal space are subcutaneous here. 75. A patient has been thrown from a motorcycle,
(D) It is a location of back trauma. landing on the shoulder such that the neck and
(E) It is a location for dorsal rami to pass to shoulder are widely separated. You suspect an
the superficial back. upper brachial plexus injury. What signs do you
expect?
71. A patient cannot raise the trunk (as in climb- (A) “clawhand”
ing). What is most likely the problem?
(B) paralysis of flexor carpi ulnaris, flexor
(A) damage to the ventral rami of C5–C6–C7 digitorum superficialis, and flexor digito-
(B) paralysis of the latissimus dorsi rum profundus
(C) injury to the dorsal scapular nerve (C) adducted shoulder, medially rotated arm,
(D) damage to the dorsal rami of C8–T1 and extended elbow
(E) injury to the axillary nerve (D) loss of sensation in the medial forearm
(E) “wrist-drop”
72. The scapula on one side of a patient is located
farther from the midline than that on the nor- 76. A patient exhibits “clawhand.” What might
mal side. What might be the problem? have happened?
(A) paralysis of the rhomboids on one side (A) upper brachial plexus injury
(B) injury to the long thoracic nerve (B) acute brachial plexus neuritis
(C) a lesion of C7–C8 (C) compression of the cords of the brachial
(D) dislocated shoulder plexus
(E) separated shoulder (D) lower brachial plexus injury
(E) damage to dorsal rami that send fibers to
73. The axillary nerve is damaged. What is the the brachial plexus
likely result?
20 2: The Upper Limb

77. A patient receives a knife wound to the axilla. (D) amelia . . . long bones are absent, and
What problems do you expect? small hands or feet are attached to the
trunk by short, irregular bones
(A) damage to the axillary nerve
(E) cleft hand (lobster claw deformity) . . .
(B) paralysis of the coracobrachialis, biceps,
absent third metacarpal, fusion of digits
and brachialis
1–2 and 4–5
(C) inability to extend the wrist and digits at
the metacarpophalangeal joints 81. Syndactylyl involves
(D) loss of sensation on the medial surface of
the arm (A) extra fingers or toes.
(E) “clawhand” (B) absence of a digit or limb.
(C) abnormal fusion of fingers and toes.
78. A patient tries to make a fist, but digits 2 and (D) small hands or feet being attached to trunk
3 remain partially extended. What nerve is by short bones instead of long bones.
injured? (E) congenital dislocation of glenohumeral
(A) ulnar nerve joint.
(B) radial nerve
82. Which of the following is NOT correct?
(C) median nerve
(D) musculocutaneous nerve (A) During development, dorsal cells orga-
nize as the epimere and ventral cells orga-
(E) axillary nerve
nize as the hypomere.
79. Which of the following is true in respect to ulnar (B) Dorsal rami innervate muscles derived
nerve injuries? from the epimere.
(C) Ventral rami innervate muscles derived
(A) The injury often occurs where the nerve from the hypomere.
passes posterior to the medial epicondyle
(D) Myoblasts of the hypomere form the
of the humerus.
extensor muscles of the vertebral column.
(B) The patient experiences numbness and
(E) Somites and somitomeres form the mus-
tingling on the lateral part of the palm
culature of the limbs.
and the thumb.
(C) The patient may exhibit “waiter’s tip 83. A patient in surgery has no pectoralis major.
hand.” What do you suspect?
(D) Patients have difficulty because they can-
not flex their first, second, and third digits (A) trauma
at the DIP joints. (B) dominant pectoralis minor
(E) Power of abduction is impaired, and (C) drug-induced muscle hypoplasia
when the patient attempts to flex the (D) atrophy of the muscle
wrist, the flexor carpi ulnaris brings the (E) congenital absence of the muscle
hand to the medial side.

80. Which limb defect is correctly matched with its

definition?
(A) meromelia . . . complete absence of one or
more extremities
(B) phocomelia . . . all segments of extremities
are present but abnormally short
(C) micromelia . . . partial absence of one or
more extremities
 Questions: 77–93 21

DIRECTIONS (Questions 84 through 88): Identify the anatomical features indicated on the art below.

