Upper Limb Anatomy Answers

1) The Correct Answer is (A)

Scaphoid fractures are the most common of carpal bone fractures. They are frequently result from fall onto
an outstretched arm that cause direct axial compression or wrist hyperextension. A scaphoid fracture should
be suspected in any patient with persistent wrist pain and tenderness in the anatomical snuff box following a
fall. The snuffbox is a triangle deepening on the dorsoradial aspect of the hand at the level of the carpal
bones. The scaphoid and trapezium bones form the floor of the snuffbox.

The scaphoid is the largest bone of the proximal carpal row and is located on the radial aspect of the hand
just distal to the radius itself. The dorsal scaphoid branch of the radial artery supplies the majority of the
scaphoid after entering near the bones distal pole. Blood supply to the proximal pole proceeds in a retrograde
manner and can be easily interrupted by a fracture. Thus, scaphoid fractures are at risk for avascular necrosis
and nonunion.

(Choice B) Carpal tunnel syndrome is caused by median nerve compression as it travels through the carpel
tunnel. It is associated with repetitive wrist movements, hypothyroidism, diabetes mellitus, and rheumatoid
arthritis.

(Choice C) Acute compartment syndrome occurs when increased pressure within a fascial compartment
compromises blood circulation and tissue function within that space. It develops after significant trauma,
particularly long-bone fractures of the leg or forearm.

(Choice D) Dupuytrens contracture is a benign, slowly progressive fibroproliferative disease of the palmar
fascia. As the scarring progresses, nodules from the palmar fascia and the fingers gradually lose their
flexibility, eventually resulting in contractures that draw the fingers into flexion.

(Choice E) Osteomyelitis commonly results from either hematogenous seeding of bone with bacteria or by
contagious spread of organisms from a nearby wound. However, unexposed bone is unlikely to develop
osteomyelitis. Staphylococcus aureus is the most common cause of hematogenous osteomyelitis.

Educational Objective

Fall on outstretched hand may cause fracture of the scaphoid bone. Examination shows tenderness in the
anatomical snuff box. The scaphoid bone is vulnerable to avascular necrosis and ununion due to its tenuous
blood supply.

** Palmar Fascia = Dupuytrens contracture ** RECALL

2) The Correct Answer is (C)

This patient has symptoms suggestive of injury to the musclocutaneous nerve. The Musculocutaneous nerve
is derived from C5-C7 ventral rami. As its name implies, the musclocutaneous nerve provides both motor and
sensation. It innervates the major upper arm flexors including the biceps brachii, coracobrachialis, and
brachialis muscles. After innervating these muscles, the remaining fibers continues as the lateral cutaneous
nerve of the forearm, providing sensory innervations to the skin of the lateral arm.

(Choice A) The posterior arm is innervated by a branch of the radial nerve (posterior cutaneous nerve of the
arm)

(Choice B) The posterior arm is innervated by a branch of the radial nerve (posterior cutaneous nerve of the
arm)

(Choice D) The medial arm is innervated by a branch of the ulnar nerve (medial cutaneous nerve of the arm)

(Choice E) The thenar eminence is innervated by the recurrent branch of the median nerve

Educational Objective:

Musculocutaneous nerve innervates the flexor muscles of the upper arm and provides and provides sensory
innervations to the lateral forearm. The Musculocutaneous nerve is derived from the upper trunk of the
brachial plexus and can be injured by forceful injuries that cause separation of the neck and shoulder.
3) The Correct Answer is (D)

The rotator cuff is made of the tendons of the supraspinatous, infraspinatous, subscapularis, and teres minor
muscles. These tendons, along with the tendon of the long head of the biceps brachii muscle and the
ligaments of the glenohumeral joint, contribute to the stability of the joint. In rotator cuff syndrome, the most
commonly injured tendon is the supraspinatous because this tendon is prone to repeated impingement
trauma between the humeral head and the acromion. Rotator cuff syndrome is most commonly associated
with pain during abduction of the humerus.

