Blue Boxes

Question 1

Fracture Of Scapula

Answer 1

Usually the result of severe trauma
Occurs in pedestrian-vehicle accidents
Usually also have fractured ribs
Most fractures require little treatment because the scapula is covered on both sides by muscles. Most fractures involve the protruding subcutaneous acromion

Question 2

Fracture of Humerus

Answer 2

Most injuries of the prox. End of the humerus are fractures of the surgical neck. Especially in elderly with osteoporosis. Most humeral fractures often result in one fragment being driven into the spongy bone of the other fragment (impacted).
Injuries usually result from a minor fall on the hand, with the force being transmitted up the forearm bones of extended limb
Sometimes fracture is stable due to impaction of fragments
Middle-aged/elderly may see allusion fracture of greater tubercle. Resulting from a fall on the acromion. In younger people it’s usually due to fall on hand when arm is abducted
Transverse Fx: direct blow to arm usually.
Indirectly injury from fall on outstretched hand is spiral fracture
Intercondylar fracture: severe fall on flexed elbow. Olecranon is driven like a wedge between medial and lateral epicondyles
Surgical neck: axillary nerve
Radial groove: radial nerve
Distal end of humerus: median nerve
Medial epicondyle: ulnar nerve

Question 3

Fractures of Radius and Ulna

Answer 3

Usually result of severe injury
Direct injury: usually transverse Fxs at the same level, usually middle third of bones
Due to interosseous membrane: Fx of one bone is likely to be associated with dislocation of the nearest joint
Fracture of distal radius: common fracture in adults 50+, usually more in women due to osteoporosis. Transverse fracture is a Colles fx (most common of the forearm)-distal fragment is dorsally displaced and often broken into pieces.

Question 4

Fracture of the Scaphoid

Answer 4

Most frequently fractured carpal bone. often results from a fall on the palm when the hand is abducted, the fracture occurring across the narrow part of the scaphoid
Pain occurs primarily on the lateral side of the wrist, especially during dorsiflexion and abduction of the hand
May be misdiagnosed a severe sprain. proximal portion may lead to AVN due to poor blood supply. Sometimes degenerative joint disease may occur

Question 5

Fracture of Hamate

Answer 5

Fracture of the hamate may result in non-union of the fractured bony parts because of the traction produced by the attached muscles
Ulnar nerve may be injured due to close proximity, causing decreased grip strength of the hand. Ulnar artery may be damaged as well

Question 6

Fracture of Metacarpals

Answer 6

Isolated fractures tend to be stable because they’re all closely bound together (except the 1st). These bones have good blood supply and fractures usually heal rapidly
Severe crushing injuries of the hand may produce multiple metacarpal fractures resulting in instability
Boxer’s fracture: 5th metacarpal when an unskilled person punches someone with a closed and abducted fist. Flexion deformity

Question 7

Fracture of Phalanges

Answer 7

Crushing injuries of the distal phalanges are common (finger caught in door)
Very painful
Distal phalanx fractures are usually comminuted and a painful hematoma usually develops
Proximal and middle fractures are usually due to crushing or hyperextension injuries (bones need to be carefully realigned to restore function due to close relationship with flexor tendons)

Question 8

Paralysis of Serratus Anterior

Answer 8

Due to injury to the long thoracic nerve: the medial border of the scapula moves laterally and posteriorly away from the thoracic wall, giving scapula the appearance of a wing, especially when a person leans on a wall.
Winged scapula: When the arm is raised, the medial border and inferior angle of the scapula pull markedly away from the posterior thoracic wall
Upper limb may not be able to be abducted above the horizontal position because the serratus anterior muscle cannot rotate the glenoid cavity superiorly to allow complete abduction of the limb

Question 9

Triangle of Auscultation

Answer 9

Near Inferior angle of the scapula, small triangular gap in the musculature. Superior horizontal border of the lattimus dorsi, medial border of the scapula, and inferolateral border of the trapezius form a triangle of auscultation. Good place to examine posterior lungs

Question 10

Injury of Spinal Accessory Nerve (CN XI)