DIRECTIONS (Questions 89 through 93): Identify the anatomical features indicated on the art below.
22 2: The Upper Limb

DIRECTIONS (Questions 94 through 98): Identify the anatomical features indicated on the art below.
 Answers and Explanations

1. (B) The lateral end of the clavicle is flat where 7. (C) From lateral to medial, the four bones of the
it articulates with the acromion at the acromio- distal row of carpals are the trapezium, trape-
clavicular (AC) joint (Moore, pp 665–666). zoid, capitate, and hamate (Moore, p 674).

2. (A) The trapezius attaches to the lateral third of 8. (A) The intercostobrachial nerve is the lateral
the clavicle, acromion, and spine of the scapula. cutaneous branch of the second intercostal nerve
The deltoid attaches to the deltoid tubercle, the from T2, innervating the skin of the medial sur-
conoid ligament attaches to the conoid tubercle, face of the arm (Moore, p 684).
the subclavius attaches to the subclavian groove,
and the trapezoid ligament attaches to the trape- 9. (D) The posterior cutaneous nerve of the arm,
zoid line (Moore, pp 666, 691). posterior cutaneous nerve of the forearm, and
inferior lateral cutaneous nerve of the arm are
3. (B) The lateral surface of the scapula forms the branches of the radial nerve. The superior lateral
glenoid cavity, superior to which the coracoid cutaneous nerve is a branch of the axillary nerve
process projects anterolaterally. The glenohum- (Moore, p 684).
eral joint itself represents the true shoulder joint,
whereas the scapulothoracic joint, which is a con- 10. (C) The pectoralis major, pectoralis minor, sub-
ceptual joint, is a location where the scapula clavius, and serratus anterior are anterior tho-
moves easily on the thoracic wall. The spine of racoappendicular muscles. The deltoid is a
the scapula continues laterally as the acromion scapulohumeral (shoulder) muscle (Moore, pp
(Moore, pp 668–669). 688, 691).

4. (E) The condyle of the humerus (the distal end) 11. (A) The pectoralis minor stabilizes the scapula
includes the epicondyles, trochlea, capitulum, by drawing it inferiorly and anteriorly against
and the three fossae (radial, coronoid, and radial) the thoracic wall (Moore, p 688).
(Moore, p 670).
12. (A) The pectoralis minor, biceps brachii (short
5. (B) The radial styloid process is much larger head), and coracobrachialis attach to the cora-
than the ulnar styloid process and extends far- coid process of the scapula (Moore, p 688).
ther distally (Moore, p 671–672).
13. (D) The latissimus dorsi, teres major, and sub-
6. (C) The scaphoid articulates proximally with scapularis medially rotate the arm. The infra-
the radius and has a large tubercle. The lunate spinatus and teres minor rotate the arm laterally.
articulates with the radius and is broader anteri- The deltoid is unique in that its anterior part
orly than posteriorly. The triquetrum articulates rotates the arm medially, and its posterior part
proximally with the articular disc of the distal rotates the arm laterally (Moore, p 691).
radioulnar joint. The pisiform lies on the palmar
surface of the triquetrum (Moore, p 674). 14. (A) The supraspinatus initiates abduction of
the arm. The deltoid becomes fully effective as

