Blue Boxes Flashcards
Rib fractures (1st, middle, lower)
1st rib is rarely fractured, when it is, brachial plexus injuries and subclavian impingments can occur
Middle ribs - most common, weakest just anterior to angle
Lower ribs- may tear diaphragm
Flail chest
multiple rib fractures
paradoxical movements with respiration
thoracotomy is the surgical opening of
Anteriorly - thoracic chest - H shaped cut through perichondrium
5th-7th intercostal spaces, posterolaterally (abduct patients arm, lateral recumbent) - pneumonectomy
supernumarary ribs
normally 12 ribs each side, some people have
Cervical ribs (.5-2%)
Lumbar ribs
Failure of 12th pair to form
protective function and aging of costal cartilages
prevents fracturing from blows (although injury still occurs)
costal cartilages brittle in old folks
ossified xiphoid process occurs at what age
partially ossifices in early 40s
complaints of hard lump in pit of stomach
sternal fractures
rare- usually comminuted (multiple)
displacement of fragments uncommon due to fascia
eldery - sternal angle where manubriosternal joint is fused
primary concern is heart/lung injury
median sternotomy is used in what procedures
split in median plane and retracted
coronary artery bypass
tumors in superior lobe of lung
sternal biopsy done by
bone marrow needle biopsy
evaluate for metastatic cancer, blood dyscrasias
sternal anomolies
normal development involves fusion of bilateral vertical condensation of sternal band/bars (precartilaginous tissue)
partial clefts - can be repaired by direct apposition/fixation
complete cleft may result in ectopia cordis
perforation (sternal foramen) - not clinically significant, shows up in xrays
pectus excavatum/pectus cavinatum
perforated xiphoid process in elderly
anteriorly protruding xiphoid process in neonates does not require correction
Thoracic outlet syndrome
arteries and T1 spinal nerves emerge from thorax
dislocation of ribs
common in body-contact sports
dislocation of sternocostal joint
dislocation of interchondral joint occurs unilaterally at ribs 8,9,10 and trauma may affect underlying structures
separation of ribs
dislocation of costochondral junction
3rd-10th ribs usually tears pericondrium and periosteum
overrides rib above causing pain
paralysis of diaphragm
phrenic nerve damage will affect one half (each dome has separate nerve supply)
if this has occured, paradoxical movement of affected dome will be noted
dyspnea
individuals with respiratory problems/heart failure will have difficulty breathing (dyspnea)
will utilize their accessory respiratory muscles to assist in expansion of thoracic cavity
lean on knees/arms of a chair to fix pectoral girdle
extrapleural intrathoracic surgical access
loose, thin endothoracic fascia
separation from costal parietal pleura lining the thoracic wall allows intrathoracic access to extrapleural structures (lymph nodes) without opening and contaminating pleural cavity around lungs)
herpes zoster infection of spinal cord
causes classic dermatomally distributed skin lesion known as shingles
described as painful af
virus invades ganglion, producing sharp burning pain in dermatome supplied by involved nerve - skin becomes red and vesicular eruptions occur
intercostal nerve block
local anesthesia produced by injected anesthetic agent around intercostal nerves between paravertebral line and are of required anesthesia
changes in breasts
branching of lactiferous ducts occurs during menstrual periods and pregnancy
colostrum (premilk) may be secreted during third trimester, rich in protein, immune agents and growth factor for intestines
multiparous women - breasts become large and pendulous
elderly - small because decrease in fat and atrophy of glandular tissue
breast quandrants
superiomedial
Superiolateral
inferolateral
inferomedial
carcinoma of the breast
typically adenocarcinomas (glandular cancer) arising from epithelial cells of lactiferous ducts lymphedema (caused by interference with lymphatic drainage by cancer) may cause Peau d'orange sign fingertip size dimples (from shortening of supsensory ligaments) retraciton of nipples
