NEB Formative Assessment Gait, Skeletal Supports & Locomotion

Prof. Saeed Shafi SMC/SFLT

During a military drill in PMA Kakool, an army cadet got his medial

aspect of the sole injured by a barbwire which resulted in

excruciating pain on medial aspect of foot extending to the leg and

lower thigh. A week later he developed painful enlarged lymph

nodes in the groin.

(A) Give drainage area of inguinal lymph nodes.

(5)

(B) Draw & label cutaneous nerve supply of sole of foot.

(5)

Saleem Khan, chukidar of Boy’s Hostel of SMC

got bullet injury of left femoral sheath. He was

brought immediately to CMH Emergency, where

Vascular surgeon ligated both ends of his

damaged femoral artery. His postoperative

recovery was smooth.

A. Enumerate alternate source/s of arterial

supply to lower limb in this case. (5)

B. Illustrate the compartments and contents of

femoral sheath. (5)

A football player while kicking the football

twisted his right leg at right angle to convert the

ball into goal. He fell down and was unable to

flex his fully extended knee.

A. Name the movements taking place at

knee joint and muscles responsible for

each movement. (6)

B. Which muscle initiate unlocking

mechanism in a fully extended knee and

how? (4)

Mallala, a young university student presented in

SSMC with difficulty in running and jogging. She

was rejected from PAF on medical grounds.

After thorough work-up her physician declared

that her problem is due to flat feet.

A. Enumerate structures/ factors

responsible for formation and

maintenance of medial longitudinal arch

of foot. (6)

B. Draw & label cutaneous nerve supply of

dorsum of foot. (4)

Eiman, a 2nd year medical student of Poonch

Medical University is expecting her menstrual

bleeding from 8th March, 2013. All of her family

members are planning a week long trip to Saudi

Arabia to perform Umrah in 2nd week of March,

2013. Her mother and sister compelled her to

accompany the family to Mecca to perform

Umrah. She visits you (being the family

Physician) to get medical and/or religious

advice to delay her menstrual bleeding.

A. Is this possible in our religious and social

context? What medical advice you can offer

Eiman, enabling her to perform Umrah with

her family during these days? 6

B. What is corpus luteum? Give its formation and

function/s. 4

An elderly woman with osteoporosis is taken to

emergency department following a fall in

washroom. One of her legs appeared shortened

and externally rotated. Radiological

examination of affected hip revealed fracture of

neck of femur. The Consultant Orthopedic

Surgeon advised her hip prosthesis.

A. What is the anatomico-physiological basis of

her presentation? (4)

B. Enumerate extensors of hip, along with their

nerve supply. (6)

During change of Command parade at Army

stadium Rawalpindi, an army cadet fell down

and fractured his medial epicondyle of left

humerus. A week later he developed claw hand.

A. What is the anatomical basis of claw-hand

in such cases? (4)

B. Draw & label cubital fossa and give its

contents. (6)

Khansa Gull, a tall, slim fashion model, noticed

a midline dimple and a tuft of hair at

lumbosacral junction of her spine. X-ray lumbo-

sacral spine revealed incomplete vertebral arch

and absence of spinous process of L4 & L5

Vertebrae.

A. What is the embryological basis of Khansa’s

presentation? (6)

B. What future complications may happen in

such cases? (4)

During Skill Lab session, Faryal, a 2nd year

medical student of SMC was given the task to

inject intravenous injection to a classfellow in

cubital fossa.

A. Enumerate the boundaries and contents

of cubital fossa. (6)

B. Give the attachment and function of

bicipital aponeurosis and tendon. (4)

Ammal, a 45-year unmarried City School

teacher developed carcinoma in upper & outer

quadrant of her right breast. She underwent

radical mastectomy with ipsilateral clearance

of axillary lymph nodes. Her postoperative

convalescence was trouble free. Four weeks

later, she reported in surgical OPD with inability

to raise her right arm vertically upward. The

examining physician asked Ammal to press his

hands against the wall in front. It was found that

the medial border and inferior angle of his right

scapula became prominent.

A. What is the neuroanatomic basis of her

clinical presentation? (4)

B. Enumerate boundaries and contents of axilla.

(6)

Ismat, a 1st year medical student of RMC,

Rawalpindi, developed atrophy of right thenar

eminence a months after mid-shaft fracture of

her radius in a road traffic accident at Kohala

bridge. She can perceive general sensations

over thenar eminence and perform adduction

of thumb; whereas, all other movements of

thumb are absent.

