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21 Cards in this Set
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[May09] Which distinguishes C8-T1 from an ulnar nerve lesion at elbow?
A. Paraethesia of the 5th digit B. Paraesthesia over index finger C. Flexor carpi ulnaris function D. Paraesthesia/sensory loss over medial forearm E. Adductor pollicis function |
D. Paraesthesia/sensory loss over medial forearm
- a. Paraesthesia of the 5th digit - false - both nerve lesions will show this b. Paraesthesia over index finger - false - neither nerve lesions will show this. C. Flexor carpi ulnaris function - false - supplied by ulnar nerve which is derived from C8-T1. Weakness of this muscle will not differentiate between either lesion. D. TRUE - Medial forearm is supplied by Medial cutaneous nerve of the forearm which is from C8-T1. Paraesthesia here implies that it is a C8-T1 nerve lesion rather than an ulnar nerve lesion. E. Adductor pollicis function - supplied by ULNAR nerve which is also derived from C8-T1 so again, weakness will not differentiate between either lesion. (previous stem listed ABductor pollicis function which is supplied by MEDIAN nerve) ----------- |
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ANZCA version [Aug91] [Mar93] [2002-Aug] Q15
The first cervical vertebra has A. two spinous processes B. an odontoid process C. no anterior tubercle D. a facet on its anterior arch E. no foramen transversarium |
D. a facet on its anterior arch
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NV01 [1986] [1988] [Mar95] [Aug95] [Apr96] [Aug96] [Mar00] (type K)
Klumpke's palsy is (not) associated with: A. Wasting of the small muscles of the hand B. Ptosis C. Anaesthesia of the medial side of the forearm D. The Waiter's tip deformity E. Horner's syndrome F. Loss of adductor pollicis |
D. The Waiter's tip deformity
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NV09 ANZCA version [2003-Apr] Q37, [2005-Apr] Q14, [Jul05]
In the hand the median nerve supplies A. abductor pollicis brevis B. adductor pollicis C. the first dorsal interosseous D. abductor pollicis longus E. extensor indicis |
A. abductor pollicis brevis
FOUR muscles of the hand are supplied by the median nerve. The remainder are supplied by the Ulnar nerve. 'LOAF' muscles L - Lateral two lumbricals O - Opponens pollicis A - Abductor pollicis brevis F - Flexor pollicis brevis ----------- |
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NV16 ANZCA version [1985] [1988] [Mar94] [Aug94] [Mar95] [Aug95] [Apr96] [Jul97] [2001-Aug] Q122, [2002-Mar] Q124
Block of the ulnar nerve immediately proximal to the pisiform bone usually produces 1. paralysis of the adductor pollicis muscle 2. analgesia within the area of distribution of the eighth cervical nerve 3. analgesia of the palmar aspect of the ulnar one and a half fingers 4. analgesia of the dorsal aspect of the ulnar one and a half fingers |
1. paralysis of the adductor pollicis muscle
2. analgesia within the area of distribution of the eighth cervical nerve 3. analgesia of the palmar aspect of the ulnar one and a half fingers The ulnar nerve has two sensory branches that provide sensory innervation to ulnar side of the hand; *palmar branch - found radial to FCU tendon at proximal crease; *dorsal branch - divides from palmar branch approx 4-5 cm proximal from wrist ~5 cm proximal to the pisiform - supplies dorsoulnar aspect of the hand and the ulnar 1 1/2 fingers; - courses under FCU tendon to dorsal ulnar side of the hand; Motor supply of ulnar n at wrist Superficial branch; *palmaris brevis Deep banch; *All 3 hypothenar ms; Abductor digiti minimi, flexor digiti minimi, opponens digiti minimi *The 2 ulnar lumbricals *All the interossei, palmar and dorsal *Adductor pollicis ----------- |
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NV23 ANZCA version [Aug94] [2001-Apr] Q102, [2001-Aug] Q113
The radial artery 1. accompanies the superficial radial nerve in the forearm 2. has no branches in the forearm 3. lies superficial to the distal end of the radius, between the tendons of flexor carpi radialis and brachio-radialis muscles 4. enters the palm under the flexor retinaculum to become the superficial palmar arch |
1. accompanies the superficial radial nerve in the forearm