breast cancer typically spreads by lymphatic vessels (most of which goes to axillary LN)
if breast elevates when pectoral muscle contracts, cancer has advanced enough to invade retromammary space (overlying pectoral fascia)
mammography
radiographic examination of the breasts
carcinoma appears as large, jagged density
skin thickening in area over tumor
surgical incisions of breast
typically done at inferior quadrants - less vascular structures
inferior cutaneous crease best aesthetic results, crease may hide incisions
areolar incisions are made radially to either side of nipple or circumferentially
simple masectomy
breast is removed down to retromammary space
radical masectomy
removal of breast, pectoral muscles, fat, fascia, as many LN as possible in axilla and pectoral regions
polymastia
supernumary breasts
usually mistaken for nevus until color change during pregnancy, may lactate
can appear anywhere down milk line (from axilla to groin)
polythelia
accessory nipple
breast cancer in men
Accounts for 1.5% of BC
metastasizes to bone, pleura, lung, liver, skin, pectoral fascia
visible/palpable subareolar mass or secretion from nipple may indicate malignant tumor
frequently goes undetected until metastasis has occured
gynecomastia
breast hypertrophy in males after puberty
rare, may be age/drug related (diethylstilbesterol for prostate cancer)
may result from imbalance between estrogenic and androgenic hormones or from a change in metabolism of sex hormones by liver (therefore, gynecomastia may indicate suprarenal/testicular cancers)
40% of klinefelters experience gynecomastia
injuries of cervical pleura and apex of lung
IGNORE UNTIL CP
lungs and pleural scs may be injured in wounds to the base of the neck (cervical pleura and apex of lung project through opening of first ribs)
results in pneumothorax (air in pleural cavity)
especially vulnerable in children as cervical pleura reaches higher levels
Injury to other parts of pleurae
IGNORE UNTIL CP
pleura descend past costal margin in three areas
right part of infrasternal angle
right and left costovertebral angles
pneumothorax may occur from an incision in these areas
pulmonary collapse
IGNORE UNTIL CP
atelectasis - primary - lung does not inflate at brith
secondary - collapse of inflated lung
distension of lungs can be disrupted by a penetrating wound, causing the lungs normal elasticity to pull it free from the pleural cavity (also due to air filling negative pressure of pleural cavity and disrupting surface tension forces of pleural fluid)
pleural sacs do not communicate, so one lung may collapse without concomitant collapse of the second lung
Pneumothorax,hydrothorax, hemothorax
IGNORE UNTIL CP
pneumothorax - entry of air into the pleural cavity from penetrating wound of parietal pleura, rupture of pulmonary lesions, fractured ribs
Hydrothorax - significant amount of fluid in pleural cavity
Hemothorax - blood in the pleural cavity (commonly due to injury to major intercostal/internal thoracic vessel)
Thoracentesis procedure and use
IGNORE UNTIL CP
insertion of hypodermic needle through an intercostal space into pleural cavity to obtain sample of fluid/remove blood or pus
must avoid intercostal nerve and vessles by inserting superior to rib (typically 9th intercostal space) angled upward
insertion of chest tube
IGNORE UNTIL CP
used to remove fluid/air/pus/ from pleural cavity
incision made at 5th or 6th intercostal space and tube is inserted, connected to special pump
removal of air allows reinflation of collapsed lung
failure to remove fluid may cause fibrosis to occur (requires lung decortication) to fix
Pleurectomy and Pleurodesis
IGNORE UNTIL CP
pleurectomy - obliteration of the pleural cavity (by surgery but disease can do it too) does not produce any functional problems
Pleurodesis - coating of irritating agent to parietal and visceral layers of pleura to induce adhesion to prevent spontaneous secondary alectasis
thoracoscopy
IGNORE UNTIL CP
examine pleural cavity with thorascope
can take biopsies and disrupt adhesions/ remove plaques
how is the clavicle different from other long bones?