Answer 10

Ipsilateral weakness when the shoulders are elevated against resistance

Question 11

Injury of the Thoracodorsal nerve

Answer 11

Surgery in the inferior part of the axillary puts the thoracodorsal nerve (C6-8) at risk of injury. (Supplies the latissimus dorsi). Nerve passes inferiorly along the posterior wall of the axillary and enters the medial surface of the latissimus dorsi
Nerve also vulnerable during mastectomies
Person cannot raise the trunk with the upper limbs as occurs during climbing

Question 12

Injury to Dorsal Scapular Nerve

Answer 12

Nerve to rhomboids, affects actions of these

If one side is affected, the scapula is located farther from the midline than on the normal side

Question 13

Injury to Axillary Nerve

Answer 13

Deltoid atrophies.
Because it passes inferior to the humeral head and winds around surgical neck, nerve is usually injured during fracture of this part of humerus. May also be damaged during dislocation of the glenohumeral joint and by compression from the incorrect use of crutches
Rounded contour of shoulder usually flattens on injured side. Loss of sensation may occur over the lateral side of the proximal part of the arm q

Question 14

Fracture-dislocation of Prox. Humerus Epiphysis

Answer 14

Direct blow or injury to the shoulder of a child or teen may produce this. Because the joint capsule of the glenohumeral joint is stronger than the epiphyseal plate.
In severe fractures, the shaft of the humerus is markedly displaced but the humeral head retains its normal relationship with the glenoid cavity of the scapula

Question 15

Rotator Cuff Injuries

Answer 15

Injury or disease may damage the rotator cuff.
Producing instability of the glenohumeral joint
Trauma may tear or rupture one or more of the tendons of the SITS muscles. The supraspinatus tendon is most commonly ruptured
Degenerative tendinitis of the rotator cuff is common, especially in older people.

Question 16

Brachial Plexus Injuries

Answer 16

Affect movements and cutaneous sensations in the upper limb
Disease, stretching and wounds in the lateral cervical region of the neck or in the axillary may produce injuries
Signs and symptoms depend on the part of the plexus involved
Injuries usually result in paralysis or anesthesia
In complete paralysis: no movement is detected. Incomplete paralysis: not all muscles are paralyzed and therefore a person can move but it’s weak compared to normal side. Determining a person’s ability to feel pain determines the degree of anesthesia
Injuries to the superior parts of the brachial plexus usually result from excessive increase in the angle between the neck and shoulder

Question 17

Erb’s Palsy

Answer 17

Superior brachial plexus injury.
Paralysis of the muscles of the shoulder and arm supplied by the C5 and C6 spinal nerves occurs: deltoids, biceps, brachialis.
Clinical appearance: and upper limb with an abducted shoulder, medially rotated arm and extended elbow
lateral aspect of the forearm loses some sensation.
Chronic micro trauma to the superior trunk from carrying a backpack can produce motor and sensory deficits in the distribution of the musculocutaneous and radial nerves

Question 18

Acute Brachial Plexus Neuritis

Answer 18

Unknown cause
Sudden onset of severe pain around the shoulder
Typically pain begins at night and is followed by muscle weakness and sometimes atrophy
Inflammation of the brachial plexus is often preceded by some event

Question 19

Compression of Cords of Brachial Plexus

Answer 19

May result from prolonged hyperabduction of the arm during performance of manual tasks over the head such as painting a ceiling
Cords are impinged and compressed
Pain radiates down the arm, numbness, parenthesis and erythema and weakness of the hands

Question 20

Klumpke Palsy

Answer 20

Much less common
Inferior brachial plexus injuries may occur when upper limb is suddenly pulled superiorly (person grasps something to break a fall or a baby’s arm is pulled excessively during delivery)
Short muscles of the hand are affected and a claw hand results

Question 21

Bicipital Myotatic Reflex

Answer 21

positive response confirms musculocutaneous nerve and C5-C6 spinal cord segment integrity

Question 22

Biceps Tendinitis

Answer 22

Tendon of the long head of the biceps is enclosed by a synovial sheath and moves back and forth in the intertubercular sulcus
Wear and tear of this mechanism can cause shoulder pain
Inflammation of the tendon usually results from repetitive microtrauma and is common in throwing sports