3. lies superficial to the distal end of the radius, between the tendons of flexor carpi radialis and brachio-radialis muscles ----------- |
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NV36b ANZCA version [2001-Apr] Q69, [2001-Aug] Q41, [2002-Aug] Q42, [2003-Apr] Q24
Recognised factors that predispose upper limb nerves to compression, under anaesthesia include A. forearm extension and supination B. extreme flexion of elbows across chest C. internal rotation of abducted arm D. lateral position - uppermost arm flexed in arm support E. prone position - arms by side and fingers flexed |
B. extreme flexion of elbows across chest
- Position internal rotation (pronation) with arm abducted >90 degrees pronation when by side (should be neutral) compression or stretch Elbow flexion greater than 90 degrees increases risk. One in 350 patients under anaesthesia report post-op ulnar nerve injuries. The ASA closed claims study states that 15% of claims are for nerve injuries and that 1/3 of these are ulnar. Predispositions include: Male, Diabetes melitus, thoracic outlet anomalies, arthritis or instability of the elbow, extremes of body habitus, hypovolaemia or hypotension, hypoxaemia, and electrolyte anomalies, prolonged surgical time, Median sternotomy and CABG surgery are big risk factors (6-38%, and 15% respectively). Regional anaesthesia and needle misplacement for jugular CVL placement are also risks. Positioning injuries: 1. Stretching: Due to arm abduction >60deg either while prone or supine. 2. Flexion: arms folded across the torso with extreme flexion at the elbow 3. Abduction: In the lateral decubitus position with shoulder abduction and elbow flexion. 4. Tourniquet use: especially if rigid and low on the arm. Peripheral nerve injuries may take up to a week to present post-op Padding and careful positioning will reduce but not eliminate the risk of nerve injury. Greater than 20% of patients have a more medial ulnar nerve position at the elbow, such that the nerve rides over the posterior tip of the epicondyle. This increases the risk of flexion injury. References: 1) Gravenstein N, Kirby R. Complications in Anesthesiology 2nd edn pages 103, 367, 374-5. 2) Sawyer RJ et al. Peripheral nerve injuries associated with anaesthesia. Anaesthesia 2000, 55, pages 980-991 ----------- |
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NV36c ANZCA version [2001-Aug] Q73, [2002-Apr] Q12
Post-operative ulnar neuropathy A. usually presents within 48 hours of surgery B. symptoms usually persist for over two years C. is more common in men D. can usually be avoided by careful positioning E. can usually be avoided by protective padding of the elbow |
C. is more common in men
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NV36d ANZCA version [2003-Aug] Q78, [2004-Apr] Q99, [2004-Aug] Q70, [Apr07] Q78, [Jul07]
The best predictor of poor outcome for a peri-operative ulnar nerve injury is A. a delay in symptom onset to more than 48 hours postoperatively B. association with anaesthesia lasting more than 2 hours C. association with a brachial plexus block D. presence of bilateral injury E. presence of mixed sensory and motor deficit |
E. presence of mixed sensory and motor deficit
Miller - Only 36% recovered at one year with a mixed sensory loss ASA closed claims 79% of ulnar nerve injuries were to men metabolic problems and chronic illness e.g DM, alcoholism, Vitamin defic and anaemia may predispose to postop ulnar lesion but importance not well understood or defined Farny, et al “Review of Ulnar nerve palsy at the elbow after GA” CJA 1992) ----------- |
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NV36e ANZCA version [2005-Apr] Q42, [Mar06] [Jul06][Apr08][Oct09]
Factors associated with post-operative ulnar nerve palsy include all of the following EXCEPT A. male gender B. sternal retraction for cardiac surgery C. cardiopulmonary bypass for cardiac surgery D. internal jugular vein catheterisation E. diabetes mellitus |
C. cardiopulmonary bypass for cardiac surgery
