Clinical Correlations ch. 17 Flashcards
Pain in tip of shoulder: C4/C3
- subdiaphragmatic irritation due to peritonitis, gall bladder inflammation, hepatic abscess, pleurisy or accumulations of CO2
- due to phrenic nerve (C3,4,5) or supraclavicular nn. C3,4
Pain from the left chest, down the left lower limb
Angina pectoris, due to heart pain. Pain fibers associated with sympathetics from T1-T4: T1-T3 dermatomes of upper limb
P’eau d’orange
- dimpling of skin overlying the breast due to tighetning of suspensory “coopers ligaments” via tumor growth
Dupuytren’s Contracture
pathological thickening and contracture of longitudinal connective tissue bundles of palmar aponeurosis
- draws fingers into palm by tugging on digital sheaths - so that they become useless
Subacromail/subdeltoid bursitis
inflammation/pain/swelling within synovial space of bursa surrounding glenohumeral/shoulder joint
- results in grating of shoulder joint
olecranon bursitis
inflammation/pain/swelling within synovial space of bursa surrounding elbow joint
ganglion cyst
- distention of a weakened portion of a tendon sheath at the extensor surface of the wrist
DeQuervain’s Disease
- inflammation of synovial sheath surrounding the extensor pollicis brevis and abductor policis longus tendons
- results in trouble using the thumb
DeQuervain’s Disease
- inflammation of synovial sheath surrounding the extensor pollicis brevis and abductor policis longus tendons
- results in trouble using the thumb
Trigger Finger
Bursitis for flexor tendon sheats in hand.
- the node forms in sheath and it can’t pass through the fibrous tendon sheath pully - thus the finger stays in a flexed position.
Pressure on Axilla compartment
- stretching of cords of brachial plexus
- could be due to humeral dislocation, tumor
- could compress axillary artery to stop profuse bleeding distally
- could be due to neoplastic lymph nodes due to breast carcinoma metastasis
Cubital Fossa Compartmental damage
could damage TAN (tendon of biceps, brachial artery, median nerve)
- must take care during venapuncture not to go too deep
Carpal Tunnel Syndrom
- increased activity of wrist results in edema, compression and inflammation of median n.
Symptoms:
1. parasthesias of lateral 31/2 fingers
2. Paresis (weakness) upon flexion, abduction, and opposition of thumb
3. wasting of thenar eminence
4. loss of fine motor control of 2nd/3rd digits due to paralysis of 1st and 2nd lumbricals (may result in median claw)
5. loss of opposition/grasp reflex
NOTE: falls on outstretched palm can injure the recurrent branch of the median n.
infection in deep palmar spaces
- if get infections in the deep spaces of palm (through maybe a deep puncture wound) - can fester and cause large amounts of pain in palm
infection in deep palmar spaces
- if get infcetions in the deep spaces of palm (through maybe a deep puncture wound) - can fester and cause large amounts of pain in palm
Clavicle
- first to start, last to end ossifying (2nd-3rd decade)
- most commonly broken bone in body: b/c of architecture of shoulder joint and natural curve of clavicle it will often “green stick” fracture in its middle 1/3rd
- medial posterior clavicular dislocation –> pressure on carotid sheath
- dislocation –> mechanical stimulation to vagus n. (CN X) from pressure placed on it by medial end of clavicle –> decreased heart rate and contractility
acromioclavicular separation
- torn AC joint: often happens when someone falls on their shoulder
Graded 1-6:
1: stretched AC ligs
2: torn AC ligs with stretched CC ligs
3: torn AC and CC with 3-5x increase in CC space (everything is free)
Rotator Cuff
- supraspinatus, infraspinatus, teres minor, subscap
- supraspinatus is most often torn b/c of “over the top”position –> due to lifting too much or catching a heavy falling object, or repetitive overhead motion activities
- also susceptible to erosion via osteophytes which grow down from an arthritic AC joint
Rotator Cuff
- supraspinatus, infraspinatus, teres minor, subscap
- supraspinatus is most often torn b/c of “over the top”position –> due to lifting too much or catching a heavy falling object, or repetitive overhead motion activities
- also susceptible to erosion via osteophytes which grow down from an arthritic AC joint
Ruptured tendon of long head of biceps
intracapsular tendon becomes inflamed and erodes over time
Ruptured tendon of long head of biceps
intracapsular tendon becomes inflamed and erodes over time
bicipital tendonitis
inflammation of synovial sheath around tendon of long head of biceps within the intertubercular (bicipital) groove; can lead to dislocation of long head of biceps from intertubercular groove
- this happens due to overuse and throwing sometimes
Anterior Glenohumeral dislocation
- 95% of dislocations: b/c glenohumeral ligaments are on posterior side
- loss of normal shoulder contour: appears flat
- subcoracoid is most common
- muscles “pull” head of humerus into axilla, humerus is slightly abducted
- humeral head is prominent anteriorly
- symptoms include parestheisas in C5 axillary (skin shoulder patch) and musculocutaneous nerve (forearm)
Anterior Glenohumeral dislocation
- 95% of dislocations: b/c glenohumeral ligaments are on posterior side
- loss of normal shoulder contour: appears flat
- subcoracoid is most common
- muscles “pull” head of humerus into axilla, humerus is slightly abducted
- humeral head is prominent anteriorly
- symptoms include parestheisas in C5 axillary (skin shoulder patch) and musculocutaneous nerve (forearm)
Humero-ulnar dislocation
movement of the ulna and readius posteriorly relative to the distal end of humerus
- may be associated with fractures of ulna/humerus
- ulnar n. may be stretched within fibro-osseous canal
- “struther’s dislocation
Humero-ulnar dislocation
movement of the ulna and readius posteriorly relative to the distal end of humerus
- may be associated with fractures of ulna/humerus
- ulnar n. may be stretched within fibro-osseous canal
- “struther’s dislocation
Radial head subluxation
“nurse maid’s elbow”
- distal movement of radial head from undercover of the annular ligament of the radius
- occurs when parents swing children by hands and they are lifted from the ground while the forearm is pronated
Radial head subluxation
“nurse maid’s elbow”
- distal movement of radial head from undercover of the annular ligament of the radius
- occurs when parents swing children by hands and they are lifted from the ground while the forearm is pronated
three scapular anastomoses
- if ligated distal to thoracoacromial trunk: acromial branch to posterior circumflex humeral
- if ligated more distally: could go two ways from thyrocervical trunk: could go through transverse cervical(dorsal scapular) –> thoracodorsal –> subscapular –> axillary … or… could go suprascapular a. –> circumflex scapular –> subscapular a. –> axillary a.
