Clinical Conditions - Exam 2 Flashcards
Inflammation of bursa at the elbow from leaning too much on it (happens to people in nursing homes)
Subcutaneous olecranon bursitis
Supracondylar fracture
Fracture above the condyles (Common in children and the elderly)
Nursemaids elbow
Radial head is pulled out of annular ligament (Common in children because their annular ligament is not fully formed yet)
From a bony standpoint, elbow is fairly stable in what position
Extension
If elbow is not stable, patients will…
Report pain, will be unable to have any kind of resistance or loading to that joint
What kind of stress does the ulnar collateral ligament protect the joint from
Valgus stress (abduction or from lateral side)
What kind of stress does the radial collateral ligament protect the joint from
Varus stress (adduction or from medial side)
Significance of brachial artery
Important for blood pressure
Will someone be able to flex their elbow if they have damage to their musculocutaneous nerve?
Yes, because although the biceps brachii and brachialis are innervated by the musculocutaneous nerve, the brachioradialis also does weak flexion of the elbow and is supplied by the radial nerve.
Will a patient be able to extend their elbow if they have damage to the radial nerve?
No, because both elbow extensors are supplied by the radial nerve (C6-C8)
Where is the radial nerve located and what can damage it?
The radial nerve is located in the radial groove or spiral groove on the posterior humerus. A fracture of the humerus can damage the radial nerve which will in turn affect extension of the elbow.
Major flexors and extensors at elbow
- Biceps brachii, brachialis, brachioradialis
- Triceps brachii, anconeus
Path of musculocutaneous nerve
Comes off lateral cord, supplies biceps brachii, brachial and coracobrachialis, goes through biceps brachii, comes out and forms lateral cutaneous nerve
What group of people most commonly injure their medial or ulnar collateral ligament
Baseball pitchers ( corrected by tommy john’s surgery)
If a person has shortened biceps, they may have trouble with
Full extension at the elbow
If a person has shortened triceps, they may have trouble with
Full flexion at the elbow
What is going to limit radial deviation
Ulnar collateral ligament and bony structures (if ulnar collateral ligament is torn, bony structures will still limit radial deviation)
What is going to limit ulnar deviation
Radial collateral ligament will limit ulnar deviation
Which is stronger: anterior or posterior radoiocarpal ligaments
Anterior radiocarpal ligament
What is the function of the scapholunate ligament?
To stabilize the scaphoid bone
What is the function of the lunotriquetral ligament
To stabilize the proximal medial row of carpal bones
A fracture to the wrist can fracture the scaphoid bone but can also damage what?
The scapholunate ligament. This often goes undiagnosed. Although the fracture will heal, the patient will still have instability in their wrist because the ligament is not healed.
Ligaments at the mid carpal or interracial joints include
Anterior and posterior ligaments (anterior fibers run obliquely).and interracial ligaments
What is the most important action of the flexor digitorum superficialis?
Flexion at the PIP joint of digits 2-5 (although it also flexes the wrist and MCP)
Movement of thumb toward the palm
flexion of thumb at cmc joint
Lateral epicondylosis (Tennis Elbow)
- Inflammation of the extensor muscles that attach to the lateral epicondyle due to repeated overuse
- Major symptoms: pain with wrist extension, tenderness over lateral epicondyle, weak grip
- Mostly associated with extensor carpi radialis brevis, extensor digitorum, and extensor carpi radialis longus
- If a person complains of pain in the lateral elbow, there is probably some kind of pain affecting this
- Problems with gripping because your wrist should be in 20-30 degrees of extension to grip or do gross motor activities, you get pain with extension with lateral epicondylitis
- itis = acute/inflammation
- osis = disease/chronic
What innervates the flexor digitorum profundus
Index and middle (tendons 2+3) – Anterior interosseus branch of median nerve (C8-T1)
Ring and pinky (tendons 4+5) - ulnar nerve (C8-T1)
What would happen to pronation if the median nerve was injured?
Pronation wouldn’t be possible because both pronators (pronator trees and pronator quadratus) are innervated by the median nerve. An alternative to pronation would be internal rotation of the shoulder
What symptoms will someone from carpal tunnel have and why?
Someone with carpal tunnel will complain of numbness in their first three fingers and half of the fourth digit. Because their median nerve which innervates these fingers is compressed. This happens for two reasons: 1. They overuse their muscles in repetitive actions (meat packing, typing), and the tendons that run through the carpal tunnel get inflamed and they compress the median nerve or 2. They have osteoarthritis or arthritis and the carpal tunnel space itself gets small.
What is the solution to carpal tunnel?
Surgery that cuts some of the flexor retinaculum back so that the carpal tunnel space is bigger. It will eventually come back but not as tight.
