1.

Give an account of Erbs duchenne paralysis

Lesion-upper trunk of brachial plexus

Affected nerve root-C5 ,C6
Cause-undue separation of head from shoulder (birth injury, fall on shoulder)
During anaesthesia
Deformity- Arm- adducted, medially rotated
-Forearm-extended, fully pronated (porters tip hand)

Muscles paralyzed-Deltoid, supraspinatus,infraspinatus,teres minor

Brachialis,biceps brachii, Supinator, brachioradialis

Disability-Arm cannot abducted or laterally rotated, Forearm cannot be flexed or

supinated
-Sensory loss of skin over half of the deltoid (badge sign)
-wasting of deltoid

2. Give an account of Klumpkeys paralysis

Lesion- Lower trunk of brachial plexus

Affected nerve root-C8, T1
Cause-Undue abduction (birth injuries), clutching something when falling from height
Deformity-Complete claw hand
Muscles paralyzed- All the intrinsic muscles of the hand,
-Flexor carpi ulnaris, medial half of flexor digitorum profundus

Disability- Complete claw hand

-Sensory loss on along the medial aspect of forearm and hand
-Vasomotor changes-Dry and warm skin in the area with sensory loss
-Trophic changes-Scaly skin, easily cracking nails
-Horners syndrome-(ptosis, miosis, enopthalamos, anhydrosis)

3. Explain the Axillary lymph nodes

Scattered in fibrofatty tissue in axilla,
Arrested in 5 groups as- Anterior, posterior, lateral, central, apical

Anterior(pectoral) group

-Along lateral thoracic vessels (lower border of pec.minor)

-Direct contact with axillary tail of the breast
-Receive lymph from Upper half of ant. Wall of trunk, - Major part of breast

Posterior( Scapular)

-Along subscapular vessels

-on posterior fold of axilla
-Receive lymph from Upper half of post. Wall of trunk ,- Axillary tail of breast

Lateral group

-Medial to axilary vein

-Along upper part of humerus
-Receive lymph from upper limb

Central group

-In axillary fat

-Receive from ant. Post. Lateral groups
-Drain into apical
-some direct vessels from axillary floor
-Intercostobrachial nerve closely related

Apical

-Deep to clavipectoral fascia

-Along axillary vessels
-Receive lymph from- central & others upper part of breast thumb & its web

4. Explain the anatomy of axilla

A pyramidal region situated between upper part of arm and chest wall
Has an apex, base, 4 walls- anterior, posterior, lateral & medial
Apex
- directed towards root of neck
truncated
-correspond to cervicoaxillary canal (anterior-clavicle, posterior-superior border scapula
Medial- outer border of 1st rib
{axillary artery & brachial plexus enter}

Base directed downwards

-skin, fascia
Anterior wall Pectoralis major in front
-Clavipectoral fascia enclosing pec.minor & subclavius deep to that
Posterior wall Subscapularis above
Teres major , latismus dorsi below
Medial wall - upper 4 ribs with intercostals muscle
-serratus anterior

Lateral wall - upper part of the shaft of the humerus

-coracobrachialis, short head of biceps.

Contents
o Axillary artery & its branches [SALSAP]
o Axillary vein & its tributaries [SALSAP, cephalic]
o Infraclavicular part of brachial plexus
o Axillary lymph nodes- 5 groups & lymphatics
o Long thoracic nerve, intercostobrachial nerve
o Axillary fat & areolar tissue
Lump in axilla due to,
o Axillary artery aneurysm
o Axillary lymph node enlargement

5. Course and distribution of median nerve

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Root values anterior primary rami of C5-C8, T1