23
24 2: The Upper Limb

an abductor following the initial 15 degrees of pass through the gap between the anterior and
abduction. The serratus anterior rotates the middle scalene muscles. Gray rami contribute
scapula, elevating its glenoid cavity so that the sympathetic fibers to each root. The roots of the
arm can be raised above the shoulder (Moore, brachial plexus form three trunks, each of which
pp 695, 696, 689). divides into anterior and posterior divisions.
The cords of the brachial plexus surround the
15. (B) The dorsal scapular nerve innervates the axillary artery (Moore, p 708).
levator scapulae, rhomboid major, and rhom-
boid minor (Moore, p 691). 24. (B) The dorsal scapular nerve, long thoracic
nerve, nerve to the subclavius, and supra-
16. (C) The trapezius, latissimus dorsi, levator scapular nerve are supraclavicular branches of
scapulae, and rhomboids are extrinsic shoulder the brachial plexus, whereas the lateral pectoral
muscles. The deltoid, teres major, supraspinatus, nerve is an infraclavicular branch, originating
infraspinatus, teres minor, and subscapularis are from the lateral cord (Moore, pp 708–709).
intrinsic shoulder muscles (Moore, pp 691–692).
25. (D) The quadrangular space is bounded superi-
17. (E) The trapezius, innervated by the spinal root orly by the subscapularis and teres minor, infe-
of the accessory nerve (XI), is composed of three riorly by the teres major, medially by the long
types of fibers. Its superior fibers elevate the head of triceps, and laterally by the humerus. It
scapula, its middle fibers retract the scapula, and contains the axillary nerve and the posterior cir-
its inferior fibers depress the scapula. Its superior cumflex humeral artery (Moore, p 711).
and inferior fibers act together in rotating the
scapula on the thoracic wall (Moore, p 694). 26. (D) The suprascapular nerve innervates the
supraspinatus, infraspinatus, and glenohumeral
18. (B) To test the rhomboids, the patient is asked (shoulder) joint (Moore, p 710).
to place the hands posteriorly on the hips and to
push the elbows posteriorly against resistance 27. (E) The posterior cord gives rise to the upper and
(Moore, p 695). lower subscapular nerves, thoracodorsal nerve,
axillary nerve, and radial nerve. The long tho-
19. (A) The supraspinatus is the only rotator cuff racic nerve originates from C5–C6–C7 (Moore,
muscle that does not rotate the humerus (Moore, pp 711).
pp 697–698).
28. (E) The brachialis originates from the distal half
20. (B) The axillary nerve innervates both the del- of the anterior surface of the humerus and inserts
toid and the teres minor (Moore, p 691). on the coronoid process and tuberosity of the
ulna. It crosses one joint, flexing the forearm in
21. (C) The axilla contains axillary blood vessels, all positions. While it is primarily innervated by
lymph nodes, the cords and branches of the the musculocutaneous nerve, some of its lateral
brachial plexus, and the axillary nerve. The part is innervated by a branch of the radial nerve
trunks and divisions are found superior to (Moore, p 722).
the axilla in the neck (Moore, p 699).
29. (A) To test the triceps brachii, the arm is abducted
22. (A) The subscapular artery arises from the third 90 degrees and then the flexed forearm is extended
part of the axillary artery and contributes to against resistance (Moore, p 724).
blood supply of muscles near the scapula and
humerus (Moore, p 701). 30. (A) The deep artery of the arm accompanies
the radial nerve through the radial groove and
23. (E) The brachial plexus is formed by the union passes around the body of the humerus (Moore,
of the ventral rami of C5 through T1. The roots p 728).
of the brachial plexus and the subclavian artery
 Answers and Explanations: 15–44 25

