Blue Boxes Flashcards
Absence of pectoral muscles is uncommon but may occur. Which muscle is typically missing? What disability does this result in?
Sternocostal part of pec major, no disability results
The anterior axillary fold is absent on affected side, and nipple is more inferior than usual
_____ syndrome occurs when both pec major and pec minor are absent, which results in breast _________, and absence of _________ segments
Poland
Hypoplasia
2-4 rib
Paralysis of serratus anterior is caused by injury to the __________ nerve, which is typically protected when the limbs are held at your sides.
What makes this nerve unique?
Long thoracic
Unique bc it courses on superficial aspect of the muscle it innervates - serratus anterior, this makes it more vulnerable when the limbs are elevated
Paralysis of serratus anterior d/t injury to the long thoracic nerve results in what symptoms?
Medial border of scapula moves laterally and posteriorly away from thoracic wall = WINGED SCAPULA
When arm is raised, medial border and inferior angle of scapula pull markedly away
Upper limb may not be able to be abducted above horizontal position bc serratus anterior cannot rotate the glenoid superiorly to allow complete abduction [trapezius also helps raise arm above horizontal]
The triangle of auscultation is a small triangular gap near the inferior angle of the scapula. What makes up its 3 borders?
Superior horizontal of latissimus dorsi
Medial border of scapula
Inferolateral border of trapezius
How would you have your patient enlarge their triangle of auscultation in order to better hear their lung sounds?
Have them draw their scapula anteriorly by folding arms across chest with chest flexed
Parts of 6th and 7th ribs and 6th intercostal space will be subcutaneous
What is the primary clinical manifestation of an injury to the spinal accessory nerve?
Marked ipsilateral weakness when shoulders are shrugged against resistance
Thoracodorsal n. typically supplies lat dorsi m., it passes inferiorly along the posterior wall of the axilla and enters the medial surface of the muscle close to where it becomes tendinous.
It is most at risk during what types of procedures?
Surgery in inferior part of axilla
Mastectomies because axillary tail of breast is removed
Surgery on scapular lymph nodes because its terminal part lies anterior to them and the subscapular a.
What is the result of injury to the thoracodorsal n.?
Paralysis of latissimus dorsi –>
Inability to raise the trunk with the upper limbs (climbing)
Person cannot use axillary crutch because shoulder would be pushed superiorly by it, and they cannot initiate active depression of scapula. Passive depression is usually supplied by gravity so normal activities remain unaffected
What does the dorsal scapular nerve supply and what results from injury of this nerve?
Normally supplies rhomboids, so their actions are affected in paralysis
If unilateral rhomboids affected, scapula on affected side is located further from midline
What nerve passes inferior to humeral head and winds around surgical neck of humerus, then runs transversely under the deltoid at the same level?
Axillary n
What nerve is usually damaged during fracture of surgical neck of humerus, dislocation of glenohumeral joint, or compression from crutch use?
Axillary n
Severe damage of axillary n. Results in what?
Deltoid muscle atrophy - the rounded contour of that shoulder will be flattened, produces slight hollow inferior to acromion, reducing ability to have IM injections in that area
May alos lead to loss of sensation over the lateral side of the proximal arm = which is the area supplied by the superior lateral cutaneous nerve, a branch of the axillary n.
What type of injury is caused by a direct blow or indirect injury of a child or adolescents shoulder?
Fracture-dislocation of proximal humeral epiphysis, because the joint capsule of the GH joint, reinforced by tendons of SITS muscles, is stronger than the epiphyseal plate
In severe fractures, the shaft of the humerus is markedly displaced, but the humeral head retains normal relationship with the glenoid cavity
What muscle is most commonly ruptured in injuries to the rotator cuff?
Supraspinatous
Rotator cuff injuries result in instability of the ______ joint
________ ________ of the rotator cuff is common, especially in older people
Glenohumeral
Degenerative tendonitis
Arterial anastomoses around the scapula supply networks on the anterior and posterior side. What are the 3 major arteries that make up this anastomosis?
Dorsal scapular a.
Suprascapular a.
Subscapular a.
Collateral circulation with the scapular arterial anastomosis is important in the case of lacerated subclavian or axillary aa. Where would the axillary a. need to be ligated? Why?