Ligaments at MCP joints (2-5)
- Collateral ligaments (Cord and fan parts)
- taut in 70 to 90 degrees of flexion
- loosed or shortened in extension
- ex. in a cast that goes over MCP joints, and causes immobility and constant extension, your collateral ligaments will get shortened or loosed and you will be unable to flex again (develop extension contractors)
-Volar plates - fibrocartilogenous structuresreinforce joint capsule anteriorly and prevent anterior dislocation
What nerves supply the volar forearm
Median nerve (some anterior interosseus branches) and ulnar nerve
Ligaments at CMC joint of thumb
- 5 ligaments - provide stability to the thumb
- Since the joint capsule is so loose, count on ligaments to provide stability (once they are stretched they can’t go back unless it is with surgery)
- Radial and ulnar collateral ligaments
- Anterior and posterior oblique ligaments
- Intermetacarpal ligament
Ligaments of MCP of thumb
- Radial and ulnar Collateral ligaments
- injury at thumb MCP is common in skiers, valgus stress on MCP joint of thumb will injure ulnar collateral ligament
- Palmar or volar ligaments
Scaphoid fracture
- common fracture
- usually will cast the thumb to prevent movement of thumb so scaphoid can heal
- this may decrease the blood flow to the area which will slow down the healing process
Wrist Sprain
- Ligament that has been stretched or torn
-One of the worst because you can’t generate power in your hand
Grade 1 - Ligament stretched
-ice, elevate, rest
Grade 2 - partial tear
-may require surgery
Grade 3 - complete tear
-definitely require surgery
- What carpal bone is commonly displaced
lunate
What does the schapoid articulate with?
Trapezium, trapezoid, capitate, lunate, distal radius
(a scaphoid fracture would have an effect on range of motion, especially if it was at the mid carpal joint, because it articulates with so many other carpal bones)
What does the capitate articulate with
“Key stone bone” - provides stability to carpals
Scaphoid, Lunate, Trapezium, trapezoid, hammate, distal radius
Damage to scapholunate and lunotriquetral ligaments will cause
excessive mobility and pain
Anterior and posterior ligaments of wrist
- Stronger anteriorly
- anterior Fibers run obliquely
- difficult to distinguish fibers from capsule fibers
What is the best position for a person with carpal tunnel and how do you get that position?
The best position for a person with carpal tunnel - neutral.
- You get a brace and correct it so it is in neutral
- When a person flexes or extends their wrist with carpal tunnel, it puts pressure on the nerve and decreases the blood supply.
A person with carpal tunnel is likely to have atrophy in what muscles
Thenar muscles
If lesion of median nerve is at lower wrist, which pronator might still function
Pronator teres
If the patient fractured their proximal radius and the radius can’t pivot… how should you treat them
Treat the proximal and distal radioulnar joints because they act as hinges.
Patients having trouble with extension might not only have tightness in biceps and brachialis but also in
Anterior part of joint capsule
Explain radial deviation between your extensor carpi radialis longs and brevis
Extensor carpi radialis longus inserts at the base of 2nd metacarpal so it will do radial deviation. However, the extensor carpi radials braves inserts at the base of the 3rd metacarpal, so it will only do radial deviation together with the extensor carpi radials longs.
Extensor digitorum main action is
Extension of digits 2-5 at MCP joint
What holds the extensor tendons in place
Extensor retinaculum
Explain the anatomical snuffbox boundaries
Medial border - Extensor pollicis longus
Lateral border - Abductor pollicis longus and extensor pollicis brevis
Floor - Schaphoid (closest to radius) and trapezium (closest to metacarpal
Radial artery - run through it
Superficial radial nerve (and cephalic vein) - run over it
Dorsal compartments
Roof - extensor retinaculum
Floor - posterior surfaces of radius and ulna
-Extensor tendons pass through the compartments
-Dorsal carpal synovial tendon sheaths enclose the tendons as they pass through the compartments
Action of supinator
- Supinates the forearm when you are in extension
- Deep radial nerve goes into supinator and comes out as Posterior interosseous branch of radial nerve
- 1 supinator = 2 pronators
Actions of the thumb muscles take place at what joint
CMC joint
Pathway of arteries
Subclavian artery –> axillary artery –> brachial artery –> (deep brachial splits above cubital fossa) –> radial and ulnar arteries (split from brachial in cubital fossa)
- Radial artery –> on lateral side of forearm, through anatomical snuffbox, –> deep palmar arch
- Ulnar artery –> on medial side of forearm –> through Guyon’s canal –> splits into superficial palmar arch –> common palmar digital arteries –> proper palmar digital arteries
Movement of thumb toward the palm
flexion of thumb at cmc joint
Lateral epicondylosis (Tennis Elbow)
- Inflammation of the muscles that attach to the lateral epicondyle due to repeated overuse
- Mostly associated with extensor carpi radialis brevis, extensor digitorum, and extensor carpi radialis longus
- If a person complains of pain in the lateral elbow, there is probably some kind of pain affecting this
- Problems with gripping because your wrist should be in 20-30 degrees of extension to grip or do gross motor activities, you get pain with extension with lateral epicondylitis
- itis = acute/inflammation
- osis = disease/chronic
Position of wrist during most fine motor activities and during gross motor activities
Fine motor activities (or to pick things up) - usually flexion or neutral
Gross motor activities/Gripping - 20 to 30 degrees of wrist extension
Wrist Drop
Damage to radial nerve causes wrist to be stuck in flexion
(could be due to humeral fracture that damages radial nerve that runs through radial groove)
-Depending on what part of the structure is affected will determine what the damage is.
