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Learning objectivesq Surface anatomy of Hand
q Bony landmarks
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q Compartments and Spaces of hand
q Flexor Retinaculum & Structures passing below
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& above FRq Intrinsic muscles of hand
q Superficial & Deep Palmar Arches
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q Dorsum of hand & Dorsal venous Arch
q Nerves in hand
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q Applied anatomySurface Anatomy
Surface Anatomy
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Wrist Bones
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Wrist Bones
She
Looks
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TooPretty
Try
To
Catch
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HerHand Bones
Anatomical Snuff Box
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Compartments & Spaces
The Skin
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PALM: characteristics:Flexure creases (lines of palm)
Papillary ridges (fingerprints): improve grip & increase
surface area
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Fibrous bands connecting it to palmar aponeurosis & dividing
subcutaneous fat into small loculi (water-cushion
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withstanding considerable pressure)Abundant sweat gland
Superficial Fascia
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PALM: characteristics:Contains: cutaneous nerves & vessels
Contains: Palmaris brevis (increases the hollow of palm to
get a firmer grip
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Deep Fascia
Palmar Aponeurosis
It is a thickening of deep fascia in the middle of the palm
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DESCRIPTION: It is triangular in shape:Apex: directed proximally, continuous with tendon of palmaris
longus
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Base: directed distally, divided into 4 slips for the medial 4 fingersMargins: send septa to metacarpal bones separating the structures
under the aponeurosis from thenar & hypothenar muscles
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FUNCTION: It protects the underlying tendons, vessels & nervesCLINICAL ANATOMY: DUPUYTREN'S CONTRACTURE:
shortening of the medial part of aponeurosis resulting in flexion of
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the little & ring fingersDeep Fascia
Flexor retinaculum:
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DefinitionAttachments
Relations
Functions
Clinical anatomy:
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Carpal tunnel
syndrome
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Flexor RetinaculumIt is a thickening of deep fascia that lies over the front of the
carpal bones converting the carpal groove (formed by carpal
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bones) into a tunnelATTACHMENTS:
Lateral: by 2 laminae: superficial (to tubercles of scaphoid &
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trapezium) & deep (to the medial lip of the groove on thetrapezium)
Medial: to pisiform & hook of hamate
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Flexor Retinaculum
RELATIONS:
Superficial: from lateral to medial:
Superficial palmar branch of radial artery
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Palmar cutaneous branch of median nerveTendon of palmaris longus
Palmar cutaneous branch of ulnar nerve
Ulnar vessels
Ulnar nerve
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Deep: Structures passing through carpal tunnelTendon of FPL & its synovial sheath (radial bursa)
Tendons of FDS & FDP & their common synovial sheath (Ulnar bursa)
Tendon of FCR & its synovial sheath ( in a special compartment)
Median nerve
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Flexor Retinaculum
FUNCTION: It keeps the flexor tendons in position during
movement of wrist joint
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CLINICAL ANATOMY (CARPAL TUNNEL SYNDROME):
Compression of median nerve under the flexor retinaculum
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Deep Fascia
Fibrous flexor
sheaths
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Definition
Attachments
Function
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Fibrous Flexor SheathDEFINITION: It is a thickening of deep fascia in front of the
fingers
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ATTACHMENTS:Proximal: to the slips of palmar aponeurosis
Distal: to the base of distal phalanx
On either side: to the side of phalanx
FUNCTION: It holds the long flexor tendons during flexion of
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the fingers
Intrinsic Muscles Of Hand
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Situated totally within the handDivided into 4 groups:-
?Thenar
?Hypothenar
?Lumbricals
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?Interossei musclesIntrinsic Muscles
LATERAL GROUP:
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FOUR THENAR MUSCLES
MEDIAL GROUP:
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THREE HYPOTHENAR MUSCLESPALMARIS BREVIS
CENTRAL GROUP:
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FOUR LUMBRICALSFOUR PALMAR INTEROSSEI
FOUR DORSAL INTEROSSEI
ALL MUSCLES ARE SUPPLIED BY C8 & T1 SPINAL
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SEGMENTS THROUGH MEDIAN & ULNAR NERVES
Intrinsic Muscles
Thenar Muscles:
Abductor Pollicis Brevis
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Flexor Pollicis BrevisOpponens Pollicis
Adductor Pollicis
Hypothenar Muscles:
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Abductor Digiti MinimiFlexor Digiti Minimi
Opponens Digiti Minimi
The Thenar Group
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?Abductor Pollicis
Brevis
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?Flexor Pollicis Brevis?Opponens Pollicis
?Adductor Pollicis
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Muscles
ABDUCTOR POLLICIS BREVIS
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Origin Scaphoid & Trapezium &Flexor Retinaculum
Insertion Lateral side of base of
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proximal phalanx of thumb
Action Abducts thumb
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Innervation median nerve (C8 andT1
Flexor Pol icis Brevis
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Origin S-Tubercle of Trapezium
D-Capitate & Trapezoid bones
Insertion Lateral side of base
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of proximal phalanx of thumb
Action Flexes thumb
InnervationRecurrent branch of
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median nerve (C8 and T1)Opponens Pol icis
Origin Flexor retinaculum and
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Tubercles of TrapeziumInsertion Lateral side of 1st
metacarpal
Action Draws 1st metacarpal
