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ANATOMY EXAM - 7-MARK MODEL ANSWERS

Upper Limb | BD Chaurasia Vol 1 & Vishram Singh Vol 1

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Q1. Describe the Attachments of Rotator Cuff Muscles [7M]

The Four Muscles (Mnemonic: SITS)

Diagram

        POSTERIOR VIEW
    Supraspinatus -----> [Greater tubercle - SUPERIOR facet]
    Infraspinatus -----> [Greater tubercle - MIDDLE facet ]
    Teres minor  -----> [Greater tubercle - INFERIOR facet]
    
        ANTERIOR VIEW
    Subscapularis -----> [Lesser tubercle              ]

Clinical Function

Clinical Significance

• Painful arc syndrome: Supraspinatus tendon is most commonly torn (between 60-120° abduction); this is the "impingement zone" under the coracoacromial arch.
• Rupture leads to inability to initiate abduction and wasting of supraspinous/infraspinous fossae.

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Q2. Attachments, Actions and Nerve Supply of Deltoid Muscle [7M]

Origin (Attachments - Proximal)

1. Anterior part: Anterior border and upper surface of lateral 1/3 of clavicle
2. Middle part: Lateral border of acromion
3. Posterior part: Spine of scapula - lower lip, as far back as the deltoid tubercle

Insertion (Distal Attachment)

• Deltoid tuberosity on the middle of the lateral surface of the shaft of the humerus (V-shaped roughening)

Actions

Nerve Supply

• Axillary nerve (C5, C6) - posterior cord of brachial plexus
• The axillary nerve winds around the surgical neck of humerus in the quadrangular space

Diagram

         Clavicle (lateral 1/3)
              |
         Acromion ------[Deltoid muscle]-----> Deltoid tuberosity
              |
         Spine of scapula
         
    Nerve: Axillary nerve (C5,C6) - winds around surgical neck

Clinical Significance

• Fracture of surgical neck of humerus or dislocation of shoulder joint injures the axillary nerve.
• Results in: paralysis of deltoid (loss of shoulder abduction after 15°) + loss of skin sensation over the "regimental badge" area (lower deltoid - patch over lateral arm)
• Wasting of deltoid = flattening of shoulder contour ("squaring of shoulder" in old dislocation)

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Q3. Enumerate Structures Under Cover of Deltoid Muscle [7M]

1. Glenohumeral (Shoulder) Joint

• The joint capsule, rotator cuff tendons (SITS), and related bursae

2. Subdeltoid (Subacromial) Bursa

• Lies between deltoid and rotator cuff; does NOT communicate with joint normally
• Site of subacromial impingement

3. Tendons of Rotator Cuff

• Supraspinatus, infraspinatus, teres minor (posteriorly), subscapularis (anteriorly)

4. Surgical Neck of Humerus + Axillary Nerve

• Axillary nerve (C5, C6) with posterior circumflex humeral vessels passes through quadrangular space and wind around surgical neck

5. Quadrangular Space Contents

• Axillary nerve (posterior cord)
• Posterior circumflex humeral artery (branch of 3rd part of axillary artery)

6. Triangular Space (medial to teres minor)

• Contains circumflex scapular artery (branch of subscapular artery)

7. Upper End of Humerus

• Greater tubercle, lesser tubercle, intertubercular sulcus (with biceps long head tendon)

8. Coracobrachialis and Short Head of Biceps (partially)

• Pass deep to anterior part of deltoid near coracoid process attachment

Diagram

     [Deltoid - superficial layer]
            |
    --------------------------
    | Subacromial bursa      |
    | Supraspinatus tendon   |
    | GHJ capsule            |
    | Quadrangular space:    |
    |   - Axillary nerve     |
    |   - Post. circ. hum. A |
    | Surgical neck humerus  |
    --------------------------

Clinical Pearl

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Q4. Attachment of Pectoralis Major Muscle [7M]

Origin (Proximal Attachments)

Insertion (Distal Attachment)

• Lateral lip of the intertubercular sulcus (bicipital groove) of humerus
• The tendon is folded on itself (twisted): clavicular fibres insert lower, abdominal fibres insert higher
• This twist creates the anterior axillary fold

Diagram

    Medial 1/2 clavicle  ]
    Sternum + costal     ]--[Pect. Major]---> Lateral lip
    cartilages 2-6       ]                    intertubercular sulcus
    Rectus sheath (abd.) ]