or D. internal jugular vein catheterisation C>D (Stan says D) - From Anesth Analg 2000;91:1358-69 Nerve Injury during cardiac surgery: "The duration of cardiopulmonary bypass (CPB), aortic cross-clamp times, total anaesthesia times, hematocrit during CPB, or type of oxygenator used have also not been associated with increased frequency of brachial plexus neuropathies after CABG" Same article mentions CVC placement as a risk albeit small. - One in 350 patients under anaesthesia report post-op ulnar nerve injuries. The ASA closed claims study states that 15% of claims are for nerve injuries and that 1/3 of these are ulnar. Predispositions include: Male, Diabetes melitus, thoracic outlet anomalies, arthritis or instability of the elbow, extremes of body habitus, hypovolaemia or hypotension, hypoxaemia, and electrolyte anomalies, prolonged surgical time, Median sternotomy and CABG surgery are big risk factors (6-38%, and 15% respectively). Regional anaesthesia and needle misplacement for jugular CVL placement are also risks. Positioning injuries: 1. Stretching: Due to arm abduction >60deg either while prone or supine. 2. Flexion: arms folded across the torso with extreme flexion at the elbow 3. Abduction: In the lateral decubitus position with shoulder abduction and elbow flexion. 4. Tourniquet use: especially if rigid and low on the arm. Peripheral nerve injuries may take up to a week to present post-op Padding and careful positioning will reduce but not eliminate the risk of nerve injury. Greater than 20% of patients have a more medial ulnar nerve position at the elbow, such that the nerve rides over the posterior tip of the epicondyle. This increases the risk of flexion injury. References: 1) Gravenstein N, Kirby R. Complications in Anesthesiology 2nd edn pages 103, 367, 374-5. 2) Sawyer RJ et al. Peripheral nerve injuries associated with anaesthesia. Anaesthesia 2000, 55, pages 980-991 ----------- |
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NV38a ANZCA version [2004-Apr] Q45, [2004-Aug] Q132 (Similar question reported in [Apr99] [Aug99])
The median nerve A. provides sensation to the radial side of the palm and radial three fingers B. can be blocked at the elbow with the arm abducted, and injecting immediately lateral to the brachial artery on the intercondylar line C. at the wrist is blocked 2 cm proximal to the distal crease between palmaris longus and flexor carpi ulnaris D. lies medial to the flexor carpi ulnaris if palmaris longus is absent E. is formed from fibres from the lateral, medial and posterior cords of the brachial plexus |
A. provides sensation to the radial side of the palm and radial three fingers
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NV38b ANZCA version [2005-Apr] Q65 [Mar06] [Jul06] [Apr07]
The median nerve A. can be blocked at the elbow immediately lateral to the brachial artery B. can be blocked at the wrist between palmaris longus and flexor carpi ulnaris C. can be blocked at the wrist medial to flexor carpi ulnaris D. is formed from the lateral, medial, and posterior cords of the brachial plexus E. provides sensation to the radial half of the palm |
E. provides sensation to the radial half of the palm
- Lies medial to the brachial art. beneath the bicipital aponeurosis. - From the elbow, the median n. descends between the 2 heads of pronator teres and beneath the fibrous arch of flexor digitorum superficialis. Adherent to the deep surface of the ms, it emerges on the radial side, lying between flexor carpi radialis and palmaris longus before passing through the carpal tunnel into the hand. - lateral and medial cords only ----------- |
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NV39b ANZCA version [2003-Aug] Q106
Blockade at the wrist of the nerve marked '1' in the figure usually results in A. anaesthesia of the entire thumb B. anaesthesia of the palmar aspect of the hypothenar eminence C. anaesthesia of the palmar aspect of the radial 3 digits D. paralysis of adductor pollicis E. paralysis of the medial lumbrical muscles |
C. anaesthesia of the palmar aspect of the radial 3 digits
Medial n. injury or block at the wrist Sensory loss; - radial 3 1/2 fingers, palmar surfaces, and finger tips. Motor loss; Pointing finger position (index finger out straight and all other fingers flexed) Weak thumb abduction (abductor pollis brevis) FOUR muscles of the hand are supplied by the median nerve. The remainder are supplied by the Ulnar nerve. The mnemonic LOAF is a handy reminder. L - Lateral two lumbricals O - Opponens pollicis A - Abductor pollicis brevis F - Flexor pollicis brevis ----------- |