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laterally to oppose thumb toward
center of palm
Innervation Recurrent branch of
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median nerve (C8 and T1)
Adductor Pol icis
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It has 2 heads that are separated by agap through which the radial artery
passes
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Origin: Oblique head ? capitate &bases of 2nd and 3rd metacarpals,
Transverse head ? anterior surface of
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body of 3rd metacarpal boneInsertion: medial side of base of
proximal phalanx of thumb
Innervation: ulnar nerve
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Action: adducts thumb towards middledigit
The Hypothenar Group
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Hypothenar muscles
1. Opponens Digiti
Minimi
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2.Abductor Digiti Minimi3.Flexor Digiti Minimi
Brevis
4.Palmaris Brevis
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Opponens Digiti Minimi
Origin Hook of hamate
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and flexor retinaculumInsertion Medial border
of 5th metacarpal
Action Brings little finger
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(5th digit) into opposition
with thumb
InnervationDeep branch
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of ulnar nerve (C8 and T1)
Abductor Digiti Minimi
The most superficial of the
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hypothenar muscles forming
the hypothenar eminence
Origin : Pisiform bone
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Insertion: Medial side ofbase of proximal phalanx of
5th digit
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Action:Abducts 5th digit
Flexor Digiti Minimi Brevis
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Origin Hook of hamate
and flexor retinaculum
Insertion Medial side of
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base of proximal phalanx
of little finger
Action
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Flexes proximal
phalanx of little (5th) finger
Innervation
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ulnar
nerve
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Palmar BrevisIt lies in the fascia deep to the
skin of the hypo thenar em
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inence
A relatively unimportant mu scle
except that it covers and
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protects the ulnar nerve and
artery
Origi n: Flexor retinaculum and
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palmar aponeurosis
Inserti on: Skin on the medial side
of the palm
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Acti on: Wrinkles the skin on themedial side of the palm and
deepens the hollow of the palm, as
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in cupping of the hand, thereby
aiding the grip
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INTEROSSEI MUSCLESInterosseous Muscles
They are located between the
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metacarpal bones
Arranged in 2 layers: 4 Palmar
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and 4 DorsalLocated between bones 1. Dorsal
interossei 1 to 4
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Origin: Adjacent sides of 2 metacarpal
bones
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Insertion : Extensor expansion's andbases of proximal phalanges of digit 2
to 4
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Action: Abducts digits and assist
lumbricals
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2. Palmar interossei 1 to 4Origin : Palmar surfaces of 2nd, 3th , 4th
and 5th metacarpal bones
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Insertion: Extensor expansion of digits
and bases of proximal phalanges of
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digits 2, 4, and 5Action: Adducts digits and assist
lumbricals
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Lumbrical Muscles
They are named as such because
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of their elongated worml i ke
form
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1.Lumbri cal s 1 and 2Ori gi n : lateral 2 tendons of flexor
digitorum profundus
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2.Lumbri cal s 3 and 4Ori gi n: medial 3 tendons of flexor
digitorum profundus
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Insertion: lateral sides of extensorexpansions of digits 2 to 5
Acti on: To flex digits at MCP joints
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and extend IP jointsARTERIAL ARCHES IN HAND
SUPERFICIAL PALMAR
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ARCHDEEP PALMAR ARCH
Formation
Site
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Surface anatomyBranches
Superficial Palmar Arch
FORMATION:
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Direct continuation of ulnar artery (mainly)Superficial branch of radial artery
SITE: between palmar aponeurosis & long flexor tendons
SURFACE ANATOMY: level with the distal border of the fully
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extended thumbBRANCHES: digital branches to the medial three & half fingers
N.B.: Radial artery gives 2 branches that supplies the lateral one &
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half fingers:Radialis indicis: supplies lateral side of index
Princeps pollicis: supplies both sides of thumb
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Deep Palmar ArchFORMATION:
Direct continuation of radial artery (mainly)
Deep branch of ulnar artery
SITE: between long flexor tendons & metacarpal bones
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SURFACE ANATOMY: lies one inch proximal to superficialpalmar arch
BRANCHES:
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Branches sharing in anastomosis around wrist jointArticular & muscular branches
NERVES IN HAND
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Cutaneous innervation
Nerves In Hand
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Muscular innervationULNAR NERVE:
? Superficial Branch:
Palmaris brevis
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? Deep Branch:Adductor pollicis
Hypothenar muscles
Interossei
Medial two lumbricals
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Ulnar nerve
Is responsible for the innervations
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of the following.1. Flexor carpi ulnaris
2. Flexor digitorum profundus
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Nerves In HandMuscular innervations
MEDIAN NERVE:
Abductor pollicis brevis
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Flexor pollicis brevisOpponens pollicis
Lateral two lumbricals
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Median nerveIs responsible for the innervations of
the following soldiers.