Actions

1. Adduction of arm (all fibres)
2. Medial rotation of arm (all fibres)
3. Flexion (clavicular head - when arm below 90°)
4. Extension from raised position (sternocostal head)
5. Accessory muscle of inspiration (when arms fixed)

Nerve Supply

• Medial pectoral nerve (C8, T1) - lateral head (sternocostal)
• Lateral pectoral nerve (C5, C6, C7) - medial head (clavicular)

Clinical Significance

• Mastectomy: pectoralis major may be partially or totally removed
• Poland's syndrome: congenital absence of pectoralis major
• Tightness = rounded shoulder posture

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Q5. Attachments, Actions and Nerve Supply of Serratus Anterior Muscle [7M]

Origin

• Muscular slips (8-9 digitations) from outer surfaces and upper borders of upper 8-9 ribs (sometimes described as ribs 1-9)
• Slips interdigitate with external oblique muscle at lower ribs

Insertion

• Costal (anterior/deep) surface of the medial border of the scapula, with the inferior angle receiving the largest slip

Actions

Nerve Supply

• Long thoracic nerve of Bell (C5, C6, C7)
• Runs down the lateral thoracic wall on the external surface of the muscle, just deep to skin and fascia
• Root values remembered: C5, 6, 7 - takes the arm to heaven (elevation requires serratus)

Diagram

        Ribs 1-9 (outer surface)
               |
        [Serratus anterior]
               |
        Medial border + costal surface of scapula
        (inferior angle - largest attachment)
        
    Nerve: Long thoracic nerve (C5,C6,C7) - on external surface of muscle

Clinical Significance

• Winging of scapula: Long thoracic nerve palsy (e.g., stab wound to lateral chest, radical mastectomy, carrying heavy loads on shoulder) causes medial border + inferior angle to project posteriorly.
• Test: Ask patient to push against a wall - winging becomes prominent.
• Elevation of arm beyond 90° becomes impossible.

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Q6. Describe the Boundaries and Contents of Carpal Tunnel. Explain Carpal Tunnel Syndrome [7M]

The Carpal Tunnel

Boundaries

Contents (9 tendons + 1 nerve = 10 structures)

1. Flexor digitorum superficialis - 4 tendons (in 2 rows)
2. Flexor digitorum profundus - 4 tendons
3. Flexor pollicis longus - 1 tendon (in its own synovial sheath)
4. Median nerve - lies superficially just beneath the retinaculum (most lateral content)

Diagram

         FLEXOR RETINACULUM (anterior)
    |-----------------------------------------|
    |  FDS (4)    FDP (4)    FPL (1)          |
    |                                         |
    |  MEDIAN NERVE (lateral/superficial)     |
    |-----------------------------------------|
    CARPAL BONES (posterior)
    
    Lateral: Scaphoid + Trapezium
    Medial:  Pisiform + Hook of Hamate

Carpal Tunnel Syndrome (CTS)

• Decreased tunnel size: Colles' fracture, acromegaly, rheumatoid arthritis, wrist osteoarthritis
• Increased tunnel contents: Tenosynovitis, lipoma, anomalous muscles, hematoma
• Physiological: Pregnancy (fluid retention), hypothyroidism, diabetes mellitus

1. Pain and paraesthesia in lateral 3.5 fingers (median nerve distribution) - worse at night
2. Thenar wasting - due to denervation of LOAF muscles (Lumbrical 1&2, Opponens pollicis, Abductor pollicis brevis, Flexor pollicis brevis)
3. Weakness of thumb opposition (APB most sensitive)
4. Positive Tinel's sign: Tapping over flexor retinaculum reproduces tingling
5. Positive Phalen's test: Full wrist flexion for 60 seconds reproduces symptoms

• Conservative: Wrist splint (neutral), steroid injection
• Surgical: Division of flexor retinaculum (carpal tunnel decompression)

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Q7. Specify the Nerve Supply and Actions of Interossei of Hand [7M]

Dorsal Interossei (4 muscles)

• Abduct fingers away from the axis of the middle finger
• Flex metacarpophalangeal joints
• Extend interphalangeal joints (via extensor expansion)

Palmar Interossei (3 muscles)

• Adduct fingers toward the axis of the middle finger
• Flex metacarpophalangeal joints
• Extend interphalangeal joints

Nerve Supply

• ALL interossei (both palmar and dorsal): Deep branch of ulnar nerve (C8, T1)
• The first dorsal interosseous is the largest and most commonly tested clinically

