Anatomy

1). (OBQ04.162) What is the main blood supply to the abductor digiti minimi? Review
Topic

QID: 1267

1. Ulnar artery
77% (1242/1605)

2. Posterior interosseous artery

3% (49/1605)

3. Anterior interosseous artery

2% (37/1605)

4. Palmar metacarpal artery

14% (231/1605)

5. Radial artery
2% (36/1605)

PREFERRED RESPONSE 1
The main blood supply to the abductor digiti minimi is the ulnar artery.

The abductor digiti minimi is responsible for abducting the 5th digit away from midline. It is
innervated by the deep branch of the ulnar nerve (C8 + T1). The main blood supply to the
muscle is provided by the deep branch of ulnar artery.

Uysal et al. explored the vascular anatomy of the abductor digit minimi. They suggest that the
abductor digit minimi could be used as a flap in severe crushed injuries of the hand. The
vascular supply to the muscle is via 1 major and 2 constant minor pedicles. The anatomy is
important during dissection as the major pedicle branches off the ulnar artery just distal to its
origin off the pisiform.

Illustration A shows the arterial supply to the hand. Illustration B shows microangiography of
the left hand with hypothenar compartment excised, showing ulnar artery supply to abductor
digiti minimi (ADM) and flexor digiti minimi (FDM). (+, the hamate bone; *, the ulnar
artery; d, dominant major pedicles; m1, first minor pedicles; m2, second minor pedicles)

Incorrect Answers:
Answer 2: Posterior interosseous artery supplies the superficial and deep extensor
compartment muscles in the forearm.
Answer 3: Anterior interosseous artery supplies the flexor compartment muscles in the
forearm.
Answer 4: Palmar metacarpal artery supply the palmar interossei muscles.
Answer 5: Radial artery supplies the thenar muscles in the hand
2) (OBQ04.228) Which of the following nerves innervates the short head of biceps femoris?
Review Topic

QID: 1333

1. peroneal division of the sciatic nerve

66% (651/983)

2. tibial division of the sciatic nerve

26% (253/983)

3. femoral nerve
4% (41/983)

4. superior gluteal nerve

2% (24/983)

5. saphenous nerve
1% (8/983)

PREFERRED RESPONSE 1
The biceps femoris has two heads as its name implies. Each head has its own nerve supply.
The long head is innervated by the tibial branch of the sciatic nerve (L5, S1, S2, and S3). The
short head is innervated by the peroneal branch of the sciatic nerve (L5, S1, and S2). Thus
answer 1 is the correct choice.
3) (OBQ12.231) A 32-year-old female sustains a proximal humerus fracture shown in Figure
A. This fracture goes on to uneventful union, but she complains of a lack of sensation over
the lateral deltoid and has weakness with the Hornblower's test at final follow-up. Which of
the following structures is most likely injured in this patient? Review Topic

FIGURES: A
QID: 4591

1. Anterior branch of the axillary nerve

26% (494/1892)

2. Posterior branch of the axillary nerve

64% (1203/1892)

3. Posterior cord of the brachial plexus

4% (80/1892)

4. Suprascapular nerve
4% (71/1892)

5. Musculocutaneous nerve
1% (25/1892)

PREFERRED RESPONSE 2
The patient scenario above describes an injury to the posterior branch of the axillary nerve.

The axillary nerve divides into an anterior, a posterior, and a collateral branch to the long
head of the triceps brachii. The anterior branch winds around the surgical neck of the
humerus to provide innervation to the anterior deltoid and overlaying skin. The posterior
branch supplies the teres minor and the posterior part of the deltoid and supplies the skin over
the lower two-thirds of the posterior deltoid.

Ball et al. performed a cadaveric study of 19 specimens and found that the posterior branch of
the axillary nerve separates from the main nerve anterior to the origin of the long head of the
triceps. They also found that the superolateral brachial cutaneous nerve and motor innervation
of the teres minor always arises from the posterior branch.

Uno et al. performed cadaveric dissection of 12 shoulders and found that the axillary nerve is
adjacent to the shoulder capsule at the 5 to 7 o'clock position during arthroscopy when the
shoulder is in neutral, extension, or internal rotation. However, they found that shoulder
abduction, external rotation, and traction increases the distance from the capsule to the nerve.