31. (A) The anconeus assists in extension of the fore- 36. (B) A patient who is unable to flex the arm and
arm, resists abduction of the ulna during prona- forearm is likely to have a lesion in the ventral
tion of the forearm, and tenses the capsule of the rami of C5, C6, and C7. The biceps brachii and
elbow joint so that it is not pinched when the brachialis receive fibers from C5 and C6, and the
joint is extended (Moore, p 724). coracobrachialis receives fibers from C5, C6, and
C7. C6 is the main source of fibers for each
32. (C) The axillary artery gives rise to the superior (Moore, p 722).
thoracic, thoracoacromial, lateral thoracic, sub-
scapular, and anterior and posterior circumflex 37. (A) The brachioradialis is a flexor of the forearm,
humeral arteries. The brachial artery gives rise to but it is located in the extensor compartment and
the deep artery of the arm, the nutrient humeral is innervated by the radial nerve (Moore, p 734).
artery, and the superior and inferior collateral
arteries. The ulnar artery gives rise to the anterior 38. (A) The superficial muscles (pronator teres,
and posterior ulnar recurrent, common inter- flexor carpi radialis, palmaris longus, flexor
osseous, anterior and posterior interosseous, and carpi ulnaris, and flexor digitorum superficialis)
dorsal and palmar carpal branch arteries (Moore, cross the elbow joint. The deep muscles (flexor
pp 699, 727–728, 750). digitorum profundus, flexor pollicis longus, and
pronator quadratus) do not (Moore, p 734).
33. (C) The median and ulnar nerves supply no
branches to the arm (Moore, p 730). 39. (E) All muscles in the anterior compartment
of the forearm are innervated by the median
34. (B) The median nerve gives rise to a palmar nerve, except for the flexor carpi ulnaris and the
cutaneous branch; the ulnar nerve as well has a medial part of the flexor digitorum profundus,
palmar cutaneous branch. The radial nerve gives which are innervated by the ulnar nerve (Moore,
rise to the posterior brachial cutaneous nerve, pp 736–737).
the posterior antebrachial cutaneous nerve, the
inferior lateral brachial cutaneous nerve, and a 40. (B) The radial artery lies lateral to the tendon of
superficial branch that innervates the dorsum of the flexor carpi radialis (Moore, p 737).
the hand and the digits. The musculocutaneous
nerve continues as the lateral antebrachial cuta- 41. (C) The palmaris longus tendon is a guide for
neous nerve. The axillary nerve gives rise to the locating the median nerve at the wrist (Moore,
superior lateral brachial cutaneous nerve. The p 737).
medial cord of the brachial plexus gives rise to
the medial brachial cutaneous nerve and the 42. (A) To pronate the forearm, the pronator quad-
medial antebrachial cutaneous nerve. The supra- ratus initiates pronation, assisted later by the
clavicular nerves (from C3–C4) and the inter- pronator teres (Moore, p 741).
costobrachial nerve (from T2) also contribute
to the cutaneous innervation of the arm (Moore, 43. (D) The extensor carpi radialis longus tendon
pp 684, 758–759). is crossed by the abductor pollicis longus and
extensor pollicis brevis (Moore, p 745).
35. (E) The cubital fossa contains the terminal part
of the brachial artery (and the beginning of the 44. (E) The supinator, which forms the floor of the
ulnar and radial arteries), deep accompanying cubital fossa along with the brachioradialis, is
veins, the median nerve, and the biceps brachii innervated by the deep branch of the radial
tendon. In the tissue superficial to the fossa are nerve. It supinates the forearm by rotating the
the median cubital vein and medial and lateral radius. The biceps brachii also supinates the
antebrachial cutaneous nerve. The deep and forearm when the forearm is already flexed
superficial branches of the radial nerve are (Moore, p 746).
within the floor of the fossa (Moore, pp 731–732).
26 2: The Upper Limb

45. (C) The abductor pollicis longus originates from ulnaris and medial half of the flexor digitorum
the posterior surfaces of the ulna, radius, and profundus. The palmar cutaneous branch inner-
interosseous membrane. The following muscles vates the skin of the medial part of the palm, and
take at least one of their origins from the lateral the dorsal cutaneous branch innervates the pos-
epicondyle of the humerus: extensor carpi radi- terior surface of the medial part of the hand and
alis brevis, extensor digitorum, extensor digiti digits. The deep branch innervates the hypo-
minimi, extensor carpi ulnaris, and supinator thenar muscles, adductor pollicis, interossei, and
(Moore, p 742). the 3rd and 4th lumbricals (Moore, pp 759–760).

