Q1

Q1 Hand Arterial Supply

Please describe the arterial supply of the hand.

PROMPT –  What happens to these arteries in the palm? How are they arranged? How do they terminate?

  • The Ulnar and Radial arteries supply all of the blood supply to the hand.
  • Radial Artery – Deep Palmar Arch. Lies deep to long flexor tendons and sits across the metacarpals just distal to their bases.
    • Branches: (of Deep Palmar Arch)
      • 3 x Palmar metacarpal arteries
      • Princeps pollicis artery
      • Radialis indicis artery
  • Ulnar Artery – Two terminal branches
    • Deep Palmar Branch anastomoses with the Radial Artery via the Deep Palmar Arch.
    • Superficial Palmar Arch is main terminal branch
      • 3 common Palmar Digital Arteries arise.
      • Each divides into a pair of Proper Palmar digital arteries that run along adjacent sides of 2-4th digits.

Pass Criteria:

  • Bold + 1 branch of each arch to pass

Can you identify the Ulnar artery on the picture?

 

  • Ulnar Artery (54)

Pass Criteria:

  • Bold to pass

Describe the sensory innervation to the index and middle fingers.

  • Median nerve (16) & Radial to dorsum to DIP

Pass Criteria:

  • Bold to pass
  • Thumb, Index, Middle and half of the ring finger (palmar aspect). Dorsal tips (nail beds) of the thumb, 2nd and 3rd fingers.

Can you identify on the picture muscles in the hand and forearm that are innervated by the median nerve?

Q1 Hand (Lumbricals)

  • 1st and 2nd Lumbricals (71)
  • Muscles of the Thenar eminence:
    • Opponens pollicis
    • Abductor pollicis brevis (67)
    • Flexor pollicis brevis (68).
  • Forearm:
    • Flexor carpi radialis
    • Palmaris longus
    • Flexor digitorum superficialis (60)
    • Radial half Flexor digitorum profundus (2nd and 3rd digits) (55)
    • Flexor pollicis longus (69)
    • Pronator quadratus

Pass Criteria:

  • 4 of 8 bold to pass
  • FPL and PQ supplied by the Anterior Interosseous nerve (a branch of the Median)

Q2

Hand Text Hand

Identify the bones in this hand and wrist.

  • Proximal row:
    • Pisiform
    • Triquetrum
    • Lunate
    • Scaphoid
  • Distal row:
    • Hamate
    • Capitate
    • Trapezoid
    • Trapezium
  • Metacarpals, and phalanges, proximal/middle distal

Pass Criteria:

  • All carpal bones to pass

Identify the boundaries of the carpal tunnel on this model.

  • Tubercle scaphoid and trapezoid laterally, and pisiform and hook hamate medially

Pass criteria:

  • 4/4 bony landmarks to pass

This patient develops median nerve paresis as a consequence of her fracture. What deficits will she develop?

PROMPT – What does the median nerve supply in the hand?

  • Sensory supply
    • Radial 3 1/2 digits and adjacent palm
    • Excluding central palm which is by cutaneous palmar branch passing over flexor retinaculum
  • Motor supply
    • Thenar muscles except adductor pollicis and deep head flexor pollicis brevis
    • Lateral lumbricals for digits 2 and 3

Pass Criteria:

  • Correctly identify sensory supply and one group of muscles

Q3

X-ray Wrist TextX-ray Wrist R

Identify the carpal bones.

  • Identify all carpal bones in AP view

Pass Criteria:

  • All bones required

Identify the attachments of the flexor retinaculum.

  • Scaphoid tubercle
  • Hook of hamate
  • Trapezium
  • Pisiform

Pass criteria:

  • 2 of 4

What structures pass through the carpal tunnel?

  • FCR/FPL/FDS/FDP tendons + Synovial sheaths
  • Median nerve

Pass Criteria:

  • Bold to pass

Which muscles flex the wrist?

  • Flexor Carpi Radialis
  • Flexor Carpi Ulnaris
  • Flexor Pollicis Longus
  • Flexor Digiti Minimi
  • Flexor Digitorum Superficialis
  • Flexor Digitorum Longus
  • Palmaris Longus

Pass Criteria:

  • 5/7


Q4

Q1 Hand (Lumbricals)

Identify the structures seen in this image.