Origin in the axilla, lateral axillary artery
o Union of medial root from medial cord of brachial plexus
o And lateral root from dlateral cord of brachial plexus
Upper part of the arm lateral to the brachial artery
At the level of corachobrachialis insertion- crosses superficial to artery from
lateral to medial.
Lower part of the arm- medial to the brachial artery, give a branch to pronator teres
In front of elbow joint medial to brachial artery
Cubital fossa branches to , Flexor carpi radialis, Palmaris longus, Flexor digitorum
superficialis
Goes between 2 heads of pronator teres
(deep head of pronator teres separates ulnar artery from median nerve)
Descend through fibrous arch of flexor digitorum superficialis
Gives a branch , anterior interosseous nerve
which supplies # lateral half of flexor digitorum profundus
flexor pollicis longus
Pronator quadrates
Continuation descends adherent todeep surface of Flexor digitorum superficialis
At the lower border of the forearm; gives off palmar cutaneous branch
Which goes superficial to flexor retinaculum
Supply lateral 2/3 of palm
Median nerve enters hand by passing through the carpal tunnel
Supplies muscles of thenar eminence
Flexor pollicis brevis
Abductor pollicis brevis
Opponens pollicis
1st & 2nd lumbar muscles
Cutaneous supply to palmar surface of lateral 3 & digits including their nail beds.
Median nerve most commonly damage at carpal tunnel
Carpal tunnel syndrome
o Ape like thumb deformity
o Index & middle finger lag behind when making fist
o Sensory losspalmar surface lateral 3 & digits including their nail beds
o Vasomotor dryness & warmth of areas of sensory loss
o Trophic changes- longstanding caseseasily fragile nails

6. Blood supply of the hand

o

It is consist of arterial supply and venous drainage

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Arterial supply
Hand is supplied by ulnar & radial artery
Radial artery is the main artery of the hand
Branches of these arteries anastomose to form the deep & superficial palmar arches
Superficial palmar arch is continuation of ulnar artery
Completed by princeps pollicis/ radial indicis/ superficial palmar branch of radial artery
Lie deep to the palmar aponeurosis, superficial to the flexor tendons.
4 digital branches are given
Deep palmar arch is continuation of radial artery
Completed by deep palmar branch of ulnar artery
Lies deep to the oblique head of adductor pollicis & superficial to the metacarpas &
interossei
Gives 3 palmar metacarpal arteries, which join with lateral 3 digital branches to form
common digital branches
Each common digital branche divide into 2 proper digital branches & supply to digits
Also deep palmar arch gives perforating arteries and recurrent arteries
Allens test is used to test the patency of each
Ulnar & radial artery, related to blood supply of hand
Princeps pollicis mainly supplies to thumb
Venous drainage
Mainly drainage by dorsal venous arch
It lies on dorsum of the hand
Its afferents are
o 3 dorsal metacarpal veins
o Dorsal digital veins from thumb
o Little & index figer
Medial side of dorsal venous arch is drained by basilica vein &
Lateral side is drained by cephalic vein

7.1 Describe how the cords of the brachial plexus are formed (branches of the BP is not
required) [10]
Anterior primary rami of C5,C6,C7,C8,T1 spinal nerve give rise to brachia plexus
C5,C6 join to form upper trunk
C7 alone forms middle trunk
C8,T1 join to form lower trunk
Each trunk divides into anterior & posterioe divisions
Anterior division of upper & middle trunks joins to form lateral cord
Anterior division of the lower trunk alone forms medial cord
Posterior divisions of 3 trunks join to form posterior cord
7.2 State the anatomical location of the various parts forming the brachial plexus

Trunks posterior triangle of neck

Roots between anterior and middle scalene muscles
Divisions behind the middle 1/3rd of clavicle