46. (A) The flexor pollicis longus is innervated by 52. (E) The radial nerve gives a superficial branch
the anterior interosseous nerve from the median that innervates skin on the dorsum of the hand.
nerve (Moore, pp 736–737, 742–743). The radial nerve itself innervates the brachiora-
dialis and extensor carpi radialis longus. It then
47. (C) The snuff box is bounded anteriorly by the gives a deep branch that innervates the extensor
tendons of the abductor pollicis longus and ex- carpi radialis brevis and the supinator before
tensor pollicis brevis. Posteriorly it is bounded continuing as the posterior interosseous nerve,
by the tendon of the extensor pollicis longus. The which innervates the extensor digitorum, ex-
radial artery can be felt in the floor, along with tensor digiti minimi, extensor carpi ulnaris, ab-
the radial styloid process, first metacarpal, ductor pollicis longus, extensor pollicis brevis,
scaphoid, and trapezium (Moore, p 749). extensor pollicis longus, and extensor indicis
(Moore, pp 742, 761).
48. (E) The hand is abducted at the wrist joint by the
flexor carpi radialis, abductor pollicis longus, 53. (E) The flexor pollicis brevis is located medial to
extensor carpi radialis longus, and extensor carpi the abductor pollicis brevis. It flexes the thumb
radialis brevis (Moore, pp 736, 742). at the carpometacarpal and metacarpophalan-
geal joints and assists in opposition. Its tendon
49. (A) The radial artery gives rise to the radial typically contains a sesamoid bone. It is inner-
recurrent artery as well as dorsal and palmar vated by the recurrent branch of the median
carpal branches. The ulnar artery gives rise to the nerve (C8–T1) (Moore, p 767).
common interosseous artery, anterior and poste-
rior interosseous arteries, anterior and posterior 54. (E) The palmaris brevis, innervated by the ulnar
ulnar recurrent arteries, and dorsal and palmar nerve, wrinkles the skin of the hypothenar emi-
carpal branches (Moore, p 750). nence and deepens the hollow of the palm, assist-
ing the palmar grip. The muscle actually covers
50. (A) The median nerve assists in the innervation and protects the ulnar artery and the ulnar nerve,
of the elbow joint and gives muscular branches which innervates it. The muscle is not by defi-
to pronator teres, flexor carpi radialis, palmaris nition in the hypothenar compartment. The pal-
longus, and flexor digitorum superficialis. The maris longus, on the other hand, flexes the hand
median nerve also has an anterior interosseous at the wrist and tightens the palmar aponeuro-
branch that innervates the lateral part of the sis (Moore, p 768).
flexor digitorum profundus, flexor pollicis
longus, and pronator quadratus. The recurrent 55. (B) The recurrent branch of the median nerve
branch of the median nerve innervates the innervates the abductor pollicis brevis, flexor
thenar muscles, and the palmar cutaneous pollicis brevis, and opponens pollicis, but the
branch innervates the skin of the lateral part of deep branch of the ulnar nerve innervates adduc-
the palm (Moore, pp 757–759). tor pollicis (Moore, pp 769–770).

51. (C) The ulnar nerve gives rise to articular 56. (C) Lumbricals 1–2 and palmar interossei 1–3
branches that innervate the elbow joint and mus- are unipennate muscles. Lumbricals 3–4 and dor-
cular branches that innervate the flexor carpi sal interossei 1–4 are bipennate muscles. The del-
toid is multipennate (Moore, p 770).
 Answers and Explanations: 45–70 27

57. (C) The deep branch of the ulnar nerve inner- anastomosis around the elbow and is inner-
vates the adductor pollicis, abductor digiti min- vated by the musculocutaneous, radial, and
imi, flexor digiti minimi brevis, opponens digiti ulnar nerves. It is surrounded by the intratendi-
minimi, lumbricals 3 and 4, dorsal interossei 1–4, nous olecranon bursa, the subtendinous olec-
and palmar interossei 1–3. The median nerve ranon bursa, and the subcutaneous olecranon
innervates lumbricals 1 and 2 (Moore, p 770). bursa (Moore, pp 795–798).