Price et al. performed cadaveric dissection of nine shoulders and found that the branch to the
teres minor is the closest to the glenoid rim with all shoulder motion. They also found that the
distance from the axillary nerve to the glenoid rim at the 6 o'clock position is 12.4mm and the
axillary nerve is only 2.5mm away from the inferior glenohumeral ligament.

Figure A shows a left-sided proximal humeral greater tuberosity fracture with minimal
displacement. Video V demonstrates how to perform Hornblower's test.
Incorrect Answers:
Answer 1: The anterior branch of the axillary nerve has motor fibers for the anterior deltoid.
Answer 3: A posterior cord injury would lead to more dysfunction than just the two findings
listed.
Answer 4: The suprascapular nerve innervates the supraspinatus and infraspinatus.
Answer 5: The musculocutaneous nerve provides innervation to the coracobrachialis, biceps
brachii, and medial brachialis.

4) (OBQ12.242) A 50-year-old laborer presents with clumsiness of his hand. A clinical photo
is shown in Figure A. On physical exam he is found to positive Froment sign, decreased
cutaneous sensation over the ulnar border of his small finger and has a positive Tinels sign at
the medial elbow. While undergoing elective surgery for this condition, the affected nerve is
transected while attempting to excise the medial intermusular septum. Postoperatively, what
limitation to his elbow function would you expect? Review Topic

FIGURES: A
QID: 4602

1. Decreased flexion
3% (42/1410)

2. Decreased extension
2% (22/1410)

3. No limitation
86% (1211/1410)

4. Decreased supination
2% (32/1410)
5. Decreased pronation
7% (97/1410)

PREFERRED RESPONSE 3
This patient has clinical findings consistent with cubital tunnel syndrome. Laceration of the
nerve above the level of the elbow will not affect his elbow function.

The ulnar nerve originates from the medial cord of the brachial plexus. It pierces the medial
intermuscular septum as it courses from anteromedial to posteromedial in the upper half of
the arm. As the nerve traverses distal to the cubital tunnel, it will give rise to motor branches
that feed the FCU and the FDP to the small and ring fingers. The function of the elbow is
predicated on the the motor innervations of the radial nerve, musculocutaneous and median
nerves. While the ulnar nerve innervates some of the ulnar based flexors of the forearm,
elbow function is not affected when it is transected.

Mazurek et al. review the anatomy of the median, radial and ulnar nerves, along with the
clinical implications of compression neuropathies of each. Although the ulnar nerve has a
significant course in the upper arm as it passes from the anterior to the posterior
compartment, the first branches of the ulnar nerve are sensory branches to the elbow joint
capsule. The remainder of the ulnar nerve branches are in the forearm and the hand. No
distinct contribution to elbow function is noted.

Figure A demonstrates a patient with cubital tunnel syndrome; because the FDP to the small
and ringer finger is affected as well, the degree of clawing is not as severe as in a patient with
ulnar nerve compression at Guyons canal. There is atrophy of the 1st dorsal webspace
consistent with the condition.

Incorrect Answers
Answer: 1, 2, 4, 5: Given the course of the ulnar nerve in the upper arm, an injury to the
nerve above the elbow will not compromise elbow function.

5) (OBQ09.30) A patient is undergoing percutaneous iliosacral screw fixation for a sacroiliac

joint diastasis. The proposed screw trajectory into the S1 body is represented by the red star
on the drawing of the sacrum in Figure A. What is the most common strength deficit sequela
of this proposed screw trajectory? Review Topic

FIGURES: A
QID: 2843

1. Loss of hip flexion

2% (14/928)

2. Loss of knee extension

1% (5/928)

3. Loss of ankle dorsiflexion

5% (51/928)

4. Loss of great toe extension

85% (788/928)

5. Loss of ankle plantar flexion

7% (64/928)

PREFERRED RESPONSE 4
The proposed screw trajectory as seen on the lateral view of the sacrum in Figure A would
most likely result in a L5 nerve root injury. Safe placement of sacroiliac screws include
ensuring on the lateral projection that the guidewire/screw are below the iliac cortical density
and sacral alar slope line to prevent injury to L5 nerve root. The outlet view is used to ensure
that the guidewire/screw are above the S1 sacral foramen. The inlet view is used to ensure
that the guidewire/screw are placed into the anterior aspect of the sacral body.