more varied than most other long bones
thicker in manual laborers
Fracture of clavicle
especially common in children - often caused by FOOSH transmitting force up arm (greenstick facture in younger children = bone is broken but does not separate)
sternocleidomastoid elevates medial fragment
trapezius is unable to hold up lateral fragment because weight of upper limb, patients will carry limb in opposite arm
Ossification of clavicle
clavicle is first long bone to ossify (via intramembranous ossification in middle)
ends of clavicle later pass through a cartilaginous phase (endochondral ossification) and these are the last epiphyses of long bones to fuse
sometimes fusion between ossficiations centers fails to occur, creating bony defect between lateral and medial thirds of clavicle - if unsure radiograph bilaterally
fracture of scapula
usually result of severe trauma (vehicular accidents)
require little treatment because scapula is covered on both sides by muscles
most fractures invovle protruding subcutaneous acromion
fractures of humerus (just read)
most injuries of proximal end fracture surgical neck of humerus - common in eldery due to osteoporosis (axillary n involvement)
humeral fractures can often present as impacted fractures, where one fragment is driven into the spongy bone of another *patient may have some use of arm
avulsion fractures of the greater tubercle usually result form falls on the acromion - muscles tend to pull limb into medial rotation
transverse fracture results from trauma - deltoid muscle will carry the proximal fragment laterally
spiral fractures of humeral shaft may result from a FOOSH
(radial n involvement if radial groove is damaged)
intercondylar fracture results from falling on flexed elbow - olecranon separates medial and lateral parts of condyle of humerus
(median n for distal end injuries an d ulnar n for medial epicondyle injuries)
Fractures usually heal well, humerus is surrounded by muscle and has a well developed periosteum
fractures of radius and ulna
typically these bones fracture together
if one bone is fractured, typically the nearest joint will be dislocated
Fracture of the distal end of the radius is common in adults over 50
colle sfracture
complete transverse fracture of the distal 2cm of radius - common FOOSH injury
ulnar styloid process often avulsed causing dinner fork deforming (hand has the soft curve of a fork)
fracture may extend through epiphyseal plate in children and may misalign during healing
Fracture of scaphoid
most frequently fractured carpal bone - fall on palm when hand is abducted
often misdiagnosed as severely sprained wrist
avascular necrosis of proximal fragment of scaphoid may occur (bone death)
could produce degenerative joint disease of wrist
Fracture of hamate
may result in non-union due to traction of attached muscles
ulnar nerve near hook may be damaged - grip strength will be decreased
ulnar a may also be damaged
fracture of metacarpals
metacarpals are closely bound and have good blood supply - tend to heal well
boxers fracture - fracture of the 5th metacarpal (closed and abducted fist) will cause head of bone to rotate over distal end of shaft producing flexion deformity
fracture of phalanges
common in distal phalanges - because of close relationship of phalangeal fractures to flexor tendons, the bone fragments must be carefully realigned to restore normal function
absence of pectoral muscles
usually sternocostal part is uncommon but no disability occurs as a result
anterior axillary fold will be absent
In poland syndrome - both pectoralis major and minor are absent, breast hypoplasia and absence of two to four rib segments are also seen
paralysis of serratus anterior
injury to long thoracic n
causes medial border of scapula to move laterally and posteriorly away from thoracic wall
gives scapula the appearance of a wing
arm cannot be abducted above horizontal position because serratus anterior is needed to rotate glenoid cavity upward
triangle of auscultation borders and use
superior border of latissimus dorsi
medial border of scapula
inferolateral border of trapezius
used to listen to lungs
injury to spinal accessory n
marked ipsilateral weakness when shoulders are elevated against resistance
injury of thoracodorsal n
supplies the latisimmus dorsi
passes inferiorly along posterior wall of axilla
if damaged, patient will be unable to raise trunk with upper limbs or use an axillary crutch because the lat forms a muscular sling between the arm and trunk
injury to dorsal scapular n
supplies the rhomboids - if damaged, scapula on affected side will be further from midline than unaffected side
injury to axillary n
causes deltoid to atrophy