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NV40 ANZCA version [2002-Mar] Q128, [2002-Aug] Q148
On examination of the hand and forearm 1. anaesthesia of the palmar aspects of the ulnar one and half fingers only, is compatible with division of the ulnar nerve at the elbow 2. wrist drop is compatible with a lesion of the posterior interosseous nerve 3. weakness of flexion of the wrist could be due to the carpal tunnel syndrome 4. inability to pronate the forearm may be due to a median nerve injury in the upper arm |
2. wrist drop is compatible with a lesion of the posterior interosseous nerve
4. inability to pronate the forearm may be due to a median nerve injury in the upper arm ----------- |
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NV42 [Apr07] [Jul07] [Oct08][Mar10] [Aug10] [Sep11] [Mar12][Aug12]
C6/7 motor function causes (or myotome of C6-7): A. Flexion/extension of fingers B. Flexion/extension of wrist C. Flexion of elbow D. Elbow pronation/supination E. Shoulder external rotation/abduction |
B. Flexion/extension of wrist
Shoulder - ABduction C5 6 - ADDuction C7 8 Elbow - Flexion C5 6 - EXTension C7 8 Wrist - Flex C6 7 - EXT C7 8 Fingers - Flex C7 8 - EXT C7 8 - Abduction / Adduction T1 ----------- |
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NV43 [Apr07]
NV43 [Apr07] Q13 At the wrist joint A. the median nerve lies between the tendons of palmaris longus and flexor carpi radialis B. the median nerve lies medial to the tendon of flexor carpi radialis C. the radial artery is usually palpable just medial to the tendon of flexor carpi radialis D. the ulnar artery and nerve enter the hand by passing deep to the flexor retinaculum |
A. the median nerve lies between the flexor carpi radialis and palmaris longus
Three nerves supply sensation to the hand. These nerves may be conveniently blocked at the wrist. The ulnar nerve runs down in the flexor compartment of the forearm, first covered by the flexor carpi ulnaris (FCU), then passing radial to this muscle. The ulnar artery accompanies the nerve radially. The nerve divides 5 cm from the wrist into a dorsal and a palmar branch, both of which run next to, or deep to, the FCU tendon. The median nerve runs down between the deep and superficial flexor tendons. At the proximal crease it lies between the palmaris longus (PL) and the flexor carpi radialis (FCR), deep to the flexor retinaculum. If the PL is absent, the nerve runs between the flexor tendons and FCR. This is a confined space, and the nerve is broad and flat at this point. This is one reason why direct injection at this point is often associated with paraesthesia and neuropraxia. The radial nerve lies on the radial side of the forearm, at first accompanying the radial artery, but then branching about 7 cm above the wrist so that by the time it meets the wrist, it is divided into several branches. ----------- |
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NV44 [Jul07]
Post cervical spine surgery, patient has some hand neurology. Surgeon thinks this is due to an ulnar nerve palsy from poor positioning. Which sign will differentiate between a C8/T1 nerve root lesion and an ulnar nerve lesion? A. Parasthesia in little finger B. Parasthesia in index finger C. Weakness in lateral interosseus D. Weakness in Abductor pollicus brevis E. Weakness of adductor digiti minimi |
D. Weakness in Abductor pollicus brevis
~~ - Parasthesia in little finger - C8 and ulnar nerve - Parasthesia in index finger - C7 and median nerve - Weakness in lateral interosseus (C8,T1) - Ulnar nerve - Weakness in Abductor pollicus brevis - supplied by median nerve but it is C8 - Weakness of adductor digiti minimi - ?no such muscle - The ABductor Digiti Minimi Muscle is the most superficial of the three muscles forming the hypothenar eminence (C8,T1) ----------- Ulnar supplied ALL muscles of hand except LOAF - Lateral 2 lumbricals, Opponens Pollicis, Abductor & Flexor Pollicis Brevis LOAF is supplied by Median Radial - supplies Triceps, Brachioradialis and extensor muscles of the hand |
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NV44 ANZCA Version [Jul07][Apr08][Sep11][Mar12]