L5 innervates the tibialis anterior (deep peroneal n.), tibialis posterior (tibial n.), EHL (DPN),
EDL (DPN), hamstrings (tibial) & gluteus max (inf. gluteal n.), gluteus medius (sup. gluteal
n.).

Louis conducted a Level 4 study of 455 patients undergoing screw-plate lumbosacral fusion
and found that aberrant screw placement into the sacrum caused L5 nerve root pareses in a
total of 9 patients.

Aylwin described a case study of sacral stress fracture resulting in a L5 nerve radiculopathy
secondary to periosteal reaction.
6) (OBQ08.3) Which of the following unipennate muscles takes its origin on the radial side of
the profundus tendon, inserts on the radial lateral band at the middle phalanx, and creates a
force vector that is palmar to the joint axis of the metacarpophalangeal joint? Review Topic

QID: 389

1. 1st lumbrical
63% (606/968)

2. 1st dorsal interosseous

6% (57/968)

3. 4th dorsal interosseous

2% (21/968)

4. 4th lumbrical
25% (243/968)

5. 4th palmar interosseous

3% (33/968)

PREFERRED RESPONSE 1
The 1st and 2nd lumbricals are unipennate and originate on the flexor digitorum profundus
(FDP) to these fingers. The 3rd and 4th lumbricals are bipennate and each have one head that
originates from the FDP from the respective finger and a second head that originates from the
FDP of the middle and ring finger, respectively (Illustration A).

Lumbrical insertion is classically thought to be on the radial lateral band of the extensor
expansion, but Eladoumikdachi et al performed a cadaveric dissection on 14 hands and found
that the insertions were variable and included proximal phalanx and volar plate. The
lumbricals extend the PIP and DIP joints while also flexing the MCP joint.

Their mechanism is pathologically exemplified in the intrinsic-plus hand with associated

intrinsic tightness, where the contracted intrinsic muscles (lumbricals and interosseous) as
shown in (Illustration B) will prevent supple DIP/PIP flexion. The 1st and 4th dorsal
interosseous muscles are bipennate muscles originating from the adjacent metacarpals of each
web space and causes abduction of the fingers. The 3 palmar interosseous muscles are located
on the ulnar side of the index metacarpal and on the radial aspect of the ring and small
metacarpals. They insert on to the lateral bands of their respective digits and cause adduction
of the fingers.

7) (OBQ08.52) A trauma patient undergoes an upper extremity angiogram seen in Figure A.

Which of the following correctly labels the arteries W, X, Y, Z respectively? Review Topic

FIGURES: A
QID: 438

1. Brachial, radial, radial recurrent, ulnar

0% (4/904)

2. Brachial, radial, posterior interosseous, ulnar

1% (9/904)

3. Ulnar, anterior interosseous, posterior interosseous, radial

21% (188/904)

4. Radial, anterior interosseous, posterior interosseous, ulnar

75% (676/904)

5. Radial, radial recurrent, common interosseous, ulnar

3% (24/904)

PREFERRED RESPONSE 4
The correct labels are given in response 4 (W=radial, X=anterior interosseous, Y=posterior
interosseous, Z=ulnar).
The brachial artery divides at the elbow giving rise to the ulnar and radial arteries. Recurrent
arteries curve and flow back proximally. The common interosseus artery is a branch high off
the ulnar artery just distal to the brachial artery bifurcation. The key to getting this question
correct, is knowing that the interosseus arteries are branches off the ulnar. Differentiating
between the two interosseous arteries is not required for this question because it would
require a lateral view showing the one coursing anterior to the interosseous membrane, while
the posterior interosseous artery courses posterior to the interosseous membrane.

Illustration A is a diagram of the vasculature of the anterior forearm around the elbow.

8) (OBQ09.232) The axial MRI shown in Figure A shows a tumor located in one of the
muscles of the thigh. Which nerve innervates this muscle? Review Topic

FIGURES: A
QID: 3045

1. Tibial
0% (3/930)

2. Peroneal
0% (3/930)

3. Obturator
37% (341/930)

4. Femoral
60% (561/930)

5. Sartorial
2% (17/930)
PREFERRED RESPONSE 4
The MRI shows a tumor located in the sartorius muscle, which is innervated by the femoral
nerve. While the sartorius nerve shares the same name, it does not innervate the sartorius
muscle.

Correction from Illustration A: Adductor magnus receives dual nervous innervation from the
obturator and sciatic nerves.

