CLINICAL QUESTION OF UPPER LIMB

Q1. A 50-year-old man fell off his bicycle. He heard a cracking noise and felt severe pain
in his right shoulder region. He noted that the lateral part of the shoulder drooped and
medial end of clavicle was elevated.
• Which is the common site of fracture of clavicle and why?
• Why did his shoulder droop down?
Q2. A 45-year-old woman complained of a firm painless mass in the upper lateral
quadrant of her left breast. The nipple was also raised. Axillary lymph nodes were
palpable and firm. It was diagnosed as cancer breast.
• Where does the lymph from upper lateral quadrant drain?
• What causes the retraction of the nipple?
Q3. A patient came with inability to: (i) abduct right shoulder, (ii) flex elbow joint,
and (iii) supinate the forearm
• What is the site of injury of the nerves?
• What is the point called?
• What are the nerves affected?

Q4. A poor young adult felt multiple nodules in the region of his neck above the clavicle.
A lymph node biopsy was advised from right side of his neck. A few days after the
biopsy he was unable to shrug his right shoulder
• Why was the biopsy advised?
• Why is he not able to shrug his shoulder?

Q5. A patient came with injury on left shoulder region after an accident. He was not able
to abduct his shoulder joint.
• Which nerve is injured?
• Where is the sensory loss?

Q6. A patient came dehydrated with history of diarrhea and vomiting. He needed
intravenous fluids.
• Which vein is most convenient for intravenous infusion of glucose and why?
• How does one make the vein prominent?

Q7. A female patient of 60 years felt two nodular swellings in her right axilla.
• What parts of the body have to be examined?
• What is the probable diagnosis of these swellings?

Q8. In a motorcycle accident, there was injury to the middle of back of arm.
• What nerve is likely to be injured?
• What muscles are affected? Name five of them.
• What is the effect of injury?
 CLINICAL QUESTION OF UPPER LIMB

Q9. A young man practising tennis complained of severe pain over lateral part of his
right elbow. The pain was pin-pointed over his lateral epicondyle.
• Why does pain occur over lateral epicondyle during tennis games?
• Which other games can cause similar pain?

Q10. A 55-year-old woman complained of abnormal sensations in her right thumb, index,
middle and part of ring fingers. Her pain increased during night. There was weakness of
her thumb movements.
• Which nerve was affected and where? Name the syndrome.

Q11. A 70-year-old lady fell on her left forearm. She heard a crack in the wrist. There
was swelling and a bend just proximal to wrist with lateral deviation of the hand.
• Which forearm bone is fractured?
• Reason of bend just proximal to wrist.
• What joints can be subluxated?

Q12. A 55-year-old individual sustained a severe blow on his right flexed elbow. He
developed pain and swelling in the elbow region. He was taken to an orthopedic surgeon,
who on examination found that the three bony points (olecranon, medial epicondyle, and
lateral epicondyle) in the elbow region were forming an X-ray of elbow region. The X-
ray revealed supraepicondylar/supracondylar fracture of the humerus.

1. What are the three common sites of fracture of the shaft of humerus? Name the nerves
related to these sites.
2. Why the triangular relation of three bony points is not disturbed in the supracondylar
fracture of humerus?
3. Which is the most commonly injured nerve in the supracondylar fracture of humerus?
4. On clinical examination, how will you differentiate the supracondylar fracture of
humerus from the posterior dislocation of elbow?
Q13. A 55-year-old female complained to her family physician of hard painless lump in
the upper and outer portion of her right breast. The examination of breast revealed peau
d'orange appearance of the skin, loss of mobility of breast, and retraction of nipple. The
examination of axilla revealed the enlargement of axillary lymph nodes. The X-ray of
vertebral column revealed irregular shadow in the vertebral bodies of T6 and T7
vertebrae. She was diagnosed as a case of the breast cancer.
1. What do you understand of lump in the breast? What are its common causes?
2. Mention the anatomical basis of peau d'orange appearance of skin, retraction of nipple
and loss of mobility of the breast.
3. Name the three muscles lying deep to the base of the breast.
4. What is the venous route of the spread of breast cancer?
5. What is the commonest site of the breast cancer?
 CLINICAL QUESTION OF UPPER LIMB

Q14. A baby boy was delivered in the hospital by an obstetrician by pulling baby's head
using forceps (forceps delivery). Two weeks later the parents took the baby to the
pediatrician for check-up. While examining the baby, the pediatrician found that baby's
right arm was medially rotated and adducted while his forearm was extended and
pronated. He also noticed sensory loss on the lateral aspect of the right upper limb.

1. Name the position of upper limb of baby observed by the pediatrician.

2. Which position of the limb is characteristic of this clinical condition?
3. Name the site of lesion and the cause that produced this condition.
4. What is the cause of sensory loss in the upper limb?
Q15. A 45-year-old man, a chronic user of crutch went to his family physician and
complained that he had noticed loss of shoulder contour on the right side during the last 2
months. He also told that he feels no sensations in this region and could see the bony
projection at the upper end. On examination, the physician found that patient could not
abduct his arm up to the 90° and there was a loss of skin sensation over the lower half of
the deltoid muscle. He could also notice the prominence of greater tubercle of the
humerus. He was diagnosed as a case of axillary nerve injury.
1. Mention the origin and root value of axillary nerve.
2. What are the three common causes of axillary nerve injury?
3. Mention the cause of loss of skin sensation over the lower half of the deltoid.
4. What is the cause of loss of shoulder contour and prominence of greater tubercle of
humerus?
5. Name the muscles supplied by the axillary nerve.