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- 1. Flexor carpi radialis
- 2 .Flexor digitorum superficialis
- 3. Flexor digitorum profundus
- 4. Flexor pollicis longus
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- 5. Palmaris longus- Gives humans the ability to oppose
the thumb joint
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Radial Nerve- Is responsible for the innervations of
the following muscles
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- 1. Extensor Carpi Radialis Longus
- 2. Extensor Carpi Radialis Brevis
- 3. Extensor Digitorum
- 4. Extensor Carpi Ulnaris
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- 5. Abductor Pollicis Longus- 6. Extensor Digiti Minimi
- 7. Extensor Pollicis Brevis
- 8. Extensor Pollicis Longus
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Arteries:1. Deep palmar arch
2. Superficial palmar arch
3. Common palmar digital
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arteriesThe Radial artery supplies blood to:
- 1. Flexor carpi radialis
- 2. Extensor carpi radialis longus
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- 3. Extensor carpi radialis brevis- 4. Flexor pollicis longus
The Ulnar artery supplies blood to:
- 1. Flexor carpi radialis
- 2. Flexor carpi ulnaris
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- 3. Extensor carpi ulnaris- 4. Flexor digitorum superficialis
- 5. Flexor digitorum profundus
- 6. Palmaris longus
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Waste Management
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- 1. Cephalic vein- 2. Basillic vein
- 3. Superficial dorsal venous
arch (network)
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- 4. Deep dorsal venous arch
(network)
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Clinical ConcernsCarpal tunnel
Ganglion cyst
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- The transverse carpal ligament in the wrist - Is a fluid fil ed cyst that develops
puts pressure on the medial nerve
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out of a joint.- - possible cause: overuse, hormonal
- - possible cause: joint trauma
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- http://www.youtube.com/watch?v=SGyKQ - http://www.youtube.com/watch?v=
chSEJ4
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mJ6oj3lkqm8De Quervain's Tenosynovitis
-irritation of the sheath around the tendon
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- affects the tendons on the thumb side of the wrist- possibly caused by repetitive actions, over use
- http://www.youtube.com/watch?v=q87zSRYHa1o
1. Nerve damage that impairs the flexion of distal
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interphalangeal joints of index and middle fingers also
produces which of the following conditions ?
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a) Atrophy of Hypothenar eminenceb) Loss of adduction of thumb
c) Similar impairment of flexion of distal I.P joint of little finger
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d) Weakness in pronation of forearm
2.A man is unable to hold a postcard between his index and
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middle fingers because of an injury to which of thefollowing nerves ?
a) Superficial branch of ulnar nerve
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b) Deep branch of ulnar nerve
c) Recurrent branch of median nerve
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d) Posterior interosseous nerve3. All of the following muscles form the
boundry of the anatomical snuff box,
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EXCEPT :a) Brachioradialis
b) Abductor pollicis longus
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c) Extensor pollicis longus
d) Extensor pollicis brevis
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4. Which is the longest metacarpal bone ?a) Second metacarpal
b) Third metacarpal
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c) Fourth metacarpal
d) Fifth metacarpal
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5. After falling on his outstretched hand a patientcomplains of tenderness in the space between
Extensor pollicis brevis and extensor pollicis
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longus tendons. Which bone is most likely
fractured by the injury ?
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a) Scaphoidb) First metacarpal
c) Radial styloid process
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d) Trapezium
6. Which is the most frequently fractured carpal
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bone ?a) Lunate
b) Scaphoid
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c) Capitate
d) Trapezium
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7. A middle aged woman suffering from myxedema, suddenlywoke up one night by a severe bout of pain in her right wrist
and middle finger. The pain seems to move up her forearm.
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After a thorough neurological check up her physician
diagnosed her condition as Carpal Tunnel Syndrome.Which
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nerve is involved in this syndrome ?a) Median nerve
b) Palmar cutaneous branch of median nerve
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c) Ulnar nerve
d) Anterior interosseous nerve
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8. Examination of a patient reveals paralysis of the Abductor pollicisbrevis muscle. All of the following can be sites of lesion that
resulted in this paralysis , EXCEPT :
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One answer only.
a) Lower trunk of brachial plexus
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b) Lateral root of median nervec) Medial root of median nerve
d) Recurrent branch of median nerve
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9. A patient exhibits weakness of Pinch grip ;
other thumb movements are normal. There is no
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sensory loss in the hand. The probable cause isda mage to :
a) Posterior interosseous nerve
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b) Anterior interosseous nerve
c) Deep branch of ulnar nerve
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d) Median nerve proximal to flexor retinaculum10. In carpal tunnel syndrome which of the
follwoing conditions occur due to motor deficit ?
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a) Claw hand
b) Pointing index finger
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c) Benediction handd) Simian hand
Rx PG MCQ
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