Diagram

        DORSAL INTEROSSEI (DAB):
         1   2   3   4
        <-- -- | -- -->   (arrows = abduction from middle)
        I  I  M  R  L
        
        PALMAR INTEROSSEI (PAD):
         1  2   3
        --> |  <--        (arrows = adduction to middle)
        I   M  R  L
        
    All innervated by: Deep branch of Ulnar nerve (C8, T1)

Common Testing Points

• Froment's sign: Tests 1st dorsal interosseous (and adductor pollicis) - patient grips paper between thumb and index finger; if ulnar nerve palsy, thumb IP joint flexes (FPL compensates = Froment's positive).
• Guttering between metacarpals on dorsum of hand = interossei wasting in ulnar nerve palsy.

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Q8. Draw and Explain Diagram of Brachial Plexus [7M]

Formation

Components: ROOTS - TRUNKS - DIVISIONS - CORDS - BRANCHES (Mnemonic: Real Taxi Drivers Cost Bread)

ROOTS          TRUNKS         DIVISIONS      CORDS         BRANCHES
  C5 ---|                                               Musculocutaneous (C5,6,7)
        |-- UPPER TRUNK --|-- Anterior --|              Lateral cutaneous nerve of forearm
  C6 ---|   (C5,C6)       |             |-- LATERAL --- Median (lateral root)
                           |              CORD           Lateral pectoral nerve
                           |
  C7 ------- MIDDLE TRUNK -|-- Anterior -|
              (C7)         |             |-- POSTERIOR -- Axillary nerve (C5,C6)
                           |-- Posterior-|   CORD         Radial nerve (C5-T1)
                                             Thoracodorsal (C6,7,8)
  C8 ---|                  |             |   Upper/Lower subscapular
        |-- LOWER TRUNK --|-- Anterior --|
  T1 ---|   (C8,T1)        |             |-- MEDIAL --- Ulnar (C7,8,T1)
                                             CORD        Median (medial root)
                                                         Medial cutaneous nerve of arm
                                                         Medial cutaneous nerve of forearm
                                                         Medial pectoral nerve

Branches from Roots

• C5: Nerve to rhomboids (dorsal scapular nerve), Long thoracic nerve (C5,6,7)
• C6, C7: Long thoracic nerve contribution

Branches from Trunks

• Upper trunk: Suprascapular nerve (C5,6), Nerve to subclavius

Branches from Cords

Location

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Q9. Explain the Anatomical Basis of Deformity of Erb's Paralysis [7M]

Definition

Mechanism of Injury

• Caused by excessive lateral flexion of neck away from shoulder (widening of cervicohumeral angle):
  • Difficult labour - traction on baby's head/neck
  • Fall on shoulder / motorcycle accident
• The point of damage is Erb's point: where C5 and C6 join to form the upper trunk (2 cm above clavicle)

Muscles Paralysed (C5, C6 territory)

Resulting Deformity: "Waiter's Tip" or "Porter's Tip" Position

         NORMAL              ERB'S PALSY
    
    Shoulder: abducted   -> ADDUCTED (deltoid lost)
    Arm: laterally       -> MEDIALLY ROTATED (lat. rotators lost)
    rotated                 Arm hangs by side
    Elbow: flexed        -> EXTENDED (biceps, brachialis lost)
    Forearm: supinated   -> PRONATED (supinator, biceps lost)
    Wrist: extended      -> FLEXED (unopposed wrist flexors)
    
    Final posture: ARM ADDUCTED + MEDIALLY ROTATED
                   ELBOW EXTENDED + FOREARM PRONATED
                   = Waiter's tip position

Sensory Loss

• Loss of sensation over: Lower lateral arm, lateral forearm (distribution of axillary + musculocutaneous nerves)

Biceps Jerk

• Absent (C5,6 arc lost)

Clinical Note

• In birth injuries: Full recovery is possible if there is neurapraxia.
• Klumpke's palsy (C8,T1) = lower trunk injury = claw hand + Horner's syndrome (sympathetic fibres from T1 damaged).