Between 1st rib and subscapular a. because potential collateral pathways exist around the shoulder joint proximally and elbow distally.
If the artery is ligated between the origins of the subscapular a. and profunda brachii a., blood supply will be cut off to the arm
Vascular stenosis may result from atherosclerotic lesion in the axillary a., leading to reduced blood flow. What changes occur in the scapular anastomosis in this case?
Blood flow in subscapular a. is reversed, this way blood flow can reach the 3rd part of the axillar a.
What is the difference between slow and sudden occlusion in the axillary a.?
Slow occlusion due to disease or trauma allows time for sufficient collateral circulation to develop and ischemia is prevented
Sudden occlusion does not allow time for this and ischemia may develop in the arm, forearm, and hand
The subscapular a. receives blood through several anastomoses with what 3 arteries?
Suprascapular a.
Dorsal scapular a.
Intercostal aa.
The ________ artery is normally palpated in the inferior part of the lateral wall of the axilla. Compression of this artery against the ________ may be necessary during profuse bleeding.
If compression is required at a more proximal site, it can be compressed at its origin by exerting downward pressure between the clavicle and inferior attachment of the _______ muscle
Axillary
Humerus
Sternocleidomastoid
Describe an aneurysm of the axillary a.
First part may enlarge and compress trunks of brachial plexus leading to pain and anesthesia in areas of skin supplied by affected nerves
May occur in baseball pitchers and football QBs due to rapid and forceful arm movements
What vein is often implicated in wounds to axilla due to large size and exposed position?
Axillary v
When the arm is fully abducted, the axillary vein overlaps the axillary artery ________
Anteriorly
A wound in what part of the axillary vein is most dangerous? Why?
Proximal part, because of risk of profuse bleeding and risk of air entering and producing emboli in the blood
A common clinical procedure is a subclavian vein puncture in order to place a catheter there. Because the needle is advanced medially to enter the vein as it crosses the rib, the vein actually punctured is the terminal part of the _____ vein.
However, the needle tip proceeds into the lumen of the subclavian vein almost immediately. Thus, it is clinically significant that the ____ vein lies anterior and inferior to its corresponding artery
Axillary; axillary
An infection in the upper limb can cause the axillary nodes to enlarge and become tender and inflamed, a condition called _______
The _____ group of nodes is usually the first to be involved.
Enlargement of the ____ nodes may also occur, which may obstruct the cephalic vein superior to the pectoralis minor
Lymphangitis
Humeral
Axillary
In metastatic cancer of the ____ group of lymph nodes, they often adhere to the axillary vein, which may necessitate excision of part of this vessel
Apical
What are the symptoms of lymphangitis?
Warm, red, tender streaks in skin of the limb
Infections of pectoral region and breast, including superior part of abdomen (produces inflammation of axillary nodes)
Excision and pathologic analysis of _____ nodes are often necessary for staging and determining cancer treatment
Axillary
The axillary nodes are arranged and receive lymph in a specific order. Why is this important for their removal and biopsy?
They receive lymph in a specific order, and thus receive cancer cells in a specific order
removing them in that order is important in determining the degree to which cancer has developed, and is liekly to have metastasized.
Note that lymphatic drainage of the upper limb may be impeded after removal of axillary nodes, resulting in lymphedema in subcutaneous tissue
What 2 nerves are at risk during axillary node dissection?
Long thoracic n. to serratus anterior m.
Thoracodorsal n. to lat dorsi
If the thoracodorsal nerve is cut, what is the rsult?
Paralysis of lat dorsi –> weak medial rotation and adduction of arm, but no deformity
If during axillary node dissection the nodes surrounding thoracodorsal n. are malignant, they may need to be sacrificed in order to resect the cancer
Variations in brachial plexus are common. In addition to 5 anterior rami (C5-8 + T1), small contributions may be made by the anterior rami of C4 or T2.
When the superiormost root is C4 and the inferiormost root is C8, it is a ________ brachial plexus.