(Choice A) Flexion of the humerus at the shoulder is not accomplished by any of the rotator cuff muscles. The
anterior segment of the deltoid is an important flexor of the humerus.

(Choice B) Extension of the humerus is not accomplished by the rotator cuff muscles

(Choice C) Adduction of the humerus is not accomplished by any of the rotator cuff muscles. The main s
adductor of the humerus is the latissumus dorsi muscle.

(Choice E) Medial rotation of the humerus is accomplished by the subscapularis muscle, which originates on
the subscapular fossa and inserts onto the lesser tubercle of the head of the humerus.

Educational objective:

The most commonly injured structure in the rotator cuff syndrome is the tendon of the supraspinatus muscle.
Because the supraspinatous is an abductor of the humerus, injury to the tendon causes pain on abduction of
the arm.
4) The Correct Answer is (B)

The ulnar nerve is a branch of the medial cord of the brachial plexus derived from the C8-T1 ventral rami. The
ulnar nerve provides sensory innervations to the fifth digit and the medial half of the fourth digit as well as to
the palmar and dorsal surfaces of the hand. The ulnar nerve also provides motor innervations to the flexor
carpi ulnaris and to the medial section of the flexor digitorum profundis in the forearm. In the hand, the ulnar
nerve innervates all of the palmar and dorsal interosseous muscles, the muscles of the hypothenar
eminence, the Palmaris brevis muscle, the third and fourth lumbrical muscles, and the adductor pollicis
muscles.

The ulnar nerve enters the forearm after passing behind the medial epicondyle of the humerus where it is
covered by a small amount of overlying soft tissue. This region, sometimes referred to as the funny bone, is a
common site of ulnar nerve injury. Ulnar nerve injury at this site classically causes a claw hand deformity. In
the wrist, the ulnar nerve passes between the hook of the hamate and the pisiform bone in a tunnel known
as Guyons canal. The ulnar nerve injury at the Guyons canal causes dysthesia of the ulnar side of the hand
and weakness of the intrinsic muscles of the hand.

(Choice A) In carpal tunnel syndrome, some factors reduces the size of the carpal tunnel causing median
nerve compression. Patients typically experience difficulty with fine motor control of the thumb.

(Choice C) Fracture of the surgical neck of the humerus may cause axillay nerve injury leading to paralysis of
the deltoid and teres minor muscles as well as loss of sensation of the lateral upper forearm.

(Choice D) The deep branch of the radial nerve can be affected by radial head sublaxation leading to
weakness or paralysis of many of the muscles of the extensor compartment of the forearm.

(Choice E) The coracobrachialis muscle is an arm flexor that lies deep to the biceps brachii and overlies the
median nerve and brachial artery. It is innervated by the musclocutaneous nerve.

Educational objective:

Ulnar nerve injury classically causes a claw hand deformity. The ulnar nerve can be injured either near the
medial epicondyle of the humerous or in the Guyons canal near the hook of the hamate and pisiform bone in
the wrist.
5) The Correct Answer is (K)

The superficial branch of the radial nerve passes along the front of the radial side of the forearm to the
commencement of its lower third. It is a sensory nerve. It lies at first slightly lateral to the radial artery,
concealed beneath the Brachioradialis.

In the middle third of the forearm, it lies behind the same muscle, close to the lateral side of the artery. It
quits the artery about 7 cm. above the wrist, passes beneath the tendon of the Brachioradialis, and,
piercing the deep fascia, divides into two branches: lateral and medial.
6) The Correct Answer is (C)

7) The Correct Answer is (D)

2nd question about humorous radial nerve injury. The nerve lesion leads to wrist drop.
7B) The Correct Answer is (C)

The man lift his son and something happened in his cervical spines compressive cervical radiculopathy is
recognized to be a common source of arm pain with or without sensory and motor dysfunction. A radiculopathy is a
pathologic process affecting the nerve root. Most radiculopathies arise from nerve root compression (figure 2). The two
predominant mechanisms of compressive cervical radiculopathy are cervical spondylosis and disc herniation.