(A) What is the neuroanatomic basis of her

presentation? (4)

(B) Draw and label the cutaneous nerve supply

of hand. (6)

Faiza Kiran, a grade 9 student of AAA high

school Muzaffarabad fell from bicycle and got

fracture of surgical neck of right humerus. Her

arm was immobilized by a PAHALWAN for 4-

weeks. Later on, she was unable to perform

abduction of affected shoulder and had sensory

loss on its overlying skin.

A. What is the neuro-anatomical basis of her

presentation? (5)

B. Enlist the abductors of shoulder along with

their nerve supply. (5)

Saady, a 55-year old Pakistan Railway Qully,

whose work involved carrying heavy loads on

the shoulder, experienced difficulty in raising his

right arm vertically upward after lifting a large

suit-case at Rawalpindi Station. The examining

physician asked Amman to press his hands

against the wall in front. It was found that the

medial border and inferior angle of his right

scapula became prominent.

A. What is the neuroanatomic basis of his

presentation? (6)

B. Define axilla. Give its contents. (4)

Shakeel, a left handed A.C. technician was

fixing a split air conditioning unit in the wall.

While fixing screws he attempted many times to

tighten screws with his left hand but ultimately

he has to use his right hand to accomplish the

task.

A. What movement of Shakeel’s upper limb

is essential for mannual tightening of

screws? (3)

B. Which joint/s participate in such movement.

(3)

C. Why Shakeel ultimately used his right

hand for this action, whereas, he was a left

handed guy? (4)

Turbat khan, a short stature Chukidar of PC

Muzaffargarh developed abnormal backward

bulging of his dorsal spine during school-age.

A. Compare primary and secondary curvatures

of vertebral column. (6)

B. Enumerate parts of a typical vertebra. (4)

Ronaldo, a famous football player while kicking

the football twisted his right leg, which resulted

in excruciating pain in the right knee joint and

spasm of ipsilateral hamstrings. Moreover, he

was unable to extend his affected knee.

A. Which structure of the knee joint is most

liable to injury in this case and why? (5)

B. Which muscle initiate unlocking mechanism

in a fully extended knee and how?

(5)

After a major abdominal operation, a patient

was given a course of antibiotics by

intramuscular injections. The nurse was

instructed to give the injections into the right

buttock. After leaving hospital, patient felt

impaired skin sensation on the lateral side of the

right leg.

a) Give neuro-anatomic basis of impaired

sensation in this case.

5

b) Name two safe sites for intramuscular

injections in human body and justify it.

5

A 38-year-old woman presented with

complaints of headache, high-grade fever,

neck stiffness, nausea, and vomiting. The

neurologic examination revealed intact cranial

nerves, normal reflexes, and no sensory or

motor deficits. Her white blood cell count was

21,800/mm3 with 67% polymorphonuclear

leukocytes and 26% band cells. A lumbar

puncture was suggested by her physician. Using

your knowledge of Basic Medical Sciences:

a. Name the structures (from superficial to

deep) pierced by the needle during lumbar

puncture. 6

b. What are the different abnormal curves of

vertebral column?

4

Misry Khan, a retired military personal got bullet

injury of left femoral artery in femoral sheath.

He was brought immediately to Emergency,

where Surgeon ligated both ends of his

damaged femoral artery. His postoperative

recovery was smooth.

a. Enumerate alternate source/s of arterial

supply to lower limb in this case.

6

b. Enumerate clinical applications of femoral

artery. 4

a. Draw and label the compartments and

contents of femoral sheath. (6)

b. Enlist the components of Quadriceps

femoris muscles along with their nerve

supply and action/s. (4)

a. Illustrate the cutaneous nerve supply of

dorsum of foot. (4)

b. Enlist muscles of flexor compartment of

leg giving their nerve supply and action/s of

each. (6)

Noor Afshan brought her one year old boy to

pediatrician for deformed foot. After a

thorough work up, pediatrician diagnosed him

a case of talipes equinovarus/club foot.

a. Name two characteristic features of club

foot. 4

b. Enlist structures (from medial to lateral)

passing deep to flexor retinaculum of foot. 6

a. Enumerate Hamstring muscles along with

their nerve supply and action/s. 5

b. Enlist veins commonly used for venae

puncture in lower limb; and why? 5

A 50 year old lady presented with drooping of

eyelids. She is unable to raise her hands above

her head. After investigation the doctor finds

that it is some autoimmune disorder of

neuromuscular junction.