9) (OBQ07.16) The inferior and superior gluteal nerves are designated as such based on their
relationship to what structure? Review Topic

QID: 677

1. The gluteus maximus

2% (19/968)

2. The gluteus minimus

3% (32/968)

3. The piriformis muscle

75% (722/968)

4. The sciatic nerve

4% (37/968)

5. The sacrospinous ligament

16% (151/968)

PREFERRED RESPONSE 3
The superior gluteal nerve arises from the posterior roots of L4, L5 and S1 in the lumbosacral
plexus. It exits the pelvis through the superior part of the greater sciatic notch, just superior to
the piriformis tendon. It courses between the gluteus medius and minimus, supplying both
muscles, as well as the tensor fascia lata. The inferior gluteal nerve arises from the posterior
roots of L5, S1 and S2 in the lumbosacral plexus and exits the pelvis through the greater
sciatic notch, under the piriformis. It courses on the deep surface of gluteus maximus and
provides the sole motor innervation for this muscle.
10 ) (OBQ07.185) Which of the following items is located medial to the iliocostalis and
lateral to the semispinalis muscle? Review Topic
QID: 846

1. Multifidus
16% (143/871)

2. Rotatores
2% (15/871)

3. Longissimus
72% (630/871)

4. Quadratus lumborum
7% (62/871)

5. Latissimus
1% (11/871)

PREFERRED RESPONSE 3
The illiocostalis, longissimus, and spinalis muscles share a common origin sacrum, iliac crest,
and lumbar spinous process. A mnemonic to help remember the anatomy is from lateral-to-
medial: "I(liocostalis) L(ongissimus)ike S(pinalis)tanding". The iliocostalis muscle inserts on
the ribs; the longissimus on the thoracic and cervical transverse process and mastoid process;
and the spinalis muscle on the thoracic spinous processes. They all act to laterally flex, extend
and rotate head and vertebral column.

Illustration A shows the anatomic relationship of these muscle groups.

11) (OBQ11.258) Which of the following muscles originates from the ventral surface of the
sacrum? Review Topic

QID: 3681

1. Obturator internus
20% (192/960)

2. Obturator externus
5% (46/960)

3. Quadratus femoris
4% (43/960)

4. Piriformis
67% (642/960)

5. Superior gemellus
3% (31/960)

PREFERRED RESPONSE 4
Of the muscles listed, only the piriformis muscle originates from the ventral surface of the
sacrum. Illustrations A and B show the origin and insertion of the piriformis muscle from the
sacrum to the piriformis fossa on the proximal femur.

Illustration C is a T1 MRI showing the origin of the piriformis muscle from the ventral
surface of the sacrum. (a) shows the right piriformis muscle overlying the S2 nerve (arrow).
(p) shows the left piriformis muscle.

Incorrect answers:
1&2: Obturator internus and externus both originate from the anterior pelvis inferior pubic
ramus (Illustration B) and obturator membrane.
3: Quadratus femoris originates from the inferior pubic ramus near the ischial tuberosity
(Illustration B)
5: Superior gemellus originates from anterior pubic ramus near the acetabulum (Illustration
B)
12 ) (OBQ11.108) During total hip arthroplasty (THA) via a posterior approach, where is the
sciatic nerve most likely to be found? Review Topic

QID: 3531

1. Superficial to the piriformis and superficial to the short external rotators

5% (50/1038)

2. Superficial to the piriformis and deep to the short external rotators

12% (122/1038)

3. Deep to the piriformis and deep to the short external rotators

4% (38/1038)

4. Deep to the piriformis and superficial to the short external rotators

78% (812/1038)

5. Splits the piriformis and is superficial to the short external rotators

1% (11/1038)

PREFERRED RESPONSE 4
During the posterior approach to the hip, the most predictable course of the sciatic nerve is
deep to the piriformis and superficial to the short external rotators exiting above the superior
gemellus. As such, most recommend identification of the sciatic nerve by palpation in
primary THA. In revision THA, many advocate identification of the sciatic nerve by both
palpation and direct visualization.

The most common anatomic variant in the relationship of the short external rotators and the
sciatic nerve is with the sciatic nerve traveling between the capsule and the short external
rotators exiting below the superior gemellus.