Cervical radiculopathy is a common cause of both acute and chronic neck pain. Lower cervical roots, particularly C7, are
more frequently affected by compression than higher cervical roots MRI is currently the study of choice in most patients
for the initial neuroimaging evaluation of the cervical spine.

Clinical signs and symptoms in typical solitary cervical root lesions:

c7 :
-pain .. Neck, shoulder, middle finger, hand
-numbness .. Index and middle finger, palm
-weakness .. Elbow and wrist extension (radial), forearm pronation, wrist flexion
-reflex affected .. Triceps

8) The Correct Answer is (B)

Remember that an injury to the long thoracic nerve denervates serratus anterior, meaning that there
will be no muscle protracting the scapula and counteracting trapezius and the rhomboids, powerful retractors
of the scapula. The long thoracic nerve is derived from the nerve roots of C5-7; this nerve is particularly
vulnerable to iatrogenic injury during surgical procedures because it is located on the superficial side of
serratus anterior.

The axillary nerve innervates deltoid. It wraps around the surgical neck of the humerus and is
endangered by fractures of the surgical neck. If the axillary nerve was damaged and deltoid was denervated,
the patient would be unable to abduct his upper limb beyond 15 to 20 degrees.

The Musculocutaneous nerve innervates biceps brachi, coracobrachialis, and brachialis. If this nerve was
disrupted, the patient would be unable to flex her or his forearm, and have weakened arm flexion.

The radial nerve innervates extensors of the forearm and triceps brachi--if this nerve was injured, the
patient would no longer be able to extend forearm, but only have slightly weakened arm extension
(latissimus is the powerful extensor of the arm).

Finally, the suprascapular nerve innervates supraspinatus--the muscle that initiates abduction. Damage
to this nerve would prevent the patient from starting to abduct her or his arm.

9) The Correct Answer is (B)

Flexion at the elbow is produced by biceps brachii and brachialis, and both of these muscles are innervated by
the musculocutaneous nerve. So, you know that the musculocutaneous nerve was damaged. Beyond
innervating the muscles that flex the forearm, the musculocutaneous nerve gives off the lateral antebrachial
cutaneous nerve which provides sensory innervation to the anterolateral surface of the forearm. This means
that the other symptom that would be present is a loss of cutaneous sensation on the anterolateral surface
of the forearm. The biceps brachii and coracobrachialis muscles flex the arm, so you should have weakening of
flexion at the shoulder - you would still have pectoralis major, a powerful arm flexor.

10) The Correct Answer is (E)

Let's take the observations one by one to break down this question. If the diaphragm is functioning
normally, you know that the phrenic nerve is probably uninjured, which means that the C5 root has not been
damaged. Since the scapula is not winged, there was no damage to the long thoracic nerve or the C5-7 nerve
roots. Finally, since the patient cannot initiate abduction of the arm, you know that the suprascapular nerve
is injured and supraspinatus has been denervated. But, the patient can abduct the arm once it is lifted to 45
degrees, so the deltoid muscle and the axillary nerve must be intact.

Taking the answer choices one by one: The axillary nerve is ok, because deltoid is functioning. The
posterior cord of the brachial plexus must also be intact, since this cord gives off the axillary nerve. The roots
of the brachial plexus are ok, since the phrenic nerve and long thoracic nerve (which are derived from the
roots) are still functioning. The superior trunk of the brachial plexus must also be undamaged, since this trunk
contributes to the posterior cord which is intact. So, this means that the injury must be to the suprascapular
nerve.

11) The Correct Answer is (C)

Serratus anterior is innervated by the long thoracic nerve. Serratus anterior keeps the scapula held
forward, balancing trapezius and the rhomboids which retract the scapula. If the long thoracic nerve is injured
(which is common in surgery, since the long thoracic nerve is on the superficial side of serratus anterior), you
may see a "winged scapula" protruding posteriorly.

The anterior scalene muscle is innervated by C5-C7, and the middle scalene is innervated by C3-C8. Teres
major is innervated by the lower subscapular nerve from the posterior cord of the brachial plexus.
Subscapularis is innervated by the upper and lower subscapular nerves from the posterior cord of the brachial
plexus.