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Q10. Pronation and Supination [7M]

Definitions

• Supination: Rotation of the forearm so that the palm faces anteriorly (upward when elbow is flexed to 90°)
• Pronation: Rotation of the forearm so that the palm faces posteriorly (downward when elbow is flexed)

Bones Involved

• Radius rotates around the ulna (which remains relatively fixed)
• At the proximal radioulnar joint (pivot joint) and distal radioulnar joint (pivot joint)
• The interosseous membrane maintains the relationship

Muscles of Supination

Muscles of Pronation

Mechanism Diagram

    SUPINATION                    PRONATION
    
    Radius  Ulna                  Ulna   Radius
      |      |                      |   X
      |      |        ----->        | X
    Radius swings                 Radius crosses
    laterally -                   anterior to ulna
    palm up
    
    Proximal radioulnar joint = pivot (annular ligament)
    Distal radioulnar joint = pivot (articular disc)

Range of Motion

• Supination: ~90° from neutral
• Pronation: ~90° from neutral
• Total arc: ~180°

Clinical Significance

• Pulled elbow (Nursemaid's elbow): Subluxation of radial head through annular ligament in children
• Colles fracture: Immobilisation in supination
• Radioulnar synostosis: Loss of pro-supination

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Q11. Median Nerve in Hand and Forearm [7M]

Formation

• Lateral root from lateral cord (C5, C6, C7)
• Medial root from medial cord (C8, T1) These unite anterior to the third part of the axillary artery.

Course in the Forearm

1. Enters forearm between two heads of pronator teres
2. Lies deep to flexor digitorum superficialis (on anterior surface of FDP)
3. Emerges between FDS and FDP about 5 cm above wrist
4. Becomes superficial just above flexor retinaculum
5. Passes through carpal tunnel (under flexor retinaculum)

Branches in the Forearm

1. Muscular branches: To pronator teres, FCR, palmaris longus, FDS
2. Anterior interosseous nerve (most important): branches at level of pronator teres
   • Supplies: FDP (lateral half - index + middle), FPL, pronator quadratus
3. Palmar cutaneous branch: Arises 5 cm above wrist, passes superficial to retinaculum (NOT through carpal tunnel) - supplies central palm

Course in the Hand

• Enters hand through carpal tunnel under flexor retinaculum
• Immediately gives recurrent (motor) branch (enters thenar muscles)

Branches in the Hand

• LOAF muscles:
  • Lumbricals 1 and 2 (lateral two)
  • Opponens pollicis
  • Abductor pollicis brevis
  • Flexor pollicis brevis (superficial head only)

• Palmar digital nerves to lateral 3.5 fingers (thumb, index, middle, and lateral half of ring)
• Supplies nail beds of same fingers on dorsal side distally

Diagram

    Median nerve in hand:
    
    FLEXOR RETINACULUM
           |
    Median nerve enters carpal tunnel
           |
    Recurrent branch --> Thenar muscles (LOAF)
           |
    Common palmar digital nerves
           |
    Proper palmar digital nerves
    (Lateral 3.5 fingers + nails)

Clinical: Carpal Tunnel Syndrome

• Compression within the tunnel spares the palmar cutaneous branch (arises proximal to tunnel).
• Hence: central palm sensation is PRESERVED but digital sensation is lost.
• APB weakness is the most sensitive test.
• High lesion (above pronator teres) = "hand of benediction" (inability to flex index + middle fingers fully)

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Q12. Musculocutaneous Nerve [7M]

Origin

• Branch of lateral cord of brachial plexus (C5, C6, C7)

Course

1. Arises from lateral cord in the axilla at the level of the lower border of pectoralis minor
2. Pierces coracobrachialis muscle (which it also supplies)
3. Descends between biceps brachii (anterior) and brachialis (posterior)
4. Emerges lateral to biceps tendon at elbow level, piercing deep fascia
5. Continues as the lateral cutaneous nerve of the forearm (lateral antebrachial cutaneous nerve)

Branches and Distribution

• Lateral cutaneous nerve of the forearm (continuation below elbow)
• Divides into: anterior branch (lateral forearm, thenar eminence) and posterior branch (posterolateral forearm)

Diagram

    Lateral cord (C5,6,7)
           |
    Musculocutaneous nerve
           |
    Pierces CORACOBRACHIALIS (supplies it)
           |
    Between BICEPS (ant.) and BRACHIALIS (post.)
    [Supplies both]
           |
    Pierces deep fascia at elbow (lateral to biceps tendon)
           |
    LATERAL CUTANEOUS NERVE OF FOREARM
    (Anterior + Posterior divisions)
    Supplies: Lateral forearm skin