You are asked to see a 60 y.o. male 2 days following a cervical laminectomy because he has new new neurological symptoms in his right arm. The surgical team think these may be due to poor patient positioning. The sign that would most help differentiate c C8-T1 nerve root injury from an ulnar nerve injury is A. loss of sensation in the index finger B. loss of sensation in the little finger C. weakness of the abductor digiti minimi muscle D. weakness of the abductor pollicis brevis m E. weakness of the first dorsal interosseous m. |
D. weakness of the abductor pollicis brevis
true: T1 and ulnar nerve have very similar sensory and motor distribution. HOWEVER, the one difference is that the LOAF muscles are supplied via the median nerve and provide a point of differentiation. Meat LOAF - Median n. supplies 2 Lateral Lumbricals, Opponens pollicis, Abductor and Flexor policis brevis. ----------- |
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NZ03 ANZCA version [2003-Aug] Q123, [2004-Apr] Q79, [Apr07] [Oct08][Oct09][Mar10]
Pre-ganglionic sympathetic fibres pass to the A. otic ganglion B. carotid body C. ciliary ganglion D. coeliac ganglion E. all of the above |
D. coeliac ganglion
- Somatic nerves all get postganglionic. Head and neck receives postganglionic fibres from the sympathetic chain. The VISCERAL plexuses: coeliac, hypogastric and pelvic receive preganglionic via splanchnic nerves to supply postgangionic to viscera (except adrenal medulla). Ellis et al pg 221. - It receives both pre and post ganglionic sympathetic fibers. The ciliary and otic ganglia are parasympathetic ganglia which receive pre-ganglionic parasympathetic fibers but post-ganglionic sympathetics. The carotid body is a sensory organ that transmits afferents to the CNS ----------- |
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TMP-105 [Mar10][Aug10]
The median nerve A. can be blocked at the elbow immediately medial to the brachial artery B. can be blocked at the wrist between palmaris longus and flexor carpi ulnaris C. can be blocked at the wrist medial to flexor carpi ulnaris D. is formed from the lateral, medial, and posterior cords of the brachial plexus E. provides sensation to the ulnar half of the palm |
A. can be blocked at the elbow immediately medial to the brachial artery
- From wiki: The median nerve is formed by a lateral and medial head (from the lateral and medial cords respectively), but has no contribution from the posterior cord (D=FALSE). It runs down the upper arm initally lateral to the brachial artery, but changes to be medial to the artery about halfway down the arm, and is therefore MEDIAL to the brachial artery at the elbow (A=TRUE). It can be blocked at the wrist between palmaris longus and flexor carpi radialis (B=FALSE). It is located LATERAL to the flexor carpi ulnaris at the wrist (C=FALSE), and provides sensation to the lateral 3 and a half fingers and corresponding lateral area of palm - radial side (E=FALSE). ----------- |
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TMP-Oct09-013
All these nerves provide some sensation to upper arm EXCEPT a. Musculocutaneous b. Intercostobrachial c. Radial d. Circumflex e. Median antebrachial? |
a. Musculocutaneous
and e. (must have been remembered incorrectly)... - a. Musculocutaneous - derives from lateral cord (C5,6) - It has only muscular branches above elbow and only sensory branches below as the lateral ante brachial cutaneous nerve at elbow. b. Intercostobrachial - a branch joins the medial cutaneous nerve of the arm (C8,T1) to supply skin over the distal half of the medial side of the arm as far as the elbow. c. Radial - (C5-T1) Provides cutaneous innervation to the posterior and inferior lateral portion of the arm, posterior forearm, and lateral dorsum of the hand and dorsum of digits 1 through 3 and half of digit 4. d. Circumflex also known as the axillary nerve - supplies skin covering inferior region of deltoid muscle - the 'regimental badge' area (which is innervated by the Superior lateral cutaneous nerve branch of the axillary nerve). e. MediaL antebrachial cutaneous nerve - (C8-T1) descends in the arm anterior and medial to brachial artery. At distal to mid forearm level, nerve emerges from under brachial fascia adjacent to basilica vein. It innervates the skin of anterior and medial surfaces of forearm as far as wrist. ----------- |