axillary n is usually injured during fracture of surgical neck of humerus
shoulder will appear flattened
loss of sensation over lateral side of proximal part of arm (supplied by the superior lateral brachial cutaneous n, a branch of the axillary)
fracture-dislocation of proximal humeral epiphysis
caused by direct injury to shoulder of child/adolescent may produce this fracture as the joint capsule is stronger than the epiphyseal plate
if severe enough, shaft of humerus is displaced but humeral head retains its normal relationship in glenoid cavity
Rotator cuff injuries
injury or disease may affect rotator cuff and produce instability in the glenohumeral joint
may be trauma to one of SITS muscles - supraspinatus tendon is most commopnly ruptured
degenerative tendonitis of the rotator cuff is common in older people
arterial anastomoses around scapula
dorsal scapular, suprascapular and subscapular arteries contribute to arterial anastomoses around the scapula
direction of blood flow in the subscapular a is reversed when if the axillary a is ligated/has undergone stenosis, enabling blood to reach third part of axillary a
the subscapular a receives anastomoses from the suprascapular, dorsal scapular and intercostal aa
slow occlusion of axillary often enables sufficient blood collateral circulation (whereas sudden occlusion will not)
compression of the axillary a
compression of the third part of the axillary a against the humerus may be necessary when profuse bleeding occurs
additionally, compression can be done at the origin of the axillary a by exerting downward pressure in the angle between the clavicle and the inferior attachment of the sternocleidomastoid muscle
aneurysm of axillary a
first part of axillary a may enlarge and compress the trunks of the brachial plexus, causing pain and anesthesia in the areas of the skin
common in pitchers and quarterbacks
injuries to axillary v
wounds in the axilla often involve axillary v due to its exposed position
when arm is abducted, vein overlaps axillary artery anteriorly
air emboli may form making this injury dangerous
role of axillary v in subclavian vein puncture
subclavian vein punctures involve placing a catheter through the axillary vein as it crosses the first rib
here, axillary v is superficial (anterior and inferior) to axillary artery
branches of brachial plexus begin to surround artery at this point (aka dont nick it)
enlargement of axillary LN
infection in the upper limb can cause axillary nodes to enlarge and become tender and inflamed (lymphangitis)
humeral group usually first
lymphangitis is characterized by the development of warm, red, tender streaks in skin
infections in pectoral region also enlarge axillary LN
enlargement of apical nodes may obstruct cephalic vein superior to the pectoralis minor
dissection of axillary LN
excision and analysis of axillary LN are often necessary for staging and determining appropriate treatment for cancer
lymphatic drainage of the upper limb may be impeded after removal of axillary nodes (lymphedema)
during axillary node dissection, two nerves are at risk of injury 1) long thoracic nerve and 2) thoracodorsal n
Variations in brachial plexus
Prefixed brachial plexus - contributions are made from C4-C8 (instead of C5-T1) - trunk of plexus may be compressed by the 1st rib
Postfixed brachial plexus - C6-T2
brachial plexus injuries
injuries to brachial plexus affect movements and cutaneous sensations in upper limb
injuries to superior part of the brachial plexus usually results from an excessive increase in the angle between the neck and shoulder - makes limb hang by side stuck in medial rotation - Erb-Duchenne palsy
acute brachial plexus neuritis
neuro disorder that is characterized by sudden onset of severe pain around shoulder, usually at night followed by muscle weakness and sometimes atrophy
compression of cords of the brachial plexus
may result from prolonged hyperabduction of the arm while working overhead
n compressed between coracoid process of scapula and pectoralis minor tendon
can cause ischemia of upper limb and distension of the superficial limbs
Klumpke paralysis
injuries to the inferior parts of the brachial plexus - occur when upper limb is suddenly pulled superiorly, like when a babys arm is pulled during delivery
can result in claw hand
brachial plexus block
injection of anesthetic into or around axillary sheath blocks impulses of peripheral nerves
all deep structures of upper limb, skin distal to middle arm
bicipital myotactic reflex
biceps reflex routinely examined by placing thumb on biceps tendon and tapping examiners nail bed - produces involuntary contraction of the biceps