12) The Correct Answer is (B)

Injuries to the upper roots of the brachial plexus (C5 and C6) are the most common types of injuries--
resulting in a condition known as Erb-Duchenne Palsy. It affects especially the suprascapular, axillary, and
musculocutaneous nerves, which causes paralysis of the rotator cuff muscles, biceps, brachialis,
coracobrachialis, and deltoid. It also knocks out the upper and lower subscapular nerves, denervating
subscapularis and teres major. It knocks out most of the lateral pectoral nerve, but the majority of pect major
is innervated by medial pectoral nerve, so it is only weakened.

After this injury, the upper limb hangs limply, medially rotated by an unopposed latissimus and
pectoralis major muscles, and pronated due to a loss of biceps. So, the limb is constantly adducted and
medially rotated. However, the limb can no longer be abducted because both supraspinatus, which initiates
abduction, and deltoid, which allows for complete abduction, have been denervated.
 As far as extension and flexion go: Extension occurs through the actions of the triceps which is
innervated by the radial nerve. This nerve should still be intact. Flexion of the arm is not totally lost if biceps
brachii and coracobrachialis are denervated, because pectoralis major is not completely lost.

13) The Correct Answer is (C)

The C5 and C6 dermatomes cover the top of the shoulder and lateral side of the arm. The 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. Finally, the pectoral
region is covered by T1, T2, and T3 dermatomes. To visualize this, see Netter Plate 465.

14) The Correct Answer is (C)

The clinical scenario described suggests ulnar nerve syndrome: decreased sensations over the 4th and 5th
fingers and weak grip due to involvement of interosseous muscles of the hand are characteristic. The most
common site of ulnar nerve entrapment is the elbow where the ulnar nerve lies at the medial epicondylar
groove.

Prolonged, inadvertent compression of the nerve by leaning on the elbows while working at a desk or table is
the typical scenario (Choice C).

Ulnar nerve compression can occur at the wrist (Choice A), but is less common. The forearm (Choice B) is a
rare site for the ulnar nerve involvement; it occurs mostly in diabetic patients.

Educational Objective:

The most common site of ulnar nerve entrapment is the elbow where the ulnar nerve lies at the medial
epicondylar groove.

*Extremely high yield question for USMLE!!!

15) The Correct Answer is (B)

This patient's inability to externally rotate the shoulder after trauma indicates a rotator cuff injury. The
rotator cuff muscles stabilize the shoulder joint and include the supraspinatus, infraspinatus, teres minor, and
subscapularis.

The supraspinatus originates on the supraspinous fossa of the scapula, and the infraspinatus originates on
the infraspinous fossa. Both muscles attach to the greater tuberosity of the humerus and are innervated by
the suprascapular nerve. The infraspinatus is responsible for external rotation of the shoulder, and the
supraspinatus allows for shoulder abduction (Choice D).

The teres minor originates on the lateral scapula, inserts into the greater tuberosity of the humerus, and is
innervated by the axillary nerve. The muscle primarily controls shoulder adduction and also contributes to
external rotation.

The subscapularis originates from the subscapular fossa of the scapula, attaches to the lesser tuberosity, and
is innervated by the upper and lower subscapular nerves. The subscapularis primarily controls shoulder
adduction and internal rotation (Choice C).

(Choice A) The biceps brachii is a 2-headed muscle originating from the scapula and forming a single belly that
attaches on the upper forearm. The muscle mainly controls elbow flexion and forearm supination. Biceps
injury can cause anterior shoulder pain but does not cause inability to externally rotate the shoulder.

(Choices E and F) The teres major arises from the inferior scapula and inserts into the medial intertubercular
sulcus of the humerus. The muscle helps with humeral extension and internal rotation. The trapezius arises
from the occipital bone and spinous processes of the cervical and thoracic vertebrae and inserts on the
scapula and clavicle. The muscle helps move the scapula and support the arm. Injury to either of these
muscles would not affect external shoulder rotation.