 Cords and branches within axilla

7.3 Describe the course and distribution of the muscular branches of the radial nerve in
upper arm
Root values anterior primary rami of C5-C8, T1
Origin in axilla
o From posterior cord of brachial plexus
o Lies posterior to 3rd part of axillary artery
o Muscular branches to long head & medial head of triceps
o Cutaneous posterior cutaneous nerve of arm
Upper part of arm posterior to brachial artery
Enters to posterior compartment of arm through lower triangular space space with
profunda brachii artery
In radial groove
o Branchesmuscular medial head of triceps, lateral head of triceps, anconeus
o gives lower lateral cutaneous nerve of arm
At the level of corachobrachialis insertion,
o Radial nerve pierce the lateral intermuscular septum with anterior descending
branch of profunda brachii artery to come to anterior compartment from posterior
compartment of arm
Then it descends between brachialis and brachioradialis muscles
Radial nerve can be damage at axilla in cases like crutch palsy
Then triceps paralyse
Extension of forearm become imapared
It is damage at radial groove;
In cases like Saturday night palsy, when the nerve against bone for a long
time
Then triceps doesnt become totally paraysed because it is already supply
at axilla
7.4 Indicate the sensory loss seen in damage to the radial nerve on the midshaft region of
the humerus and give the reasons for this
Radial nerve gives posterior cutaneous nerve of arm in axilla
In radial groove it gives lower lateral cutaneous nerve of arm
Its superficial branch
o Which remains after giving posterior interosseous branch supplies dorsal 1/2 of
hand, & dorsal surface of lateral 2 fingers except their nail beds
Hence, when the nerve is damaged at midshaft, sensory loss will take place at
o Lateral lower part of arm
o Posterior aspect of forearm
o Lateral of dorsum of hand
o Dorsal surface of lateral 2 fingers except their nail beds
Clinically sensory loss can be seen only on 1st dorsal web space

8.1 List the factors which support the stability of the shoulder joint

Musculotendinous cuff (rotator cuff ) of the shoulder

The corachoacromial arch (secondary socket for the head of the humerus)
Glenoid labrum; A fibrocartilaginous rim, attached to margins of glenoid cavity
Increases depth of the glenoid cavity
Ligaments
o The capsular ligament
o Coracohumeral ligament
o Transverse humeral ligament
Atmospheric pressure

8.2 a. which nerve is likely to be damage in shoulder dislocation?

Axillary nerve
b. Discribe the course & distribution of above mentioned nerve

Root values anterior primary rami C5,C6

Origin in the axilla
From posterior cord of brachial plexus, posterior to axillary artery
enters quadrangular space with the posterior circumflex humeral artery
here superiorly- teres minor
inferiorly- teres major
medially- long head of triceps
laterally- humerus
divides into deep and superficial branches
winds around the post. aspect of surgical neck of humerus with post. Circumflex humeral
artery
supplies deltoid and teres major
cutaneous supply to skin over lower part of deltoid (upper lateral cuteneous nerve of
arm)
can be damaged in shoulder dislocation

9.1. Anatomy of the carpal tunnel

Carpal tunnel is a fibro-osseous tunnel

Posteriory (floor) formed by concavity of the carpal bones [scaphoid, lunate, triquetral,
pisiform, trapezium, trapezoid, capitates, hamate
Anteriorly (roof) flexor retinaculum
o Attachment laterally- tubercle of scaphoid, crest of trapezium
o
-medially- pisiform, hook of hamate
Contents passing through the carpal tunnel are,
o Median nerve- most superficially
o Ulnar bursa- enclosing long flexor tendons
o Radial bursa
o Flexor digitorum superficialis tendon ( Tendon of middle finger and ring finger are
more superiorly & the little & index figers inferiorly)
o Flexor digitorum profundus (Tendon of the index finger away from the other 3 )

o Flexor pollicis longus tendon

o Flexor carpi radialis tendon
Structures passing superficial to the flexor retinaculum are,
o Ulnar nerve medially
o Ulnar artery
o Palmaris longus tendon
o Palmar cutaneous branch of ulnar nerve
o Palamar cutaneous branch of median nerve