Question 23

Dislocation of Tendon of Long Head of Biceps Brachii

Answer 23

The tendon of the long head of the biceps can be partially or completely dislocated from the intertubercular sulcus in the humerus. Occurs in young people during traumatic separation of the proximal epiphysis of the humerus
Also occurs in older people with a history of biceps tendinitis
Usually a sensation of popping or catching is felt during arm rotation

Question 24

Rupture of Tendon of Long Head of Biceps Brachii

Answer 24

Rupture off the tendon usually results from wear and tear of an inflamed tendon as it moves back and forth in the intertubercular sulcus of the humerus
Typically the tendon is torn from its attachment to the supraglenoid tubercle of the scapula

Question 25

Interruption of Blood Flow in the Brachial Artery

Answer 25

Best place to control hemorrhage is medial to the humerus near the middle of the arm
May be clamped distal to the origin of the deep artery of the arm without producing tissue damage
Although this provides some protection against gradual temporary and partial occlusion, sudden complete occlusion or laceration of the brachial artery creates a surgical emergency because paralysis of muscles results from ischemia of the elbow and forearm within a few hours

Question 26

Fracture of Humeral Shaft

Answer 26

Mid humeral fracture may injure the radial nerve in the radial groove
When damaged, the fracture is not likely to paralyze the triceps because of the high origin of the nerves to two of its three heads. A fracture of the distal part of the humerus nearer the supra-epicondyle ridges is called a supra-epicondylar fracture. This may shorten the limb

Question 27

Injury to Musculocutaneous Nerve

Answer 27

Is typically inflicted with a knife. Results in paralysis of coracobrachialis, biceps and brachialis. Weak flexion may occur at the glenohumeral joint owing to the injury of the musculocutaneous nerve affecting the long head of the biceps and coracobrachialis
Flexion of the elbow joint and supination of the forearm are greatly weakened but not lost (due to brachialradialis and supinator)
Loss of sensation may occur on lateral forearm

Question 28

Injury to Radial Nerve In the Arm

Answer 28

Injury to the radial Nerve superior to the origin of its branches to the triceps brachii may result in the paralysis of the triceps, brachioradialis, supinator and extensor muscles of the wrist and fingers
Loss of sensation in the areas of skin supplied to this nerve also occurs
Injury in the radial groove typically doesn’t affect the triceps because only the medial head is affected
Characteristic sign: wrist drop. Unable to extend the wrist and fingers at the MCP joints

Question 29

Elbow Tendinitis or lateral epicondylitis

Answer 29

Following repetitive use of the superficial extensor muscles of the forearm.
pain is felt over the lateral epicondyle and radiates down the posterior surface of the forearm
Often feel pain when they open a door or lift a glass
Repeated forceful flexion and extension of the wrist strain the attachment of the common extensor tendon, producing inflammation of the periosteum of the lateral epicondylitis

Question 30

Fracture of the Olecranon

Answer 30

Fractured elbow
Fall on the elbow combined with a sudden powerful contraction of the triceps brachii
Olecranon is polled away by the active and tonic contraction of the triceps and the injury is often considered to be an avulsion fracture

Question 31

High Division of Brachial Artery

Answer 31

Ulnar and radial arteries begin in the superior or middle part of the arm and the median nerve passes between them

Question 32

Superficial Ulnar Artery

Answer 32

Needs to be kept in mind when performing venesections for withdrawing blood or making IV injections
May damage artery and produce bleeding
Certain drugs can be fatal

Question 33

Median Nerve Injury

Answer 33

When the nerve is severed in the elbow region, flexion of the proximal IP joints of the 1-3 digits is lost and flexion of the 4th and 5th digits is weakened
Flexion of the distal IP joints of the 4th and 5th digits isn’t affected because the medial part of the FDP is supplied by the ulnar nerve. The ability to flex the MCP joints of 2nd and 3rd digits is affected because the digital branches of the median nerve supply the 1st and 2nd lumbricals. This may result in a “hand of benediction” when a person tries to make a fist
Thenar muscle function is also lost as in carpal tunnel syndrome
When the anterior interosseous nerve is injured, the thenar muscles are unaffected but Partial paralysis of the FDP and FPL occur. When the person attempts to make the OK sign, opposing the tip of the thumb and index finger in a circle, a “pinch” posture of the hand results instead owing to absence of flexion of the IP joint of thumb and sitar IP joint of index finger