Educational objective:

The rotator cuff muscles (supraspinatus, infraspinatus, teres minor, and subscapularis) stabilize the shoulder
joint and allow for shoulder movements. The supraspinatus controls shoulder abduction, infraspinatus
controls external rotation, teres minor helps with adduction and external rotation, and subscapularis helps
with adduction and internal rotation.
16) The Correct Answer is (A)

The axillary nerve originates from the posterior cord of the brachial plexus and carries fibers from C5 and C6.
It courses deep in the axilla below the shoulder joint, then runs through the quadrangular space (bounded
superiorly by the teres minor, laterally by the humerus, medially by the long head of the triceps, and inferiorly
by the teres major) and along the surgical neck of the posterior humerus. At this point, it gives rise to motor
branches that supply the deltoid and teres minor muscles, and a sensory branch that innervates the skin over
the lateral shoulder.

Axillary nerve injury most commonly occurs in the setting of shoulder trauma (e.g., anterior dislocation,
proximal humeral fracture). Patients often have sensory loss over the upper lateral arm and weakness on
shoulder abduction due to denervation (and possibly atrophy) of the deltoid muscle.

(Choice B) The dorsal scapular nerve provides motor innervation to the rhomboids (retract the scapula) and
levator scapulae muscles (elevate the scapula).

(Choice C) Long thoracic nerve injury classically occurs during axillary lymph node dissection and results in
paralysis of the serratus anterior muscle, leading to winging of the scapula.

(Choice D) Proximal injury to the median nerve (eg, due to supracondylar humerus fracture) may result in
palmar sensory loss over the first 3 digits and impairment of thumb flexion/opposition, flexion of the
second/third digits, and wrist flexion/abduction.

(Choice E) Injury to the musculocutaneous nerve can cause sensory loss over the lateral forearm and
weakened elbow flexion due to denervation of the biceps brachii and brachialis muscles.

(Choice F) Injury to the radial nerve at the axilla (eg, "crutch palsy") typically causes weakness of the forearm,
hand, and finger extensor muscles (eg, wrist drop, absent triceps reflex) with sensory loss over the posterior
arm, forearm, and dorsolateral hand.

(Choice G) The thoracodorsal nerve provides motor innervation to the latissimus dorsi muscle, which is
responsible for shoulder extension, adduction, and internal rotation.

(Choice H) Ulnar nerve injury most commonly occurs at the elbow, resulting in sensory loss over the medial
11/2 digits of the hand and weakness on wrist flexion/adduction, finger abduction/adduction, and flexion of
the fourth/fifth digits.

Educational objective:

Injury to the axillary nerve most commonly occurs in the setting of shoulder trauma (e.g., anterior dislocation,
humeral fracture) and presents with sensory loss over the lateral shoulder and weakness on shoulder
abduction (due to denervation of the deltoid muscle).
17) The Correct Answer is (A)

The radial nerve is derived from the C5-T1 spinal nerves and is one of the two final branches of the posterior
cord of the brachial plexus. The nerve initially courses medial to the surgical neck of the humerus inferior to
the teres major muscle within the axilla before entering the posterior arm to course between the long head of
the triceps brachii and the posterior humerus.

Proximal radial nerve injury can occur at the nerve's superficial location within the axilla by repetitive
pressure/trauma caused by an ill-fitting crutch ("crutch palsy") or if an individual sleeps with the arm over a
chair ("Saturday night palsy"). Injury to the nerve at this location may cause weakness or paralysis of the
forearm, hand, and finger extensor muscles (eg, wrist drop, absent triceps reflex). Sensory loss may also be
observed over the radial nerve distribution.

Injuries to the proximal radial nerve as it crosses the posterior humerus (eg, midshaft humeral fractures) spare
the triceps brachii, as the fibers innervating this muscle leave the nerve before it enters the radial groove.
(Choice A) The spinal accessory nerve (CN XI) exits the skull through the jugular foramen and courses over the
levator scapulae muscle to innervate the sternocleidomastoid and trapezius muscles.

