Mid-Block Anatomy Review:

Upper Extremity Clinical Correlates and Radiology

October 29, 2010

During a fight a man is stabbed in the lateral chest beneath the right arm.
The wound does not enter the chest cavity. Physical examination reveals
that the vertebral (medial) border of the patient's scapula projects posteriorly and
is closer to the midline on the injured side. On return visit the patient complains
that he cannot reach as far forward (such as to reach for a door knob) as he could
before the injury. The nerve injured which caused these symptoms is the:

1. axillary
2. long thoracic
3. musculocutaneous
4. radial
5. suprascapular
During a fight a man is stabbed in the lateral chest beneath the right arm.
The wound does not enter the chest cavity. Physical examination reveals
that the vertebral (medial) border of the patient's scapula projects posteriorly and
is closer to the midline on the injured side. On return visit the patient complains
that he cannot reach as far forward (such as to reach for a door knob) as he could
before the injury. The nerve injured which caused these symptoms is the:

1. axillary
2. long thoracic
3. musculocutaneous
4. radial
5. suprascapular
Long thoracic nerve  serratus anterior, loss of
protraction of the scapula which counteracts
trapezius and the rhomboids, powerful
retractors of the scapula
– Derived from the nerve roots of C5-7
– Vulnerable to iatrogenic injury during surgical
procedures due to location on superficial side of
serratus anterior
• Test clues: woman post surgery for breast cancer
MOVEMENTS OF PECTORAL (SHOULDER) GIRDLE ON TRUNK

Action Muscles involved Innervation Major Segments

of innervation
Elevation Levator scapulae Dorsal scapular C4,5
Trapezius, upper part Accessory C1- C5
Rhomboid major and minor Dorsal scapular C5

Depression Pectoralis minor Medial pectoral C7,8

Trapezius, lower part Accessory C1- C5
Latissimus dorsi Thoracodorsal C6,7,8
Pectoralis major, sternocostal part Medial pectoral C6-T1

Protraction Serratus anterior Long thoracic C5,6,7

Pectoralis minor Medial pectoral C7,8

Retraction Rhomboid major and minor Dorsal scapular C5

Trapezius, middle fibers Accessory C1- C5

Lateral rotation Serratus anterior, lower half Long thoracic C5,6,7

of scapula (in abduction) Trapezius, upper and lower parts Accessory C1- C5

Medial rotation Rhomboid major and minor Dorsal scapular C5

of scapula (in adduction) Levator scapulae Dorsal scapular C4,5
Pectoralis minor Medial pectoral C7, 8
 Scapular movements

Lateral rotation
Elevation Protraction
(during abduction)
Depression Retraction
Medial rotation
(during adduction)
A man suffers a penetrating wound through the anterior axillary fold, with
resulting damage to one of the main terminal branches of the brachial plexus.
Among the effects is a significant weakening of flexion of the elbow. One or more
other effects to be expected is (are):

1. Loss of cutaneous sensation on the tips of several fingers

2. Only loss of cutaneous sensation on the anterolateral surface of the forearm
3. Only weakening of flexion at the shoulder
4. Weakening of flexion at the shoulder and loss of cutaneous sensation on the

anterolateral surface of the arm

5. Weakening of flexion at the shoulder and loss of cutaneous sensation on the
anterolateral surface of the forearm
A man suffers a penetrating wound through the anterior axillary fold, with
resulting damage to one of the main terminal branches of the brachial plexus.
Among the effects is a significant weakening of flexion of the elbow. One or more
other effects to be expected is (are):

1. Loss of cutaneous sensation on the tips of several fingers

2. Only loss of cutaneous sensation on the anterolateral surface of the forearm
3. Only weakening of flexion at the shoulder
4. Weakening of flexion at the shoulder and loss of cutaneous sensation on the

anterolateral surface of the arm

5. Weakening of flexion at the shoulder and loss of cutaneous sensation on the
anterolateral surface of the forearm
Flexion at the elbow: biceps brachii and brachialis 
musculocutaneous nerve

Functions of the musculocutaneous nerve:

Motor: arm and forearm flexors
(Coracobrachialis, Biceps brachii, brachialis.
Sensory: lateral antebrachial cutaneous nerve 
innervation to the anterolateral surface of the forearm

Lesion: loss of cutaneous sensation on the

anterolateral surface of the forearm, severe weakness
in flexion of forearm, weakening of flexion at the
shoulder - pectoralis major intact, a powerful arm
flexor.
 C5, C6 anterior arm muscles:
Biceps brachii, Brachialis,
Coracobrachialis
MC pierces
coracobrachialis
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:
1. axillary nerve
2. posterior cord
3. roots of plexus
4. superior trunk
5. suprascapular nerve
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:
1. axillary nerve
2. posterior cord
3. roots of plexus
4. superior trunk
5. suprascapular nerve
-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.