  • Median nerve  + branches
  • Ulnar nerve  + branches
  • Ulnar artery
  • Thenar muscless – APB (67), FPB (68)
  • Adductor pollicis (67), Lumbricals (71)
  • FCR, FCU, BR, FDS (60), FDP (55)

Pass Criteria:

  • Bold and 6/10 structures

Describe the median nerve supply in the hand.

  • Motor
    • LOAF
      • 1st & 2nd Lumbricals
      • OP
      • APB
      • FPB (superficial head)
  • Sensory
    • Palmar surface of lateral 3 1/2 digits
    • Dorsum of distal halves of these digits

Pass criteria:

  • Both motor (LOAF, 2/4 muscles) and sensory

How would you clinically test the median nerve function in the hand?

  • Motor
    • Thumb opposition (OP)
    • Thumb abduction (APB)
    • Thumb flexion not reliable as deep head of FPB supplied by ulnar nerve
  • Sensory
    • Sensation over volar aspect of lateral 3 1/2 digits
    • Sensory over thenar eminence preserved as supplied by palmar cutaneous branch of median nerve

Pass Criteria:

  • Both motor and sensory

 

Q5

Identify the bones of the carpus.

•    Scaphoid
•    Lunate
•    Trapezium
•    Trapezoid
•    Capitate
•    Hamate
•    Triquetrum
•    Pisiform

Pass Criteria:

•    7 out of 8 to pass

Describe the attachments of the flexor retinaculum (Transverse palmar ligament).
Prompt: What forms the carpal tunnel?

•    Hook of hamate + pisiform medially (ulnar)
•    Trapezium (tubercle) + scaphoid (tubercle) laterally

Pass Criteria:

•    2 to pass

What nerves pass superficial to the carpal tunnel?

•    Ulnar nerve
•    Palmar cutaneous branch of median nerve

Pass Criteria:

•    1 to pass


Q6

Media: Carpal bones model

Name and identify the carpal bones on this model.

  • Scaphoid
  • Lunate
  • Triquetrum
  • Pisiform
  • Hamate
  • Capitate
  • Trapezoid
  • Trapezium

Pass Criteria:

•    6 to pass

What movements occur at the wrist joint (demonstrate them) and which muscles produce them?

  • Flexion
    • Flexor carpi radialis
    • Flexor carpi ulnaris
    • Flexors of the fingers and thumb
    • Palmaris longus
    • Abductor pollicus longus
  • Extension
    • Extensor carpi radialis longus, or
    • Extensor carpi radialis brevis
    • Extensor carpi ulnaris
    • Extensors of the fingers and thumb
  • Abduction
    • Flexor carpi radialis
    • Extensor carpi radialis longus, or
    • Extensor carpi radialis brevis
    • Abductor pollicus longus
  • Adduction
    • Extensor carpi ulnaris
    • Flexor carpi ulnaris
  • (Circumduction)

Pass Criteria:

•    Bold to pass


Q7

Media: Brachial plexus image.

A 60 year old alcoholic man is brought into the Emergency Department after being found slumped in a chair. He is noted to have wrist drop.

Identify, on the image, the nerve most likely to be injured.

Radial nerve (21)

Pass Criteria:

•    Bold to pass

Please identify some of the other numbered nerves in the plexus.
Prompt: Please show us the median and ulnar nerves.

  • Axillary nerve (1)
  • Lateral cord (6)
  • Lateral root of the median nerve (8)
  • Medial cord (12)
  • Medial cutaneous nerve of the arm (13)
  • Medial cutaneous nerve of the forearm (14)
  • Medial root of the median nerve (16)
  • Median nerve (17)
  • Posterior cord (20)
  • Ulnar nerve (26)

Pass Criteria:

•    Requires median and ulnar nerves, and an additional 2 correctly identified structures, to pass.

Apart from wrist extensor weakness, what other functions may be lost with a radial nerve lesion in the axilla?
Prompt: What nerve innervates the extensor compartment of the forearm?

Finger extension and sensory loss over the radial side of the dorsum of the hand.

Pass Criteria:

•    Need at least one of the losses of function to pass.

 


Shoulder & Arm  Elbow & Forearm