(Choice B) Fracture of the surgical neck of the humerus and anterior dislocation of the glenohumeral joint can
cause injury to the axillary nerve. The resultant paralysis of the deltoid and teres minor muscles causes
weakness on arm abduction. Sensory loss over the deltoid may also be evident.

(Choice C) Damage to the long thoracic nerve causes paralysis of the serratus anterior muscle and winging of
the scapula. This nerve is often injured during lymph node dissection in patients undergoing radical
mastectomy.

(Choice D) Proximal median nerve injury often occurs with supracondylar humerus fractures. This results in
sensory loss over the palmar aspect of the first 3 digits and impairment of thumb flexion/opposition. flexion of
the second/third digits. and wrist flexion/abduction.

(Choice F) The suprascapular nerve innervates the supraspinatus and infraspinatus muscles. These muscles
function to abduct and laterally rotate the arm. respectively.

Educational objective:

Radial nerve injury can occur with repetitive pressure/trauma at the axilla (eg, improperly fitted crutches).
Findings include weakness of the forearm. hand, and fingers extensors (eg, wrist drop. absent triceps reflex)
and sensory loss over the posterior arm and forearm. dorsolateral hand. and dorsal thumb. More distal lesions
_spare the triceps brachii.
18) The Correct Answer is (A)

The radial nerve enters the forearm anterior to the lateral epicondyle (near the humeroradial articulation)
and divides into superficial and deep branches. The superficial branch provides purely somatic sensory
innervation to the radial half of the dorsal hand, and the deep branch innervates the extensor compartment
muscles in the forearm. After passing through the supinator canal (e.g., between the superficial and deep
parts of the supinator muscle), the deep branch continues to the wrist to become the posterior interosseous
nerve, which innervates muscles involved in finger and thumb extension.

Injury to the radial nerve during its passage through the supinator canal may occur due to repetitive
pronation/supination of the forearm (eg, frequent screwdriver use), direct trauma. or dislocation of the
radius. Patients typically have weakness on finger and thumb extension ("finger drop"). The triceps brachii
(involved in elbow extension) and extensor carpi radialis longus (wrist extension) are typically not affected as
the radial nerve branches supplying these muscles come off proximal to the supinator canal. Cutaneous
sensory branches are similarly preserved.

(Choices A and E) Injury to the radial nerve at the axilla (eg, "crutch palsy") typically causes weakness of the
forearm, hand, and finger extensor muscles (eg, wrist drop, absent triceps reflex) with sensory loss over the
posterior arm, forearm, and dorsolateral hand. Injury to the nerve at the midshaft humerus (eg, radial groove)
usually causes weakness of the hand/finger extensor muscles with sparing of the triceps brachii and sensory
loss over the posterior forearm/dorsolateral hand. (Choice B) Carpal tunnel syndrome can result from any
condition that reduces the size of the carpal tunnel and compresses the median nerve (eg, pregnancy,
hypothyroidism). Patients typically have pain/paresthesias affecting the first 314 digits. Thenar atrophy with
weakness on thumb abduction/opposition may also be seen.

(Choice C) The coracobrachialis muscle lies deep to the biceps brachii and is perforated and innervated by the
musculocutaneous nerve. Nerve injury may result in decreased strength on forearm flexion and sensory loss
over the lateral forearm.

(Choice D) In the wrist, the ulnar nerve passes between the hook of the hamate and the pisiform bone in a
fibroosseous tunnel known as Guyon's canal. Ulnar nerve injury at this site can cause weakness on finger
abduction/adduction and clawing of the 4 and 5, digits.

(Choice G) Fracture of the surgical neck of the humerus is usually associated with axillary nerve injury. Patients
may have weakness of the deltoid and teres minor muscles as well as loss of sensation in the lateral upper
arm. Educational objective: Injury to the radial nerve during its passage through the supinator canal may occur
due to repetitive pronation/supination of the forearm, direct trauma, or subluxation of the radius. Patients
typically have weakness during finger and thumb extension ("finger drop") without wrist drop or sensory
deficits.
19) The Correct Answer is (C)

This patient is exhibiting signs of radial nerve injury (e.g., wrist drop). The radial nerve is a terminal branch of
the brachial plexus that carries fibers originating in the C5-T1 nerve roots. It innervates most of the forearm
extensors at the elbow (e.g., triceps) and most of the hand extensors at the wrist. It also innervates the
extrinsic extensors of the digits and the brachioradialis and Supinator muscles.