-Since the patient cannot initiate abduction of the arm, you know that the suprascapular
nerve is injured and supraspinatus has been denervated.
-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.
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?

1. adduction
2. abduction
3. flexion
4. extension
5. medial rotation
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?

1. adduction
2. abduction
3. flexion
4. extension
5. medial rotation
Erb-Duchenne Palsy: Injuries to the upper roots of the brachial plexus (C5 and C6) (MOST
COMMON BP INJURY!!)

Damage to:
Suprascapular-rotator cuff (which ones?!?)
Axillary-deltoid, teres minor
Musculocutaneous-biceps, brachialis, coracobrachialis
Upper and lower subscapular nerves-subscapularis, teres major
Lateral pectoral nerve-weakness in pec major

Paralysis: rotator cuff muscles,, and deltoid, subscapularis and teres major, weakness in pec
minor
Limb will be:
-medially rotated by an unopposed latissimus and pectoralis major muscles
-pronated due to a loss of biceps
- adducted due to loss of supraspinatus and deltoid

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.
Patient has Erb’s paralysis with
A “waiter’s tip” hand position:
Shoulder/ anterior arm
muscles mainly affected
Following the above injury there would most likely be diminished cutaneous
sensation over what part of the upper limb?

1. the back of the shoulder

2. the pectoral region
3. the top of the shoulder and the lateral side of the arm
4. the medial side of the arm and forearm
5. the tip of the little finger
Following the above injury there would most likely be diminished cutaneous
sensation over what part of the upper limb?

1. the back of the shoulder

2. the pectoral region
3. the top of the shoulder and the lateral side of the arm
4. the medial side of the arm and forearm
5. the tip of the little finger
-C5 and C6 dermatomes: top of the
shoulder and lateral side of the arm

-T1 and C8 dermatomes cover the medial

side of the arm, with C8 extending to the
tip of the little finger.

-The back of the shoulder is covered by

numerous dermatomes, including C6, C7,
C8, and T1

-Pectoral region is covered by T1, T2,

and T3 dermatomes.
During an industrial accident, a sheet metal worker lacerates the anterior
surface of his wrist at the junction of his wrist and hand. Examination reveals
no loss of hand function, but the skin on the thumb side of his palm is numb.
Branches of which nerve must have been severed?

1. Lateral antebrachial cutaneous

2. Medial antebrachial cutaneous
3. Median
4. Radial
5. Ulnar
During an industrial accident, a sheet metal worker lacerates the anterior
surface of his wrist at the junction of his wrist and hand. Examination reveals
no loss of hand function, but the skin on the thumb side of his palm is numb.
Branches of which nerve must have been severed?

1. Lateral antebrachial cutaneous

2. Medial antebrachial cutaneous
3. Median
4. Radial
5. Ulnar
Median nerve: enters the hand by
crossing over the anterior side of the
wrist.
-Sensory: skin of the radial 3.5
fingers of the palm.

Lateral and medial antebrachial

cutaneous nerves:
-Sensory innervation to the
anterior side of the forearm

Radial nerve:
-Sensory: radial side of the
dorsum of the hand not the palmar
side of the hand

Ulnar nerve:
-Sensory: medial (ulnar) side of
both the dorsum and palm of the
hand
The nerve which passes through the quadrangular space of the posterior
shoulder innervates which muscle?

1. Deltoid
2. Infraspinatus
3. Subscapularis
4. Supraspinatus
5. Teres major
The nerve which passes through the quadrangular space of the posterior
shoulder innervates which muscle?

1. Deltoid
2. Infraspinatus
3. Subscapularis
4. Supraspinatus
5. Teres major
The quadrangular space:
medial: tendon of the long head of the
triceps
lateral: humerus
superior: teres minor
inferior: teres major

The posterior circumflex humeral artery and

the axillary nerve traverse this space.
The axillary nerve innervates 2 muscles:
deltoid and teres minor.