58. (E) The carpal tunnel contains the median nerve, 64. (C) The proximal and distal radioulnar joints
the four tendons of the flexor digitorum superfi- are pivot-type synovial joints. The radiocarpal
cialis, the four tendons of the flexor digitorum (wrist) joint is a condyloid type of synovial joint.
profundus, and the tendon of the flexor pollicis Intercarpal joints are plane-type synovial joints.
longus (Moore, p 774). Metacarpophalangeal joints are condyloid types
of synovial joints. Interphalangeal joints are
59. (A) The sternoclavicular joint, which does not hinge-type synovial joints (Moore, pp 800, 803,
dislocate easily, is a saddle-type synovial joint 807, 809).
but functions as a ball-and-socket joint. It is the
articulation of the sternal end of the clavicle with 65. (A) All carpometacarpal and intermetacarpal
the manubrium of the sternum. The joint is sup- joints are the plane-type synovial joints except
plied by the internal thoracic and suprascapular for the carpometacarpal joint of the thumb,
arteries and is innervated by branches of the which is a saddle joint (Moore, p 809).
medial supraclavicular nerve and the nerve to
the subclavius (Moore, pp 781–782). 66. (E) The clavicle varies more in shape than most
other long bones and is thicker and more curved
60. (E) The acromioclavicular joint is a plane-type in manual workers. The right clavicle is stronger
synovial joint and is strengthened by the AC lig- than the left and is usually shorter. The clavicle
ament and the coracoclavicular ligament, which can also be pierced by a branch of the supracla-
is composed of the conoid and trapezoid liga- vicular nerve. The clavicle is a long bone with no
ments. It is supplied by the suprascapular and medullary cavity. It consists of spongy (cancel-
thoracoacromial arteries and is innervated by lous) bone with a shell of compact bone (Moore,
the supraclavicular, lateral pectoral, and axillary p 667).
nerves. When dislocated, it is referred to as a
“separated shoulder” (Moore, pp 784, 787). 67. (A) Fractures of the scapula typically involve the
protruding subcutaneous acromion. The remain-
61. (B) The pectoralis major (clavicular head) and der of the scapula is well protected by muscles
deltoid (anterior part) flex the arm at the gleno- and the thoracic wall itself (Moore, p 669).
humeral joint. The coracobrachialis and the bi-
ceps brachii assist (Moore, p 792). 68. (D) The surgical neck of the humerus is in direct
contact with the axillary nerve, the radial nerve
62. (A) The posterior portion of the deltoid causes runs in the radial groove, the distal end of the
extension of the arm at the glenohumeral joint. humerus is in direct contact with the median
The deltoid (as a whole, but especially the cen- nerve, and the medial epicondyle is in contact
tral part) causes abduction, whereas the pec- with the ulnar nerve (Moore, p 670).
toralis major and latissimus dorsi cause adduc-
tion. The subscapularis causes medial rotation, 69. (A) Damage to the long thoracic nerve results
whereas the infraspinatus causes lateral rota- in “winging” of the scapula (Moore, p 689).
tion (Moore, p 792).
70. (A) The triangle of auscultation, a good place to
63. (E) The elbow is a hinge type of synovial joint, examine lung sounds, is bounded by the supe-
strengthened by radial and ulnar collateral liga- rior horizontal border of the latissimus dorsi, the
ments. It is supplied by arteries derived from the medial border of the scapula, and the inferolat-
28 2: The Upper Limb