9.2. Carpal tunnel syndrome- signs and symptoms with reasons

Carpal tunnel syndrome, pressure aithin the carpal tunnel, increases

Causes ;
o Inflammation of the ulnar & radial nerve bursa
o Lunate dislocation
o Arthritis
o Old fracture of carpal bones
Median nerve is compressed
All the supply of median nerve given after going through the carpal are disturbed.
Supply to muscle of the thenar eminence (abductor pollocis brevis, flexor pollicis brevis,
opponent polices) wasting of the thenar eminence
Paralysis of opponence pollicis loss of opposition
Paralysis of abductor pollicis, flexor pollicis brevis
o But intact adductor pollicis is supplied by ulnar nerve---adducted,laterally rotated
thumb (ape like thumb deformity )
Paralysis of lateral 2 lumbricals normally flexion of metacarpopharangeal (M/P)
joints,and extension of interphalangeal joints (I/P)----o Flexion of M/P of index & middle fingers impared
o Index & middle fingers lag behind when making a fist
Cutaneous supply to palmar surface of lateral 3 & digits including than nail beds
o Sensory loss of that area
o Vasomotor changes
Dry skin due to absence of sweating
Warm reddish skin(arterial dialatation)
o Trophic changes- easily crackers nails
Sensation over skin or thenar eminence is not affected as it is supplied by palmar
cutaneous branch of median nerve, going superficial to flexor retinaculum (not
compressed in carpal tunnel syndrome)

9.3 Briefly describe the midpalmar space of the hand

Triangular space situated in inner half of hollow of palm

Proximally extend upto distant border of flexor retinaculum and distally to palmar crease
Communicates
o Distally with 3rd and 4th lumbrical canals (sometimes with 2nd)
o Proximally with forearm space of parona
Boundaries

o Anteriorly 3,4,5 flexor tendon with 3rd and 4th lumbricals, palmar aponeurosis
o Posteriorly- fascia covering the metar=carpals and interossei
o Medially- medial palmar septum
o Laterally- intermediate palmar septum
Can be infected by tenosynovitis of middle finger and ring finger/ webbed infection
spread through the lumbrical canals.

10. Give an account of shoulder joint

Its a multiaxial, ball and socket type , synovial joint

Its an articulation of glenoid fossa with the head of humerus
Genoid cavity is too small and shallow.( head of humerus is four times that of the cavity)
Has a very loose Capsule which is attached medially to the margin of the glenoid
labrum,
anteriorly anatomical neck of the humerus with exceptions of the attachment which
extends inferiorly down to surgical neck, superiorly it is deficient for passage of the long
tendon of the biceps brachii
capsule is lined with synovial membrane
capsule is reinforced by superior, inferior, middle glenohumeral ligaments
corachoacdromial ligament, transverse humeral ligament and glenoid labrum are
ligaments surround the joint
Subacromial, subscapularis and infraspinatus bursa are realted to the joint
The stability of the joint maintained mainly by
o Rotator / Musculotendinous cuff muscles
Which is originating from scapula and inserted to the humerus
Supraspinatus, Infraspinatus, Teres minor & Subscapularis
Cuff is deficient inferiorly
o Corachoacromial arch(secondary socket for the head of the humerus)
o Glenoid labrum by increasing the depth of glenoid fossa
Blood supply
o Anterior circumflex humeral vessels
o Posterior circumflex humeral vessels
o Suprascapular vessels
o Subscapular vessels
Joint is innervate mainly by
o Axillary nerve
o Musculocutaneous nerve
o Suprascapular nerve
Wide range of movements
o Flexion and extention
o Abduction and adduction
o Medial and lateral rotation
o Circumduction
Clinicals Shoulder dislocation (most inferiorly)
o Shoulder tip pain (referred pain C4 )
o Dowbarks sign/ Subacromial bursitis

Supraspinatus tendinitis (pain arch)