Question 34

Pronator Syndrome

Answer 34

Nerve entrapment syndrome
Caused by compression of the median nerve near the elbow
Nerve may be compressed between the head of the pronator teres as a result of trauma, muscular hypertrophy or fibrous bands
Individuals are first seen clinically with pain and tenderness in the proximal aspect of the anterior forearm and hypesthesia (decreased sensation) of palmar aspects of the radial three and half digits and adjacent palm

Question 35

Injury of Ulnar Nerve at Elbow and in Forearm

Answer 35

More that 27% of nerve lesions of the upper limb affect ulnar nerve
Occur at: posterior to medial epicondyle of humerus, in the cubital tunnel, wrist or hand
Occurs most commonly posteriorly to medial epicondyle of humerus. injury occurs when the medial part of the elbow hits a hard surface, fracturing the medial epicondyle. Any lesion superior to the medial epicondyle will produce parenthesis of the median part of the dorsum of the hand.
Compression of the ulnar nerve at the elbow (cubital tunnel syndrome) is also common.
Can result in extensive motor and sensory loss to the hand

Question 36

Cubital Tunnel Syndrome

Answer 36

Ulnar nerve may be compressed in the cubital tunnel formed by the tendinous arch joining the humeral and ulnar heads of attachments of FCU

Question 37

Injury of Radial Nerve in Forearm

Answer 37

usually injured by fracture of humeral shaft
Injury is proximal to motor branches to the long and short extensors of the wrist and from the common radial nerve.
Wrist drop is the primary clinical manifestation
Injury to deep branch of the radial nerve may occur when wounds of the posterior forearm are deep. Cannot extend the thumb and MCP joints of other digits. In deep branch injuries, loss of sensation doesn’t occur because this is an entirely muscular branch

Question 38

Dupuytren Contracture of Palmar Fascia

Answer 38

Disease of the palmar fascia resulting in progressive shortening, thickening and fibrosis of the plasma fascia and aponeurosis. The fibrous degeneration of the longitudinal bands on of the palmar aponeurosis on the medial side of the hand pulls the 4th and 5th finger as into partial flexion at the metacarpophalangeal and proximal interphalangeal joints
Contracture is frequently bilateral

Question 39

Hand Infections

Answer 39

Swelling resulting from hand infections usually appear on the dorsum of the hand because the palm side is thick.
The potential fasciae spaces of the palm are important because they may become infected
The fascial spaces determine the extent and direction of the spread of pus formed by these infections

Question 40

Tenosynovitis

Answer 40

The synovial sheaths of tendons of the 2-4th digits are usually separate and therefore infections can be contained but if left untreated may rupture

Question 41

DeQuervain Tendinitis

Answer 41

The tendons of the APL and EPB are in the same tendinous sheath on the dorsum of the wrist. Excessive friction between the same tendons on their common sheath results in fibrous thickening of the sheath and stenosis of the osseofibrous tunnel
Caused by use of hands during gripping and wringing

Question 42

Carpal Tunnel Syndrome

Answer 42

Results from any lesion that significantly reduce as the size of the carpal tunnel or more commonly increases the size of some of the nine structures or their coverings that pass through it
The median nerve is the most sensitive structure in the tunnel. Has 2 terminal sensory branches that supply the skin of the hand; hence parenthesis and hypesthesia or anesthesia may occur in the lateral three and a half digits. The palmar cutaneous branch of the median nerve arises proximally to and does not pass through the carpal tunnel thus sensation is in the central palm remains unaffected.
Recurrent branch also serves the thenar muscles

Question 43

Guyon Canal Syndrome

Answer 43

manifest by hypoesthesia in the medial one and a half fingersa and weakness of intrinsic muscles of the hand

Question 44

Dislocation of the Sternoclavicular Joint

Answer 44

Rare.
When a blow is received to the acromion of the scapula, or when a force is transmitted to the pectoral girdle during a fall on the outstretched hand, the force of the blow is usually transmitted along the length of the clavicle
Most dislocations in people under 25 result from fractures through the epiphyseal plate because the epiphysis at the sternal end of the clavicle doesn’t close until 23-25 years of age