Q16. A 54-year-old executive officer fell down from the stairs. He was feeling severe
pain in his right shoulder. He was taken to the emergency OPD. On examination the
doctors observed that the officer was sitting on the stool with right arm by the side of his
body and he was supporting his right elbow with his left hand. The inspection of right
shoulder revealed loss of its normal rounded contour and loss of skin sensations in the
lower half of the deltoid region. Any attempt to perform active or passive movement was
stopped by severe pain in shoulder. He was diagnosed as a case of dislocation of right
shoulder.
1. Why shoulder joint is commonly dislocated?
2. What is the most common type of shoulder dislocation?
3. What is the cause of loss of normal rounded contour of the shoulder?
4. What is the cause for loss of skin sensation in the lower half of the deltoid region?

Q17. A 38-year-old female went to the pathologist for routine blood examination. The
pathologist asked the technician to collect the blood sample of the lady. While
attempting to collect the blood sample from median cubital vein the technician noticed
 CLINICAL QUESTION OF UPPER LIMB

that the blood in the syringe is bright red. He immediately withdrew the needle.
In second attempt, he inserted the needle slightly medial to the previous puncture. The
lady felt sharp pain, which radiated to the lateral three digits.
1. What is median cubital vein?
2. Name the fascial structure, which separates median cubital vein from brachial artery
and median nerve.
3. Mention the cause of sharp pain that radiated to the lateral 3½ digits.
4. What does the bright red blood in syringe indicated during collection of the blood
sample from the median cubital vein?

Q18. A 45-year-old weight lifter while lifting the heavy weight in weight lifting
competition suddenly felt a sudden snap and severe pain in his shoulder region. He
dropped the weight and left the platform. He was taken to the hospital for check up. On
examination the doctor noticed a ball-like bulge near the centre of the distal part of the
anterior aspect of the arm. The patient was not able to supinate his arm and his forearm
was pronated and flexed. A diagnosis of rupture of tendon of long head of biceps was
made.
1. What are the causes of rupture of tendon of long head of biceps and which age
group does it mostly affect?
2. What is origin of long and short heads of the biceps brachii?
3. What caused the ball-like bulge in the front of the arm and name this deformity?

Q19. A 25-year-old girl, who was studying in the final MBBS, tried to commit suicide by
slashing her wrist with a sharp knife. She was bleeding profusely and was immediately
taken to the hospital, where the doctors, on examination, found a lacerated wound on
the radial side of her wrist. Surgical procedure was performed and her life was saved.
1. Name the structures lying in front of the wrist.
2. Name the structures that are likely to be cut by deep lacerated wound on the radial
side of wrist.
3. Injury of which structure leads to profuse bleeding?
4. Name the artery which lies in front of distal end of radius between the tendon of
flexor carpi radialis and brachioradialis and mention its clinical importance.

Q20. A 35-year-old mother was crossing the road along with her 3-year-old son. After
seeing a speeding car rushing towards them she suddenly pulled her son away by
holding his left hand to avoid danger of being crushed by the car. The child cried out
and later refused to use his left upper limb. The mother took the child to the doctor. On
examination the doctor noticed that the child held his left forearm in a position with
elbow semiflexed and forearm pronated. A diagnosis of pulled elbow' was made.
1. What is pulled elbow?
 CLINICAL QUESTION OF UPPER LIMB

2. Why is pulled elbow common in preschool (1-3-year-old) children?

3. How can pulled elbow be reduced /treated?

Q21. A 27-year-old dental student while going to the college fell from the motorcycle
with an outstretched right hand. He got up and went to the college to attend his classes.
In the class, he felt pain in his right wrist. He went to emergency department for check-
up. The Resident doctor over there, on examination, noticed tenderness in the region of
anatomical snuff box of his right hand. The X-ray of hand did not reveal any frac- ture.
The doctor made a diagnosis of sprained wrist. The elastic bandage was applied around
the wrist and sent back. Three weeks later the student was still experi- encing pain on
moving his hand. He went to a senior orthopaedic surgeon, who after careful
examination, made a diagnosis of fracture of the right scaphoid bone.
1. Name the carpal bones which form the floor of anatomical snuff-box.
2. Why fracture of scaphoid bone was wrongly diagnosed as sprained wrist?
3. The scaphoid bone is prone to avascular necrosis after its fracture. Why?
4. Why scaphoid bone is difficult to immobilize?

Q22. An elderly man fell on the road with an outstretched right hand while trying to get
into the moving bus. He developed localized pain and swelling on the dorsal aspect of
his right wrist. He was taken to the nearby hospital, where on examination, the doctors
observed a typical dinner fork deformity in the right hand. The X-ray of the region
revealed a fracture of distal end of radius with posterior displacement of the distal
fragment. A diagnosis of Colles' fracture was made.
1. What is Colles' fracture and how does it differ from Smith's fracture?
2. Which nerve is likely to be injured in Colles' fracture?
3. What is the position of styloid processes of radius and ulna before and after fracture?

Q23. A 50-year-old female with history of rheumatoid arthritis complained of pain and
'pins and needles sensations in lateral two-third of palm and palmar aspect of lateral 3½
digits of her right hand, which becomes severe at night and compels her to wake up at
night. The examination revealed wasting of the thenar eminence, and hypoesthesia to
light touch and pinprick over the palmar aspect of lateral 3½ digits. However, skin over
the thenar eminence was not affected. The cuff compression test (of Gilliatt and Wilson)
was positive.
1. Name the clinical condition on the basis of signs and symptoms.
2. Name the boundaries of carpal tunnel and enumerate its contents.
3. Compression of which nerve leads to the above condition?
4. Why does pain increase during night which makes the patient to wake up?
5. What is the most reliable clinical diagnostic test for the carpal tunnel syndrome? Give

its brief account.