11.1. Describe the cubital fossa

Cubital fossa is a triangular region situated on the front of the ebow

Bounded by laterally, medial border of brachioradialis
Medially, lateral border of pronator teres
Base, imaginary line joining the 2 epicondyle of the humerus
Apex directed downwards, meeting point of lateral & medial boundaries
Roof, Skin, superficial fascia containing median cubital vein, lateral and medial
cutaneous nerve of forearm, deep fascia & bicipital aponeurosis
Floor by brachialis and supinator
From lateral to medial, radial nerve, tendon of the biceps, brachial artery, median nerve
Median nerve leave the fossa by passing between 2 heads of pronator teres
Brachial artery ends by dividing into ulnar and radial artery
Smaller radial artery lies more laterally and gives radial recurrent branch
Larger ulnar artery lies medially, deep to the deep head of pronator teres, separated
from median nerve by deep head
Gives anterior, posterior ulanar recurrent artery and common interosseous artery which
divides into anterior and posterior interosseous arteries
Biceps tendon inserted into posterior part of radial tuberosity and gives expansion called
bicipital aponeurosis, which merge with deep fascia
Radial nerve runs between brachialis medially and brachioradialis, extensor carpi
radialis longus laterally,
At the level of lateral epicondyle it divides into superficial and deep branches
Deep branch runs between 2 layers of supinator and leaves the fossa

11.2 An eight year old boy was admitted to Lady Ridgeway Hospital
with a fall on the outstretched hand and a plain radiograph
confirmed the presence of a left supracondylar fracture of the
humerus. His left radial pulse was absent.
20.1. Describe the nerves and vessels in the cubital fossa and
explain the absence of radial pulse in this patient.

Due to supracondylar fracture , brachial artery would damage at the elbow

So mainly blood flow through radial artery( small terminal branch of the brachial artery) is
reduced and radial pulse may disappears

11.3. Few months later the boy presented to the Orthopaedic clinic. The fracture had
healed but with a marked valgus deformity at the elbow (Cubitus valgus). He also had
developed wasting of the interossei muscles of the same hand. The Surgeon explained to
the mother that this was due to stretching of a nerve around the elbow due to the
deformity and that it needed corrective surgery.
11.3.1. Name the nerve affected. (10)
11.3.2. What other clinical features would you expect in this patient as a result of this
nerve palsy? (30)

(AL2007)

Median nerve
Median nerve (MN) is damaged by the supracondylar fracture
MN supplies pronator teres, flexor carpi radialis, Palmaris longus, flexor digitorum
superficialis
Anterior interoseous nerve, a branch of the MN supplies pronator quadrates, flexor
pollicis longus, lateral half of flexor digitorum profundus
Because of MN damage at the elbow before innevate all these muscles, all the action of
those muscles are impared
As pronator teres, pronator quadrates paralysed, pronation is impaired
As flexor carpi radialis, Palmaris longus, flexor digitorum superficialis paralysed, wrist
flexion is weaken.
Ulnar deviation is seen when wrist flexion is attempted. This is due to unopposed action
of flexor carpi ulnaris as flexor carpi radialis paralysed.
Median nerve supplies opponence pollicis/ flexor pollicis brevis/ abductor pollicis brevis
(thenar muscles) these muscles are also paralysed
wasting of the thenar eminence
Paralysis of opponence pollicis loss of opposition
Paralysis of abductor pollicis, flexor pollicis brevis
o But intact adductor pollicis is supplied by ulnar nerve---adducted,laterally rotated
thumb (ape like thumb deformity ,this is charachterised by a flattened palm)
Paralysis of lateral 2 lumbricals normally flexion of metacarpopharangeal (M/P)
joints,and extension of interphalangeal joints (I/P)----o Flexion of M/P of index & middle fingers impared
o Index & middle fingers lag behind when making a fist
Cutaneous supply to palmar surface of lateral 3 & digits including than nail beds ,skin
over dorsumstal phalanges, and radial side of palm .
o Sensory loss of that area
o Vasomotor changes
Dry skin due to absence of sweating
Warm reddish skin(arterial dialatation)
o Trophic changes- easily crackers nails in longstanding cases

12. a. Describe the arrangement of the middle finger

The tendons of the middle finger are of two types

Those which are attached to the palmar and dorsal aspect of the finger
On the palmar aspect are found the tendon of the flexor digitorum superficialis and
profundus
The flexor digitorum superficialis tendon enters the proximal phalanx within the synovial
sheat, which it shares with the profundus tendon
This digital synovial sheath in turn covered by the fibrous flexor sheath