positive response confirms the integrity of musculocutaneous n and C5, C6 spinal cord segments
Excessive, diminished, or prolonged (hung) responses may indicate CNS/PNS nervous system disease or metabolic disorders
Biceps tendinitis
tendon of long head of biceps brachii is enclosed in synovial sheath that moves in the intertubercular sulcus
inflammation of the tendon is usually the result of repetitive microtrauma common in throwing sports
Dislocation of Tendon of long head of biceps brachii
tendon of the long head of the biceps can be partially or completely dislocated from the intertubercular sulcus
dislocation may occur in youths during traumatic separation of the proximal epiphysis of the humerus or older pople with history of tendinitis
usually a popping/catching sensation is felt during arm rotation
rupture of tendon of long head of biceps brachii
usually results from wear and tear of inflamed tendon as it moves back and forth in the intertubercular sulcus
rupture involves tendon being torn from its attachment at the supraglenoid tubercle of scapula associated with a snap/pop
popeye deformity results - muscle belly forms a ball near center of distal part
forceful flexion of the arm against excessive resistance or prolonged tendonitis from repetitive overhead motions
interruption of blood flow in brachial a
brachial a can be compressed medial to humerus near middle of arm
because cubital anastomeses, brachial a may be clamped distal to deep brachial a without producing tissue damage because ulnar/radial a will still receive sufficient bloodflow through this anastomoses
however sudden occlusion/laceration will result in ischemia of elbow/forearm within hours and produce a flexion deformity
Fracture of humeral shaft
midhumeral fracture may injure radial n in radial groove of shaft
supra-epicondylar fracture (distal) may be displaced over the proximal fragment by brachialis and triceps and damage any of the nerves/vasculature in this area
Injury to musculocutaneous n
although protected in axilla, if the musculocutaneous n is lacerated the coracobrachialis, biceps, and brachialis will be paralyzed
weak flexion at shoulder
flexion of elbow and supination of forearm severely weakened (but not lost)
weak flexion and supination can still occur through brachioradialis and supinator (radial n innervated)
Injury to radial n in arm
injury superior to branches to triceps will result in paralysis of triceps, brachioradialis, supinator, and extensor muscles of wrist and fingers
injury in radial groove results in weakened triceps and paralysis of muscles of posterior compartment of forearm - wrist drop syndrome
venipuncture in cubital fossa
cubital fossa is common site for sampling and transfusion of blood and intravenous injections
median cubital vein lies on top of deep fascia of bicipital aponeurosis, protecting the brachial a and median n
cardiac caths for sampling great vessels and chambers of the heart/coronary angiography are also accessibly by the median cubital vein
variation in the veins in cubital fossa
median antebrachial vein divides into median basilic vein and median cephalic vein in 20% of the population
either the median cubital vein or median basilic vein will cross superficial to the brachial a so both will be suitable for drawing blood
elbow tendonitis or lateral epicondylitis
elbow tendonitis follows repetitive use of superficial extensor muscles of forearm
felt over lateral epicondyle and radiates down posterior surface of the forearm
mallet or baseball finger
sudden severe tension on long extensor tendon may avulse part of its attachment to the phalanx
results from DIP joints being forcefully flexed (hyperflexed)
as a result, person cannot extend DIP joint which looks like a mallet
Fracture of olecranon
fall on elbow combined with contraction of triceps brachii
fracture olecranon is pulled away by active and tonic contractions of triceps
avulsion fracture - pinning is usually required, healing is slow and cast must be worn for a long time
Synovial cyst of wrist
nonpainful cyst containing mucinous fluid may appear on dorsum of hand due to mucoid degeneration
usually close to and communicate with synovial sheaths on dorsum of hand
cystic swelling of common flexor synovial sheath on anterior aspect of wrist can enlarge enough to produce compression of the median n by narrowing the carpal tunnel
high division of brachial a
sometimes, brachial a will divide more proximally
ulnar/radial a begin in superior and middle part of arm and median n passes between them
superficial ulnar a
in 3% of the population, ulnar a descends superiorly to flexor muscles, can be felt/be visible
do not mistake for a vein and puncture/inject drugs