Clinical Features of Injury

• Isolated injury is rare (usually associated with C5,6 brachial plexus lesions)
• Causes:
  • Elbow flexion weakness (biceps + brachialis lost; brachioradialis preserved as it is radial nerve)
  • Supination weakness
  • Sensory loss over lateral forearm
  • Biceps jerk absent
• Differentiated from C5,6 root lesion by intact deltoid and rhomboids

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Q13. Specify Origin, Insertion and Distribution of Radial Nerve [7M]

Origin

• Branch of posterior cord of brachial plexus (C5, C6, C7, C8, T1)
• Largest branch of the brachial plexus

Course and Relations

1. Axilla: Posterior to axillary artery; with profunda brachii artery, passes through the triangular interval (teres major above, long head of triceps medially, humerus laterally)
2. Arm (spiral groove): Winds around the posterior aspect of humerus in the radial groove (spiral groove) with profunda brachii
3. Pierces lateral intermuscular septum to enter anterior compartment of arm about 10 cm above lateral epicondyle
4. Cubital fossa: Lies in the floor between brachioradialis and brachialis, anterior to lateral epicondyle
5. Divides at/below lateral epicondyle into:
   • Superficial (sensory) branch: Under brachioradialis, exits posteriorly above wrist
   • Deep (motor) branch = Posterior interosseous nerve: Winds around radial neck through supinator

Muscles Supplied (Motor Distribution)

• Triceps (all 3 heads) - C7 mainly
• Brachioradialis (C5,6)
• Anconeus (C7,8)
• Extensor carpi radialis longus (C6,7)

• Extensor carpi radialis brevis
• Supinator
• Extensor digitorum
• Extensor digiti minimi
• Extensor carpi ulnaris
• Abductor pollicis longus
• Extensor pollicis longus + brevis
• Extensor indicis

Sensory Distribution

• Posterior cutaneous nerve of arm: Back of arm
• Lower lateral cutaneous nerve of arm: Lower lateral arm
• Posterior cutaneous nerve of forearm: Strip down back of forearm
• Superficial branch: Dorsal lateral 3.5 fingers (proximal phalanges, NOT nail beds)

Diagram

    Posterior cord
          |
    Radial nerve (C5-T1)
          |
    Axilla --> Triangular interval --> Radial groove
          |
    Divides at lat. epicondyle:
          |                    |
    Superficial branch    Deep (POST. INTEROSSEOUS)
    (sensory: dorsum     (motor: all ext. in forearm)
    lat. 3.5 fingers)

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Q14. Describe Root Value, Muscles Supplied and Clinical Anatomy of Radial Nerve [7M]

Root Value

• Primarily C7 (the "radial nerve root")
• Posterior cord origin

Complete Muscle Supply

Sites of Injury and Clinical Patterns

• ALL muscles paralysed including triceps
• Wrist drop + finger drop + loss of elbow extension
• Sensory loss: entire radial distribution

• Triceps SPARED (its branches arise before groove)
• Wrist drop (ECRL, ECRB, ED all lost)
• Cannot extend wrist, fingers, or thumb
• Sensory loss: dorsum of lateral 3.5 fingers
• Elbow extension preserved

• No wrist drop (ECRL spared - radial deviation on extension)
• Finger drop (ED, EDM, EI, EPL lost)
• No sensory loss (only motor)

    WRIST DROP DIAGRAM:
    
    Normal hand:           Radial nerve palsy:
    [Wrist extended]    -> [Wrist drops - cannot extend]
    Fingers extended    -> Fingers and thumb drop
    
    Unopposed flexors cause wrist + finger flexion

Reflexes Lost

• Brachioradialis reflex (C5,6) - supinator jerk
• Triceps jerk (C7) - in high lesions

Important Clinical Tests

• Wrist drop test: Inability to extend wrist against gravity
• Finger/thumb extension: Tests posterior interosseous nerve
• Froment vs wrist drop: Differentiates ulnar from radial palsy

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Q15. Specify the Parts, Course and Branches of the Axillary Artery [7M]

Definition

Parts

• 1st part: From lateral border of 1st rib to upper border of pectoralis minor
• 2nd part: Posterior to pectoralis minor (behind the muscle)
• 3rd part: From lower border of pectoralis minor to lower border of teres major

Branches (6 total)

    AXILLARY ARTERY
    |
    1st part (1 branch):
    └── Superior thoracic artery --> Upper axillary wall, 1st + 2nd ICS
    