Within the synovial sheath the tendon of the supeficialis divides at proximal phalanx into
2 portions which surround the tendon of flexor profundus
The two parts inserted to the sides of the palmar surface of the base of the middle
phalanx
The profundus tendon passes within the synovial sheath within the fibrous flexor sheath
and through the flexor superficialis aperture and inseted itself to the palmar aspect of the
base of the distal phalanx
On the dorsal aspect found the tendons of the extensor digitorum(ED), which attaches
itself to the triangular extensor expansion
The ED divides into 3 slips on the proximal phalanx
The central slip joined by the thickened margins of the extensor expansion and inserted
into the dorsal aspect of the middle phalanx
The collateral slips diverge and unite with the remaining parts of lateral thickened
margins of the expansion
Then they converge and unite with each other to be inserted to the base of the distal
phalanx
2nd and 3rd dorsal interossei muscles mainly attached to the either sides of the base of
the proximal phalanx and the rest to the corresponding margins of the expansion
The 2nd lumbrical is attached to the lateral thickened margin of the expansion.

12. b. What are the movements produce by these muscles

Flexor digitorum superficialis flexes the middle and proximal phalanges

At the proximal interphalageal joint and metacarpophalangeal joint
It also helps in flexion of the wrist
The flexor digitorum profundus flexes the distal phalanx
At the distal interphalangeal joint
And assist in flexion of the middle and proximal phalanges and wrist joint
The extensor digitorum mainly extends the metacarpophalangeal joint
And assist in extending the wrist joint and interphalangeal joints
The lumbrical flexes the metacarpophalangeal joint and extends the interphalangeal
joints
The position taken up in writing
This is aided by the dorsal interossei muscle
The main function of the dorsal interossei is to abduct the fingers at
metacarpophalangeal joints

13. Describe the anatomy of female breast

It is a modified apocrine sweat gland

Base of the breast is extend,
Vertically from 2nd to 6th rib in midclavicuar line
Horizontally from lateral border of the sternum to midaxillary line, in 4 th
intercostals space

Breast lies within the superficial fascia except, axillary tail which pierces the deep fascia
and lie in the axilla
Its base overlies the pectoralis major muscle, overlapping
Onto serratus anterior
And small part of external oblique aponeurosis
Retromammary space separates the breast from the pectoralis fascia
Skin covers the gland
Nipple, a conical projection located in the 4th intercostals space
Nipple consist of longitudinal and circular smooth muscle fibres
Have rich nerve supply
Pierced by 15-20 lactiferous ducts separately
Areolar is circular pigmented area around the nipple
Rich in modified sebaceous glands
It enlarges during the lactation, forming tubercle of montgomary
Nipple and areola are devoid of fat
Glandular tissue (parenchyma) secretes milk
Consist of 15- 20 lobes
Each lobe formed by a clusters of alveoli
Lobes open in to lactiferous duct
Actiferous duct converge towards the nipple and form a small dialatation called
lactiferous sinus
Gland
o Resting phase lined by cuboidal epithelium
o Secretary phase become columnar
Terminal part of the duct is lined by stratified squamous epithelium
Stroma is mainly fatty
Fibres form the suspensory ligament of cooper
Which connect the dermis to fascia
Blood supply is derived from axillary artery
o Lateral thoracic (mainly)
o Superior thoracic and acromiothoracic also supply the breast
Additional blood supply from
o Internal thoracic artery via perforating branches
o Posterior intercostals artery
Veins follows the arteries
Drain into axillary, posterior intercostals and internal thoracic veins
Nerve supply is mainly by 4,5,6 intercostal nerves
Not responsible for secretion of milk
Lymph drainage is mainly (75%) to the axillary lymph nodes
Axillary lymph nodes arranged in 5 groups
Pectoral (anterior) along lateral thoracic vessels
Subscapular (posterior) along subscapular vessels
Lateral along the distal part of the axillary vein
Central and apical
20% passes to the internal mammary nodes

5% to the posterior intercostals nodes

Breast is frequent site for carcinoma
Breast carcinoma can be spread in to
o Abdomen
o Pelvis
o Opposite breast via lymphatics
o Vertebral column and to the brain via veins
OR
14.
A) Describe the macroscopic anatomy of mammary gland and
its blood supply. (50)