Alternately, when the superior root is C6 and inferior root is T2, it is a ______ brachial plexus
Variations may also occur in the formation of trunks, divisions, and cords; in the origin and/or combination of branches and in the relationship to axillary artery and ____ muscles
Prefixed
Postfixed
Scalene
In a postfixed brachial plexus, the inferior trunk of the plexus may be compressed by the _______, producing neurovascular symptoms in the upper limb
1st rib
Injuries to the brachial plexus affect movements and cutaneous sensations in the upper limb. Disease, stretching, and wounds in lateral cervical region may produce brachial plexus injuries. Signs and symptoms depend on parts of the plexus involved.
What are the 2 major brachial plexus injuries?
Paralysis (complete vs. incomplete)
Anesthesia
What types of injuries affect the superior parts of the brachial plexus?
Excessive increase in the angle between the neck and shoulder. These can occur in a person who is thrown from a motorcycle or horse, lands on shoulder in a way that widely separates the neck and shoulder
Roots of spinal plexus may be torn from their origin (avulsion)
What part of the brachial plexus is injured in excessive stretching of neck of neonate during delivery?
Upper
What is the neurologic disorder of unknown cause that is characterized by the sudden onset of severe pain, usually around the shoulder, typically starting at night and followed by muscle weakness and potentially atrophy (neurologic amytrophy). It is usually preceded by some event like a URI, vaccination, non-specific trauma, etc.)
Acute brachial plexus neuritis
Compression of the cords of the brachial plexus may result from prolonged ______ of the arm during performance of manual tasks above the head. The cords are impinged between the coracoid process and _________ tendon. Symptoms include pain down the arm, numbness, paresthesia, erythema, weakness of hands
Hyperabduction
Pec minor
Injection of an anesthetic solution into or immediately surrounding the axillary sheath interrupts impulses of peripheral nerves, and produces anesthesia of the structures supplied by the brachial plexus. What are the different approaches to brachial plexus anesthetization?
Interscalene
Supraclavicular
Axillary
Tennis elbow results from repetitive motion of the _____ compartment of the forearm, and is also known as _____________ _________
Extensor
Lateral epicondyitis
Sudden severe tension on a long extensor tendon may avulse part of its attachment to the phalanx, resulting in _________ _________. This deformity results from the DIP joint suddenly being forced into extreme flexion. As a result the person cannot extend the DIP.
Mallet finger (aka baseball finger)
What is the typical mechanism for an olecranon fracture?
A fall on the elbow combined with the sudden powerful contraction of the triceps brachii
Fractured olecranon is pulled away by the active and tonic contraction of the triceps, and the injury is often considered an avulsion fracture
Because of the traction produced by the tonus of the triceps on the olecranon fragment, pinning is usually required. Healing is slow and cast must be worn a long time
Where do synovial cysts most commonly occur in the wrist? How big do they get, and what do they contain?
Appears on the dorsum of the hand most frequently, usually the size of a grape but can be large as a plum, filled with clear mucinous fluid
What causes synovial cysts of the wrist? What motions enlarge the cyst?
Unknown, but may result from mucoid degeneration
Enlarged by flexion and may be painful; clinically called a ganglion
What the heck is up with the high division of the brachial artery??
Sometimes the brachial artery divides at a more proximal level than usual
In this case, the ulnar and radial aa begin in the superior or middle part of the arm and the median n. passes between them
The musculocutaneous and median nerves commonly communicate
In approximately 3% of people, the ____ artery descends superficial to the flexor muscles
Pulsations of this artery can then be felt and may be visible. This variation must be kept in mind when performing venesections for withdrawing blood or making IV injections, because if mistaken for a vein it may be damaged and produce bleeding.
If certain drugs are injected into it it can be fatal
Ulnar
What is the common place for measuring pulse rate
Where radial a. lies on the anterior surface of distal radius, lateral to tendon of the flexor carpi radialis
Here the a. is only covered by fascia and skin.
It can be compressed against distal end of radius where it lies between the tendons of flexor carpi radialis and abductor pollicis longus
When measuring pulse rate, the pulp of the thumb should not be used because it has its own pulse. If pulse cannot be found, try other wrist because an ______ radial artery on one side may make pulse difficult to palpate
Where else might radial pulse be palpated??
Aberrant
Might be palpated lightly in anatomical snuff box
What are the variations in origin of radial a.?