Smoll reviewed the anatomy of the gluteal region and sciatic nerve anomalies in a meta-
analysis and review of over 6000 cadavers. They concluded that the anomalies were present
in about 16.8% of cadavers. They recommended a heightened awareness of the anomalies in
hip surgery. The most common variants are found in Illustration D which were also supported
by an earlier Beaton et al study.
Illustrations A,B and C depict the anatomy of the gluteal region including the anatomic
relationship of the sciatic nerve to the short external rotators.
13) (OBQ04.53) Injury to the deep peroneal nerve would result in which of the following?
Review Topic

QID: 1383

1. Weakness of hindfoot eversion

7% (70/1014)

2. Weakness of hindfoot inversion

2% (22/1014)

3. Weakness of great toe extension

85% (862/1014)

4. Weakness of great toe flexion

3% (32/1014)

5. Weakness of ankle plantarflexion

2% (21/1014)
PREFERRED RESPONSE 3
The deep peroneal nerve supplies the extensor digitorum longus, along with tibialis anterior,
extensor hallucis longus, extensor digitorum brevis, peroneus tertius, and extensor hallucis
brevis. Weakness of these muscles would be seen with an injury to the deep peroneal nerve.
Illustration A shows the path of the deep peroneal nerve.

The sural nerve supplies the skin on the posterior part of the distal leg and the lateral side of
the foot. The tibial nerve supplies the soleus, gastrocnemius, popliteus, tibialis posterior,
flexor hallucis longus, flexor digitorum longus, and plantaris. The superficial peroneal nerve
supplies the peroneus longus and brevis.

The referenced study by Wolinsky and Lee is a cadaveric study that reported that the deep
peroneal nerve courses along the posterior half of the tibial shaft proximally and crosses the
distal third of the tibia in a consistent region 40 to 110 mm proximal to the ankle joint. They
also report that an anterolateral approach to the ankle always exposes the superficial peroneal
nerve in the subcutaneous tissues.

Incorrect answers:
Answer 1: Superficial peroneal nerve innervates the peroneal muscles which evert the
hindfoot.
Answer 2: Tibial nerve innervates the posterior tibialis muscles which is the main hindfoot
inverter.
Answer 4: Tibial nerve innervates the flexor hallucis longus which flexes the great toe.
Answer 5: Tibial nerve innervates the soleus, gastrocnemius which flex the ankle joint.

14) (OBQ11.147) During recovery for a radial nerve palsy, what is the last muscle to be
reinnervated? Review Topic

QID: 3570

1. Brachioradialis
3% (25/958)

2. Extensor indicis proprius

80% (771/958)

3. Extensor carpi radialis brevis

4% (43/958)

4. Abductor pollicis longus

5% (47/958)

5. Extensor pollicis longus

7% (67/958)

PREFERRED RESPONSE 2
The last muscle to demonstrate evidence of reinnervation during recovery for a radial nerve
palsy is the extensor indicis proprius.

Abrams et al dissected 20 cadavers to identify the motor branches of the radial nerve. They
determined the innervation order from proximal to distal was brachioradialis, extensor carpi
radialis longus, supinator, extensor carpi radialis brevis, extensor digitorum communis,
extensor carpi ulnaris, extensor digiti quinti, abductor pollicis longus, extensor pollicis
longus, extensor pollicis brevis, and extensor indicis proprius (Illustration A).

15) (OBQ11.255) A 4-year-old male falls from monkey bars and sustains an extension
supracondylar humerus fracture with a neurologic deficit. Which of the following muscles is
most likely affected? Review Topic

QID: 3678

1. Extensor digitorum communis

14% (127/920)
2. Pronator quadratus
67% (618/920)

3. Flexor carpi radialis

10% (92/920)

4. Flexor digitorum profundus to small/ring fingers

7% (61/920)

5. Flexor carpi ulnaris

2% (18/920)

PREFERRED RESPONSE 2
Anterior interosseous nerve injury is the most common nerve injury seen in extension type
supracondylar humerus fractures in children. The anterior interosseous nerve innervates
flexor pollicis longus, flexor digitorum profundus to the index and long fingers and pronator
quadratus.

Seror describes a consecutive series of 13 patients with lesions of the anterior interosseous
nerve. Based on the difficulty of diagnosis and evaluation, these patients are most frequently
misdiagnosed with tendon injuries. In his series, only 3 patients had a correct initial clinical
diagnosis, and the most common electrophysiological abnormality found was in the
innervation of pronator quadratus.