The mammary gland is situated in the superficial surface of the

pectoral region
Except the axillary tail which pierce deep fascia & lies in the axilla.
Base lies vertically from 2nd to 6th ribs, the axis going through
midclavicular line and
Horizontally from lateral sterna edge to midaxillary line, the axis going
through 4th ICS.
It lies on Pectoralis major, Serratus anterior & External oblique
muscles.
Separated from the pectoral fascia by loose areolar tissue called
retromammary space.
Structure of the breast is divided into skin, parenchyma & stroma.
Skin has a conical projection called nipple
At the level of 4th ICS.
It is pierced by 15- 20 lactiferous ducts.
The pigmented skin surrounding the base of the nipple
Is called areola.
It is rich in sebaceous glands,
which enlarges during pregnancy & lactation.
Skin of areola & nipple are devoid of hair & fat.
The parenchyma is made up of glandular tissue consist of 15-20 lobes.
Each lobe is cluster of alveoli & drained by lactiferous ducts.
Stroma is the supporting framework which is partly fibrous & partly
fatty.
Fibrous stroma forms septa called suspensory ligament of Cooper and
anchor skin & gland to pectoral fascia.
Mammary gland is extremely vascular and supplied by
Internal thoracic artery through its perforating branches,
Lateral thoracic, superior thoracic & acromiothoracic branches of
axillary artery and
Lateral branches of posterior intercostals arteries.
Arteries converge on breast & distributed from anterior surface &
posterior surface is relatively avascular.

Veins converge towards the nipple & form an anastamotic venous

circle.
The superficial veins drain into internal thoracic & superficial veins of
lower neck and
Deep veins into internal thoracic, axillary & posterior intercostals
veins.
Any 25

x 2 = 50 marks.

B) Describe the basis of its lymphatic drainage and occurrence after a

surgical removal of carcinoma of breast. ( I meant the nerve damages
& its effects) (50)

Majority (80%) of the lymphatics from breast drains into axillary lymph
nodes,
which is arranged in 5 groups.
Anterior group lies along the lateral thoracic vein & drain major part of the
breast.
Posterior group lies along subscapular vessels & drains axillary tail of the
breast.
Lateral group lies medial to axillary vein.
Central group is embedded in axillary fat & drains the anterior, posterior &
lateral groups.
All these groups drain into apical group
which is situated in the apex of the axilla, related to axillary vein.
Subsequently these nodes drain into supraclavicular nodes.
Axillary lymph nodes are surgically classified into level I, II & III,
which lies proximal to, at the level of & distal to pectoralis minor muscle
respectively.
Most of the rest of the breast(20%), specially medial part drains into
internal mammary nodes,
which lies along the internal thoracic artery.
Few lymphatics follow intercostals arteries and
Drains into posterior intercostals nodes.
Superficial lymphatics are connected with those of the opposite breast.
Some lymph from the breast also reaches subdiaphragmatic &
subperitoneal lymph plexus.
Occasionally some lymph drains into infraclavicular nodes in the
deltopectoral groove.
These minor pathways tend to drain only when major pathways are
obstructed.

During the surgical removal of carcinoma of breast, not only the breast,
but also the pectoralis major, minor, lymphatics, axillary lymph nodes and
part of axillary vein is removed.
The long thoracic nerve can be damaged and
It will cause paralysis of serratus anterior & produce winging of scapula.
The intercostobrachialis nerve can be damaged and
This produce loss of sensation in upper medial part of arm & the floor of
axilla.
Thoracodorsal nerve can be damaged & produce paralysis of latissimus
dorsi.
Lateral & medial pectoral nerve can be damaged & produce paralysis of
pectoralis major & minor.