Infraspinatus and supraspinatus are both

innervated by the suprascapular nerve, off the
superior trunk of the brachial plexus.
Subscapularis is innervated by the upper and
lower subscapular nerves, off the posterior
cord of the brachial plexus. Teres major is also
innervated by the lower subscapular nerve.
Which of the following is not a direct branch of the axillary artery?

1. anterior circumflex humeral

2. posterior circumflex humeral
3. thoracoacromial
4. thoracodorsal
5. subscapular
Which of the following is not a direct branch of the axillary artery?

1. anterior circumflex humeral

2. posterior circumflex humeral
3. thoracoacromial
4. thoracodorsal
5. subscapular
The thoracodorsal and circumflex scapular
arteries are branches of the subscapular artery,
which comes directly off the third segment of
the axillary artery. The anterior and posterior
circumflex humeral arteries are also direct
branches of the third segment of the axillary
artery. The thoracoacromial artery is a branch
of the second part of the axillary artery.
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?

1. axillary
2. median
3. musculocutaneous
4. radial
5. ulnar
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?

1. axillary
2. median
3. musculocutaneous
4. radial
5. ulnar
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.
A 19-year-old woman was thrown while riding a bicycle. She attempted to break her
fall with an out-stretched hand and suffered a fracture. In the emergency room, an
examination reveals an inability (Q extend [he hand at the wrist.

What might have been the site of a fracture that caused the muscle weakness?

A. Clavicle
B. Hook of the hamate
C. Styloid process of the radius
D. Midshaft of the humerus
E. Scaphoid
A 19-year-old woman was thrown while riding a bicycle. She attempted to break her
fall with an out-stretched hand and suffered a fracture. In the emergency room, an
examination reveals an inability (Q extend [he hand at the wrist.

What might have been the site of a fracture that caused the muscle weakness?

A. Clavicle
B. Hook of the hamate
C. Styloid process of the radius
D. Midshaft of the humerus
E. Scaphoid

The radial nerve is commonly lesioned as a result of a spiral fracture of the midshaft of
the humerus.
Your patient suffers from compression of a nerve. The patient has weakness of pronation
and flex ion at the index and middle fingers at the distal interphalangeal joints and an
inability to form the letter 0 by touching the tip of the thumb to the tip of the index finger.
There are no sensory deficits.

What nerve may has been compressed?

A Recurrent branch of the median nerve

B. Deep branch of the radial nerve
C. Deep branch of the ulnar nerve
D. Anterior interosseous branch of the median nerve
E. Superficial branch of the radial nerve
Your patient suffers from compression of a nerve. The patient has weakness of pronation
and flex ion at the index and middle fingers at the distal interphalangeal joints and an
inability to form the letter 0 by touching the tip of the thumb to the tip of the index finger.
There are no sensory deficits.

What nerve may has been compressed?

A Recurrent branch of the median nerve

B. Deep branch of the radial nerve
C. Deep branch of the ulnar nerve
D. Anterior interosseous branch of the median nerve
E. Superficial branch of the radial nerve

A lesion of the anterior interosseous branch of the median nerve would account for
these symptoms.
A man who works as a cartoonist for a living begins to develop pain and paresthesias
in his right hand at night. The altered sensation is most evident on the palmar
aspects of the index and middle fingers.

What else might you expect to see in the patient?

A. Atrophy of the thenar eminence

B. Weakness in the ability to extend the thumb
C. Radial deviation of the hand at me wrist during wrist flexion
D. Altered sensation in skin over the anatomic snuffbox
E. Inability to spread and oppose the fingers
A man who works as a cartoonist for a living begins to develop pain and paresthesias
in his right hand at night. The altered sensation is most evident on the palmar
aspects of the index and middle fingers.

What else might you expect to see in the patient?

A. Atrophy of the thenar eminence

B. Weakness in the ability to extend the thumb
C. Radial deviation of the hand at me wrist during wrist flexion
D. Altered sensation in skin over the anatomic snuffbox
E. Inability to spread and oppose the fingers

The patient has carpal tunnel syndrome. Choices B and D result from radial nerve
lesions. Choice E results from an ulnar nerve lesion. Choice C results from a median
nerve lesion at the wrist.
What deficit would you expect in this patient?