(A) Explain the physiological mechanism

responsible for her presentation.

4

(B) Draw and label neuromuscular junction in

skeletal muscle.

6

A 15 yrs football player was hit by another

player’s helmet, striking into his axilla. On

getting up, he complained of shoulder

weakness and pain. He was taken to the ER of

AIMS, Muzaffarabad. On examination, he has

ability to initiate shoulder abduction, but he

cannot raise his arm more than 15 degree.

There was mild weakness of lateral rotation and

a patch of sensory loss over his affected upper

arm.

a. Enlist muscles responsible for abduction at

shoulder joint. 5

b. Why he cannot raise his arm more than 15

degrees? 5

A 38-years aged School teacher was travelling

from Kohala to Bahg. She placed her hands on

the dashboard immediately prior to accident.

She complained of diffuse pain and weakness

in her upper limbs. Clinical examination showed

bilateral wrist drop. X-ray examination revealed

bilateral fracture of the humerus at the spiral

groove.

a) What is the neuro-anatomic basis of wrist

drop in her case? 5

b) Which blood vessel/s in spiral groove is

liable to injury in her case and why? 5

Nazia, a 22-year old embroider from Shangla

came to her family physician complaining of

difficulty in creating patterns on cloth because

she was unable to hold a needle between her

thumb and index finger. She was awakened

from sleep at 3:00 am due to pain and tingling

sensation in her right hand. Examination

revealed decreased sensations in her thumb,

index and middle finger; and wasting of

muscles of thenar eminence.

a. Give anatomico-physiological basis of her

presentation. 6

b. Which nerve is most likely to be involved in

her case? 4

Faria, a grade seven, City School student got

fracture of left arm, while climbing to

PirChinassy mountain. She was brought to

AIMS-Muzaaffarabad by Rescue workers. After

thorough clinical examination, Resident Doctor

told her mother that she had wrist drop of left

hand. X-ray of left arm confirmed mid-shaft

fracture of Humerus.

a. Injury to which nerve is responsible for

her presentation and why? (5)

b. What is the neuroanatomic basis of wrist

drop in such cases? (5)

Rafia, a 45-year aged business executive of

Telenor presented in orthopedic OPD of CMH

Sakadu with complaints of painful movements

of right shoulder during brushing hair, changing

clothes and brushing her teeth. The symptoms

worsened over the period of four months. The

orthopedic surgeon after thorough workup

diagnosed her as a case of “rotator cuff

syndrome”.

a. Enlist structures contributing to the

formation of rotator cuff. (5)

b. Which muscle/s are responsible for

abduction of shoulder joint? (5)

Abdullah, a 12-year old school boy got fracture

of medial epicondyle of right humerus, while

playing football. On examination, he had

sensory loss involving the little finger and medial

aspect of the ring finger. He was unable to

abduct and adduct the fingers at

Metacarpophalangeal joints.

a. Which nerve is involved in this case and

why? (6)

b. If this injury is neglected, what will be the

resultant deformity? (4)

Talat, a middle aged school teacher came to

medical OPD with complaints of pain along the

medial side of her right forearm along with

parasthesia of hand. She also complained of

ischemic pain in hand on excessive use. On

thorough workup she was diagnosed as a case

of cervical rib.

a. Which cord of brachial plexus is most likely

to be affected by cervical rib and why? 4

b. Why Talat felt ischemic pain on excessive

use of her right hand? 6

Rukhsana, a 1st year nursing student, developed

atrophy of left thenar eminence two months

after mid-shaft fracture of her left radius in road

traffic accident. She can perceive general

sensations over that area.

a. What is the neuro-anatomic basis of her

presentation? 4

b. Draw and label the cutaneous nerve supply

of hand. 6

Amman, a 35-year old professional labourer,

whose work involved carrying heavy loads on

the shoulder, experienced difficulty in raising his

right arm vertically upward. The examining

physician asked Amman to press his hands

against the wall in front. It was found that the

medial border and inferior angle of his right

scapula became prominent.

a. Is this a problem of nerve injury, muscle

injury, both OR something else? 4

b. What is the neuroanatomic basis of his

clinical presentation? 4

c. What would be your priority for diagnosis of

such patient? 2