    2nd part (2 branches):
    ├── Thoraco-acromial artery --> 4 branches: pectoral, deltoid,
    |                              clavicular, acromial
    └── Lateral thoracic artery --> Serratus anterior + breast
    
    3rd part (3 branches):
    ├── Subscapular artery (largest) --> Divides into:
    |   ├── Circumflex scapular (triangular space)
    |   └── Thoracodorsal artery (latissimus dorsi)
    ├── Anterior circumflex humeral --> Anterior surgical neck
    └── Posterior circumflex humeral --> Quadrangular space,
                                        surgical neck (larger)

Relations

Clinical Significance

• Axillary artery aneurysm: Occurs in overhead throwing athletes (subclavian-axillary artery syndrome)
• Axillary artery injury: In shoulder dislocation (anterior) especially in elderly - can cause vascular compromise to upper limb
• Collateral circulation: Via subscapular/circumflex scapular - circumvents brachial artery obstruction

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Q16. Cubital Fossa [7M]

Definition

Boundaries

Contents (lateral to medial)

Diagram

    Lateral epicondyle ----BASE---- Medial epicondyle
             \                           /
    Brachioradialis                Pronator teres
              \                       /
               \  CUBITAL FOSSA      /
               |                     |
               | [Radial n.]         |
               | [Biceps tendon]     |
               | [Brachial a.]       |
               | [Median n.]         |
               APEX (inferior)
    
    FLOOR: Brachialis + Supinator
    ROOF: Deep fascia + Bicipital aponeurosis

Contents in Detail

1. Brachial artery - bifurcates at the neck of radius into radial and ulnar arteries
2. Median nerve - passes between two heads of pronator teres to enter forearm
3. Radial nerve - passes between brachioradialis and brachialis, divides into superficial and deep branches
4. Biceps tendon - inserts into radial tuberosity + sends aponeurosis medially
5. Radial and median recurrent vessels - form anastomotic network around elbow

Clinical Significance

• Brachial artery BP measurement: In cubital fossa (medial to biceps tendon)
• Venepuncture: Median cubital vein crosses roof - site for IV cannulation and blood sampling
• Supracondylar fracture: Can injure brachial artery and median nerve in cubital fossa
• Volkmann's ischaemic contracture: Ischaemia of forearm flexors following compartment syndrome from supracondylar fracture

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Q17. Axilla - Boundaries, Contents and Applied Anatomy [7M]

Definition

Boundaries

Contents of Axilla

• Formed by union of basilic vein and venae comitantes of brachial artery at lower border of teres major
• Lies medial to axillary artery

• Lateral, medial, and posterior cords surrounding the artery

Diagram

        APEX (clavicle + 1st rib + scapula)
                  |
    ANTERIOR WALL           POSTERIOR WALL
    (Pec. major +           (Subscapularis +
    Pec. minor)             Teres major +
                            Lats)
         |                      |
    MEDIAL WALL             LATERAL WALL
    (Serratus ant.)         (Intertubercular sulcus)
                  |
               BASE (skin + axillary fascia)

    CONTENTS:
    - Axillary artery (3 parts, 6 branches)
    - Axillary vein
    - Brachial plexus cords
    - Axillary lymph nodes (5 groups)
    - Fat, long thoracic nerve, intercostobrachial nerve

Applied Anatomy

1. Breast cancer spread: Axillary lymph nodes (especially anterior/pectoral group first) are the primary route of metastasis - sentinel lymph node biopsy and axillary clearance are performed here.
2. Axillary vein thrombosis ("effort thrombosis" - Paget-Schroetter syndrome): Arm swelling in athletes.
3. Crutch palsy: Prolonged pressure on axillary crutch compresses posterior cord of brachial plexus (radial nerve injury = wrist drop).
4. Axillary nerve injury: In shoulder dislocation.
5. Long thoracic nerve damage: During axillary surgery/mastectomy = winging of scapula.

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How to Use These in Your Exam Booklet

• Diagram: 1-2 marks (always draw even if rough)
• Attachments/Origin-Insertion: 2 marks
• Actions: 1-2 marks
• Nerve supply with root values: 1 mark
• Clinical significance: 1 mark

• Wrist drop = radial nerve in radial groove (humeral shaft #)
• Waiter's tip = Erb's palsy (C5,C6)
• Winging = long thoracic nerve palsy (serratus anterior)
• Carpal tunnel = median nerve compression (thenar wasting + Tinel's + Phalen's)
• "Regimental badge" anaesthesia = axillary nerve injury