May be more proximal than usual; may be branch of axillary or brachial
Sometimes runs superficial to deep fascia instead of deep to it
When superficial vessel is pulsating near the wrist, it is probably a superficial radial a., in which case it is vulnerable to laceration
When the ______ nerve is severed in the elbow region, flexion of the PIPs of digits 1-3 is lost and flexion of 4th and 5th is weakened
Flexion of DIP and MCP 2 and 3 is also lost as digital branches of this nerve supply the first and second lumbricals.
Flexion of DIP 4 and 5 is not affected because the medial part of flexor digitorum profundus is innervated by the ______ nerve.
Median; ulnar
This is hand of benediction
When the anterior interosseous nerve is injured, the thenar muscles are unaffected, but ______ (partial paralysis) of ________ ______ ______ and ______ _____ _____ occurs. This would lead to positive “OK” sign test
Paresis
Flexor digitorum profundus; flexor pollicis longus
This is anterior interosseous syndrome
What nerve entrapment syndrome results from compression of the median n. near the elbow where it may be compressed between the heads of pronator teres due to trauma, muscular hypertrophy, or fibrous bands?
Pronator syndrome
Patients present with pain in proximal aspect of anterior forearm and hypesthesia or decreased sensataion in palmar aspects of radial 3.5 digits and adjacent palm
Symptoms follow activities of repetitive pronation
Occasionally, communications occur between the median and ulnar nerves in the forearm. These branches are usually slender nerves. Why are these clinically important?
Even with a complete lesion of median n., some muscles may not be paralyzed. This may lead to erroneous conclusion that the median nerve has not been damaged
More than 27% of nerve lesions of upper limb affect the ulnar nerve. In which 4 locations do these usuall occur?
Posterior to medial epicondyle (most common)
In cubital tunnel
At the wrist
In the hand
What problems arise from ulnar nerve compression or injury in the distal part of the forearm?
Denervation of intrinsic hand muscles –> impaired wrist adduction (hand will be drawn to lateral side by flexor carpi radialis supplied by median n., since no balance from flexor carpi ulnaris)
Difficulty making a fist due to hyperextension of MCPs, inability to flex DIPs, inability to extend IPs, leads to claw hand appearance
Deformity due to atrophy of IO muscles, unopposed actions of extensors and FDP
What forms the cubital tunnel
Cubital tunnel is tendinous arch joining hjumeral and ulnar heads of FCU
Same symptoms as nerve lesion in ulnar groove
What is the primary clinical manifestation of a fracture of the proximal humeral shaft?
Radial nerve damage –> wrist drop
Wounds to the deep posterior forearm may damage the deep radial nerve. HOw would you test for this?
Have patient try to extend MP joints against resistance, if nerve is intact, should see tendons of extensor mm, confirming that this is occuring at MP joints and not IP joints
Damage to posterior forearm and deep radial nerve results in what sensation changes?
None, deep branch of radial n. has no sensory component
Sensory loss only occurs with superficial radial nerve injury, usually coin chaped area distal to bases of 1 and 2 metacarpals
__________ of the SC joint requires surgery and removal of part of clavicle because movement at SC joint is critical to movement of shoulder
Ankylosis
Dislocation of the ____ joint of the shoulder is very rare because of the strength of its ligaments and surrounding structures; a strong longitudinal force is reequired for this injury
SC
What joint of the pectoral girdle is commonly dislocated?
AC joint
What condition is characterized by inflammation and calcification of the subarcromial bursa, resulting in pain, tenderness, and limitation of movement of the glenohumeral joint?
Calcific scapulohumeral bursitis
Pain with abduction of the arm, radiating to hand, calcium deposits may irritate overlying bursa, leading to bursitis
Pain only present in abduction
In which direction to glenohumeral joint dislocations most commonly occur?
Inferior
Which type of glenohumeral dislocation occurs in athletes and young adults caused by excessive extension and lateral rotation of the humerus?
Anterior
Which nerve is likely to be damaged in glenohumeral dislocation?
Axillary nerve
Subglenoid displacement of head of humerus into quadrangular space damages axillary nerve, manifesting as paralysis of deltoid and loss of sensation over skin over deltoid
Tearing of the fibrocartilage of ______ _____ commonly occurs in athletes who throw a lot or have shoulder instability and subluxation of the glenohumeral joint
Glenoid labrum
Adhesive capsulitis of glenohumeral joint
P815