Any 25 x 2 = 50 marks

Q-BANK for UL
Write short notes on,
1.1. Distribution of median nerve in the hand. (30).
2. Give an account of the blood supply of the hand.
3.
3.1. Describe the anatomy of the carpal tunnel.(35)
3.2. State briefly the effects of nerve compressing in the carpal
tunnel.(15) (AL2004 main)
4.
4.1. Describe the course and distribution of median nerve. (70)
4.2. Add a note on blood supply of the hand. (30)
5. Describe the course and branches of the;
5.1. Axillary artery (50)
5.2. Femoral artery (50) (AL2002 rep)
6.
6.1. Describe the brachial plexus and its relations. (50)
6.2. Explain the signs and symptoms in lesion of brachial plexus.
(50)
7.
7.1. Describe the arrangement of the tendons in the middle
finger.(60)
7.2. What are the movements produced by these muscles?(40)
8.
8.1. Give attachments of the flexor retinaculum in the hand.(40)
8.2. Name the structures which pass through the carpal
tunnel.(40)
8.3. What are the effects of compression of the median nerve in
the carpal tunnel?(20)
9.
9.1. Name the muscles, tendons attached to the phalanges of the
middle finger.(40)
9.2. What are the actions and the nerve supply of each of these
muscles?(60)
10.
10.1. Describe the bony structures involved in the mechanism of full
abduction.(70)

10.2. Name the muscles involved and their nerve supply.(30)

11. Give an account of
11.1. The carpal tunnel & its contents.(50)
11.2. The origin and the course of the great saphenous vein. (50)
12. Give an account of the
12.1. The blood supply of the hand. (50)
13. Discuss the role of the median nerve in the function of the
hand.(100)
14. Compare the stability of the shoulder joint and the hip joint based
on the arrangement of the following structures.
14.1. Articular surfaces (30)
14.2. Capsule and ligaments (30)
14.3. Muscles (40) (AL2000 main)
15. Describe the origin, course and distribution of ulnar nerve. (100)
(AL2003 rep)
16.1. Describe how the cords of the brachial plexus are
formed.(branches of the brachial plexus are not
required)(10)
16.2. State the anatomical locations of the various parts
forming the brachial plexus.(10)
16.3. Describe the course & distribution of the muscular
branches of the radial nerve in the upper arm.(60)
16.4. Indicate the sensory loss seen in damage to the radial
nerve in the mid shaft region of the humerus and give the
reasons for this.(20)
17.
17.1. Define the anatomical extent of the female breast.(20)
17.2. Name the muscles which lie immediately posterior to the
female breast.(10)
17.3. Describe the lymphatic drainage of the breast.(50)
17.4. Name the nerves which could be damaged during removal of
axillary lymph nodes.(20)
18. Give a brief account on the axilla and its contents.(30)
19.
19.1. Explain the anatomical basis of Erbs palsy. (50)
19.2.
19.2.1. Explain the effects of median nerve compression atthe level of the elbow. (30)
19.2.2. List the clinical features you would expect in acute
injury to the radial nerve in the spiral groove. (20)
(AL2004 CAT 4)
20. An eight year old boy was admitted to Lady Ridgeway Hospital with
a fall on the outstretched hand and a plain radiograph confirmed
the presence of a left supracondylar fracture of the humerus. His
left radial pulse was absent.
20.1. Describe the nerves and vessels in the cubital fossa and
explain the absence of radial pulse in this patient.
20.2. Few months later the boy presented to the Orthopaedic clinic.
The fracture had healed but with a marked valgus deformity
at the elbow (Cubitus valgus). He also had developed wasting
of the interossei muscles of the same hand. The Surgeon
explained to the mother that this was due to stretching of a
nerve around the elbow due to the deformity and that it
needed corrective surgery.
20.2.1. Name the nerve affected. (10)
20.2.2. What other clinical features would you expect in this
patient as a result of this nerve palsy? (30)
(AL2007 CAT
21.
21.1. Describe the microscopic structure of the mammary gland at

different physiological stages. (40)

21.2. Discuss the different anatomical pathways in the spread of
breast cancer. (60) (AL2000 main)
22. Describe the anatomy of the shoulder joint. (100)
(AL2008 main)