The radial nerve also provides cutaneous sensory innervation to the dorsal hand, forearm, and upper arm.
Radial nerve deficits in the setting of a Midshaft humeral fracture should raise concern for an associated
injury to the deep brachial artery. The deep brachial (also termed profunda brachii) artery branches off the
brachial artery high in the arm, passes inferior to the teres major muscle, and courses posteriorly along the
humerus in close association with the radial nerve.

(Choice A) The axillary artery gives off the posterior circumflex humeral artery and becomes the brachial
artery. The brachial artery courses anteromedially in the arm and branches into the radial and ulnar arteries in
the forearm. Supracondylar fractures of the humerus may injure this artery. (Choice B) The common
interosseous artery is a short branch of the ulnar artery that gives rise to anterior, posterior, and recurrent
branches within the proximal forearm.

(Choice B) The common interosseous artery is a short branch of the ulnar artery that gives rise to anterior,
posterior, and recurrent branches within the proximal forearm.

(Choice D) The anterior and posterior circumflex humeral arteries are branches of the axillary artery that form
an anastomosis encircling the surgical neck of the humerus. The axillary nerve travels in close association with
the posterior circumflex artery. and a fracture to the surgical neck of the humerus may damage this artery and
nerve.

(Choice E) The deep brachial artery divides into the radial and middle collateral arteries. The radial collateral
artery also courses with the radial nerve, but injury to this artery from a midshaft fracture is less likely as it
originates at the lower end of the spiral groove.

Educational objective:

The deep brachial (profunda brachii) artery and radial nerve run together along the posterior aspect of the
humerus. Midshaft fractures of the humerus risk injury to these structures.
20) The Correct Answer is (B)

The glenohumeral joint is the most commonly dislocated joint in the body due to the shallow articulation
between the humeral head and the glenoid fossa of the scapula. The shoulder may dislocate anteriorly,
inferiorly, or posteriorly, but anterior dislocations are by far the most common. Anterior dislocations of the
humerus classically follow a blow to an externally rotated and abducted arm (eg, throwing a football). When
the head of the humerus is displaced anteriorly, there is flattening of the deltoid prominence, protrusion of
the acromion, and anterior axillary fullness (due to the humeral head's movement into this location). The
axillary nerve is the nerve most commonly injured by anterior shoulder dislocations. It innervates the deltoid
and teres minor muscles and provides sensory innervation to the skin overlying the lateral shoulder. (Choice A)
Acromioclavicular joint subluxation typically results from a downward blow on the tip of the shoulder and
produces swelling and upward displacement of the clavicle. It is not usually associated with specific nerve
injuries/deficits.

(Choice C) Clavicular fractures usually occur following direct trauma to the clavicle. Most fractures are in the
middle third of the clavicle and produce local swelling and tenderness. Associated neurovascular damage is
rare.

(Choice D) Fracture of the coracoid process of the scapula is rare. Individuals who engage in shotgun- or rifle-
related activities are most commonly affected.

(Choice E) Rotator cuff tears may occur during shoulder dislocation but do not cause nerve injury. The rotator
cuff is made up of the subscapularis, supraspinatus, infraspinatus, and teres minor muscles/tendons.

(Choice F) A spiral fracture of the midshaft humerus may result from torsion produced during a fall on an
outstretched hand. Patients present with swelling, bone crepitus, and ecchymoses of the arm. The radial nerve
is commonly injured.

Educational objective:

Flattening of the deltoid muscle with acromial prominence after a shoulder injury suggests an anterior
humerus dislocation. This injury most commonly results from a blow to an externally rotated and abducted
arm. There is often associated axillary nerve injury, resulting in deltoid paralysis and loss of sensation over the
lateral shoulder.