eral border of the trapezius. The 6th and 7th ribs ened. The patient would also lose sensation on
and the 6th intercostal space is subcutaneous the lateral surface of the forearm (Moore, p 731).
(Moore, p 693).
78. (C) When the median nerve is injured, the pa-
71. (B) With paralysis of the latissimus dorsi, the tient often exhibits the “hand of benediction.”
patient is unable to raise the trunk as necessary When the patient tries to make a fist, digits 2 and
for climbing. The cause could be injury to the 3 remain partially extended because flexion of
thoracodorsal nerve (C6–C7–C8) (Moore, p 693). the PIP joints is lost in digits 1–3 and weakened
in digits 4–5. Flexion of the DIP joints is lost in
72. (A) Injury to the dorsal scapular nerve (C4–C5) digits 2–3 but maintained in digits 4–5 (since the
can paralyze the rhomboids, causing the scapula ulnar nerve controls the medial part of the flexor
on one side to be located farther from the midline digitorum profundus). Flexion of the MCP joints
than that on the normal side (Moore, p 695). of digits 2-3 will also be affected due to a loss of
the lumbricals 1 and 2 (Moore, pp 757, 774, 776).
73. (B) The deltoid atrophies when the axillary
nerve (C5–C6) is damaged. Therefore, the 79. (A) The ulnar nerve is often injured where it
rounded contour of the shoulder often dis- passes posterior to the medial epicondyle of the
appears. A loss of sensation may occur on the humerus. The patient experiences loss of sensa-
lateral side of the proximal part of the arm tion in the medial part of the palm as well as in
(Moore, pp 696–697). the medial 11⁄2 digits. Most intrinsic hand mus-
cles are paralyzed, and the patient loses the
74. (B) Injury or disease may damage the rotator ability to adduct the hand at the wrist. Patients
cuff, causing instability of the glenohumeral cannot make a fist since they are unable to flex the
joint. The supraspinatus tendon is the most 4th and 5th digits at the DIP joints. The result-
commonly torn part of the rotator cuff. Acute ing deformity is known as “clawhand” (Moore,
tears are uncommon in young persons (Moore, pp 761, 776–777).
pp 698–699).
80. (E) Amelia is the complete absence of one or
75. (C) In an upper brachial plexus injury causing more extremities while meromelia is the partial
Erb-Duchenne palsy, one would expect damage absence of one or more extremities. All segments
to C5–C6, resulting in “waiter’s tip position” of extremities are present but abnormally short
(adducted shoulder, medially rotated arm, and in micromelia. In phocomelia, long bones are
extended elbow). This results from paralysis of absent, and small hands or feet are attached to
the deltoid, biceps, brachialis, and brachioradi- the trunk by short, irregular bones. In cleft hand
alis. The lateral aspect of the upper limb also (lobster claw deformity), the third metacarpal is
experiences loss of sensation (Moore, p 716). absent and digits 1–2 and 4–5 are fused (Sadler,
p 179).
76. (D) Damage to the inferior trunks of the brachial
plexus (C8–T1) affects the short muscles of the 81. (C) Syndactyly involves abnormal fusion of fin-
hand, resulting in “clawhand.” The patient might gers and toes. Cleft hand (lobster claw defor-
have grabbed a tree limb to catch himself while mity) consists of an abnormal cleft between the
falling to cause this injury. “Clawhand” may also 2nd and 4th metacarpal bones, with the 3rd
be caused by an injury to the ulnar nerve (Moore, metacarpal and phalangeal bones being absent
pp 716–717, 761). and with digits 1–2 and 4–5 being fused. Poly-
dactyly involves extra fingers or toes, while
77. (B) A knife wound to the axilla would dam- ectrodactyly involves the absence of a digit.
age the musculocutaneous nerve and result in Mutations in HOXA13 result in hand-foot-geni-
paralysis of the coracobrachialis, biceps, and tal syndrome, where carpals and short digits are
brachialis. Therefore, flexion of the elbow joint fused and the genitalia have altered structures
and supination of the forearm would be weak- (Sadler, p 181).
 Answers and Explanations: 71–98 29

82. (D) During development, dorsal cells organize 87. brachial artery
as the epimere and ventral cells organize as the
hypomere. Dorsal rami innervate muscles de- 88. median nerve
rived from the epimere, whereas ventral rami
innervate muscles derived from the hypomere. 89. lateral cord
Myoblasts of the epimere form the extensor
muscles of the vertebral column, and those of the 90. musculocutaneous nerve
hypomere give rise to muscles of the limbs and
body wall. Somites and somitomeres form the 91. medial antebrachial cutaneous nerve
musculature of the limbs (Sadler, pp 189–190).
92. ulnar nerve
83. (E) Partial or complete absence of one or more
muscles is rather common. One of the best- 93. lateral pectoral nerve
known examples is total or partial absence of the
pectoralis major (Poland anomaly). Similarly, 94. coracobrachialis
the palmaris longus, serratus anterior, and quad-
ratus femoris may be partially or entirely absent 95. brachialis
(Sadler, p 192).
96. ulna
84. biceps brachii
97. long head of triceps brachii
85. cephalic vein
98. lateral head of triceps brachii
86. radial nerve
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