A) Partial loss of sensation on the palm of the hand

B) Inability to extend wrist
C) Inability to flex wrist
D) Inability to flex the elbow
E) Inability to abduct shoulder past 30 degrees
What deficit would you expect in this patient?

A) Partial loss of sensation on the palm of the hand

B) Inability to extend wrist
C) Inability to flex wrist
D) Inability to flex the elbow
E) Inability to abduct shoulder past 30 degrees
What deficit would you expect in this
patient?

A) Partial loss of sensation on the palm of

the hand
B) Inability to extend wrist
C) Inability to flex wrist
D) Inability to flex the elbow
E) Inability to abduct shoulder past 30
degrees
What deficit would you expect in this
patient?

A) Partial loss of sensation on the palm of

the hand
B) Inability to extend wrist
C) Inability to flex wrist
D) Inability to flex the elbow
E) Inability to abduct shoulder past 30
degrees
What structure is MOST at risk of being damaged?

A) Median Nerve
B) Radial Nerve
C) Ulnar Nerve
D) Deep Brachial Artery
What structure is MOST at risk of being damaged?

A) Median Nerve
B) Radial Nerve
C) Ulnar Nerve
D) Deep Brachial Artery
What Structure Lies Medial to the arrow?

A) Femoral Nerve
B) Femoral Artery
C) Femoral Vein
D) Empty Space
E) Lymphatics
What Structure Lies Medial to the arrow?

A) Femoral Nerve
B) Femoral Artery
C) Femoral Vein
D) Empty Space
E) Lymphatics
What is the Arrow pointing to?

A) Piriformis
B) Superior Gemellus
C) Inferior Gemellus
D) Obturator Internus
E) Quadratus Femoris
What is the Arrow pointing to?

A) Piriformis
B) Superior Gemellus
C) Inferior Gemellus
D) Obturator Internus
E) Quadratus Femoris
What is tagged?

A) Superior Gluteal Artery

B) Superior Gluteal Nerve
C) Inferior Gluteal Artery
D) Inferior Gluteal Nerve
E) Inferior Gluteal Vein
What is tagged?

A) Superior Gluteal Artery

B) Superior Gluteal Nerve
C) Inferior Gluteal Artery
D) Inferior Gluteal Nerve
E) Inferior Gluteal Vein
What innervates the tagged structure?

A) Dorsal Rami
B) Dorsal Scapular Nerve
C) Thoracodorsal Nerve
D) Suprascapular Nerve
E) Axillary Nerve
What innervates the tagged structure?

A) Dorsal Rami
B) Dorsal Scapular Nerve
C) Thoracodorsal Nerve
D) Suprascapular Nerve
E) Axillary Nerve
What nerve was lesioned in this patient?

A) Lower Subrascapular nerve

B) Infrascapular nerve
C) Axillary Nerve
D) Long Thoracic Nerve
E) Upper Subscapular Nerve
What nerve was lesioned in this patient?

A) Lower Subrascapular nerve

B) Infrascapular nerve
C) Axillary Nerve
D) Long Thoracic Nerve
E) Upper Subscapular Nerve
What nerve is most
likely to be
compromised by this
injury?

A. Median N.
B. Ulnar N.
C. Radial N.
D. Axillary. N.
• Do we see the fracture?
• What bone are we looking
at?
• Where in the bone is the
fracture? (does that ring a
bell?)
• Where are the nerves in the
arm?
What nerve is most
likely to be
compromised by this
injury? Mid-shaft
humeral
fracture=radial nerve
injury

A. Median N.
B. Ulnar N.
C. Radial N.
D. Axillary. N.
What nerve is most
likely affected by
this injury?
A. Median N.
B. Ulnar N.
C. Radial N.
D. Axillary N.
• Where is the
problem? (trace the
bones)
• What bones are no
longer aligned?
• What nerves are
located in that area?
What sensory deficit will
this person experience?
A. Cutaneous numbness in
the upper back
B. Numbness over the left
chest
C. Numbness over the
anterior seratus muscle
D. Numbness over the
lateral aspect of the
shoulder
• Medial epicondyle—ulnar nerve
• Lumbar disc injury
• Hip fx—AVN
• Scaphoid fx—AVN
• Other ideas!?