DeQuervain’s Syndrome
- Affects Compartment 1 (APL and EPB)
- Any kinds of activities with sustained abducting CMC joint at thumb will cause this (new mothers, daycare workers, cooks)
- Painful with stretch to these structures
Creases of the hand
Transverse palmar creases:
- Distal - marks MCP joints - when held you can't flex - Proximal - marks metacarpals - flexion is fine * Used to make sure that casts are put on at the proximal line so you don't prevent flexion
- Radial longitudinal crease
- marks thenar eminence
Ligaments at MCP joints
- Collateral ligaments
- taut in 70 to 90 degrees of flexion
Ligaments at PIP and DIP joints
- Lateral and accessory collateral ligaments
- taut in 25 degrees of flexion
- loosed/shortened >25 degrees of flexion
- ex. in a splint with IP joints flexed more than 25 degrees - result in loosed collateral ligaments – result in flexion contractures – unable to extend again
-Volar plates - reinforce the joint anteriorly
Ligaments at CMC joint of thumb
- 5 ligaments - provide stability to the thumb
- Since the joint capsule is so loose, count on ligaments to provide stability (once they are stretched they can’t go back unless it is with surgery)-
Ligaments of MCP of thumb
- Radial and ulnar Collateral ligaments
- injury at thumb MCP is common in skiers, values stress on MCP joint of thumb will injure ulnar collateral ligament
- Palmar or volar ligaments
5 compartments of palm of hand
Thenar - abduct, flex, oppose thumb
Central compartment - forearm flexor tendons and lumbricals
Hypothenar - abduct, flex, oppose 5th digit
Interossei - interossei muscles that abduct and adduct fingers
Adductor - adductor policis adducts thumb
What are some functions of the flexor retinaculum
(Spans the entire wrist - pisiform, hamlet, scaphoid, lunate)
- Forms the carpal tunnel (roof)
- Prevents flexor tendons from bowing (fibrous digital sheaths also prevent flexor tendons from bowing out)
- Attachment site for thenar and hypothenar muscles
- Protects median nerve
What is the common flexor sheath
Synovial tendon sheaths with synovium that the FDS and FDP tendons run in
-Act like the annular ligament does and help the flexor tendons to pivot and glide within the tendon sheaths
Guyon’s Canal
- Ulnar nerve and ulnar artery
- Common site of nerve compression
- Compression of ulnar nerve could be from wrist, elbow, spinal roots at neck
- if condition was at wrist, everything above that should be fine
Palmar fascia (palmar aponeurosis)
Thick, deep, triangular, tendinous continuation of deep fascia
Innervation of thenar muscles
Recurrent branch of median nerve (motor)
**Adductor is supplied by deep branch of ulnar nerve
What joint does the thenar muscles act on primarily
CMC joint of thumb
What is the sensory nerve that comes off of the median nerve and goes superficial to flexor retinaculum
Palmar cutaneous nerve
Innervation of hypothenar muscles
Deep branch of ulnar nerve
Compression at Guyon’s canal would involve what muscles
hypothenar muscles (look for muscle atrophy after asking them to do abduction, flexion, opposition of the little finger)
What tendons does the lumbrical follow
FDP
- median nerve - for 1 and 2
- ulnar nerve - for 3 and 4
What do the lumbricals allow for
Flexion of MCP joint, while extension of IP joints (ex. holding a piece of paper)
Function of dorsal and palmar interossei
Dorsal - abduction from 3rd finger
Palmar -adduction towards 3rd finger
What happens with sustained contraction of lumbricals
They get tired because they are such small muscles
A median nerve problem would influence what muscles of the intrinsic hand (lumbricals, interossei)
The first and second lumbricals
Where does the ulnar artery enter
Enters anterior to flexor retinaculum in Guyon’s canal
Mallet finger
Tear of central slip and DIP joint is stuck in flexion
Dupuytren’s contracture
- common in eastern european men in their 60s
- palmar fascia gets tight and develop bands of contracture or tightness
- usually affects little finger and 4th fingers (holds fingers into palm)
- surgically release tight bands and sometimes allow them to heal in an open way
Trigger finger
Overuse a tendon and the tendon gets caught in the tendon sheath.
Patient will flex and won’t be able to go back to extension