Falls on outstretched hand
- youth = displacement of distal radial epiphysis
- adolescent = clavicular fracture
- elderly= colle’s fracture: fracture to the distal radius 1 inch proximal to the radiocarpal joint: presents with “silver fork” deformity
Arterial compression sites: axillary, brachial, ulnar, radial
- axillary a: proximal humerus, medial surface
- brachial a: medial to anterior humerus from above downward
- ulnar a: distal anterior wrist lateral to pisiform
4: radial a: distal anterior radius, “snuff box”, 1st dorsal digital space
avascular necrosis of scaphoid bone
non-union of distal fragment of scaphoid with proximal fragment: distal portion contains nutrient artery entrance site and therefore the fracture leaves proximal fragment without blood supply
game keeper’s (skier’s) thumb
- rupture of ulnar collateral ligament of the metacarpophalangeal joint of thumb
game keeper’s (skier’s) thumb
- rupture of ulnar collateral ligament of the metacarpophalangeal joint of thumb
lymphangitis
inflammation of lymph vessels - visible as “red streaks”
- those extending proximally from thumb and index finger follow course of cephalic vein to inferior clavicular node
- those originating medially in three fingers follow course of basilic vein to cubital and lateral axillary lymph nodes
NOTE: most lymph vessels from fingers pass to dorsum of hand and then ascend forearm: thus, infections in fingers and palm can lead to inflammatory edema or abscess on the dorsum of the hand
arterial anastamoses at elbow
4 collaterals: radial, middle, inferior ulnar, superior ulnar collateral
4 recurrents: radial, interosseus, anterior ulnar and posterior ulnar recurrents
–> these provide a way to get blood around the cubital fossa without directly going through the brachial a.
avascular necrosis of scaphoid bone
non-union of distal fragment of scaphoid with proximal fragment: distal portion contains nutrient artery entrance site and therefore the fracture leaves proximal fragment without blood supply
Raynaud’s disease
increased symp. discharge to distal blood vessels results in increased vasoconstriction with a concomitatnt decrease in vascular flow
- fingertips are coldest and limb becomes progressively warmer proximally
- danger lies in necrosis of fingers due to reduced perfusion
- cervicodorsal preganglionic sympathectomycan be performed to induce vasodilation
thrombosis
clot formation within a vessel
- can be due to prior trauma: fracture, deep contusion
- can be spontaneous: reduced physical activity for prolonged periods –> vascular stagnancy, or weakened muscular fascia resulting in diminished musculovenous pump
lymphangitis
inflammation of lymph vessels - visible as “red streaks”
-
lymphadenitis
inflamed lymph nodes as a direct result of lymphangitis
lymphadenitis
inflamed lymph nodes as a direct result of lymphangitis
injury around spiral groove of humerus
- damage of the radial n (C5-T1)
- knocks out all of the extensors
- due to poor crutch placement, falling asleep with arm over back of chair, fracture of upper humerus, downward dislocation of glenohumeral joint
- results in “wrist drop” (acute loss)
- chronically results in flexion contractures of flexors of upper limb with complete loss of limb function
NOTE: the triceps will still work because their innervation comes out before the radial injury
fracture at surgical neck of humerus, downward glenohumeral dislocation or poor crutch placement
- damage of axillary n. (C5,6) as it passes around humerus in quadrangular space
- knocks out the deltoid and teres minor
- results in wasting of deltoid contour, decreased abduction and flexion of the arm, loss of cutaneous sensation over lower 1/2 of deltoid
injuries in elbow due to medial supracondylar humeral fracture or humero-ulnar dislocation
- results in injury of median n (C6-T1, sometimes C5)
- “ape hand” appearance due to increased wrist flexion, supination of the hand (both pronators paralyzed), thumb in neutral position (laterally rotated and adducted) and wasting of thenar eminence, fingers appear long and straight
- lack of cutaneous innervation on the lateral portion of palm and tips of first 3.5 fingers
Tendon reflexes of Biceps, Triceps
Biceps: C5,6
Triceps: C7,8
Erb-Duchenne’s Palsy
- upper brachial plexus injury at C5/6
- could be due to falling on head/shoulder simultaneously or pulling baby out by head (traction placed on neck)
- -> “waitor’s tips” : loss of flexors of forearm (median/musculocutaneous) and lateral rotators of humerus (suprascapular n. - infraspinatus)
- extensors take over, pronators take over, medially rotated
Erb-Duchenne’s Palsy
- upper brachial plexus injury at C5/6
- could be due to falling on head/shoulder simultaneously or pulling baby out by head (traction placed on neck)
- -> “waitor’s tips” : loss of flexors of forearm (median/musculocutaneous) and lateral rotators of humerus (suprascapular n. - infraspinatus)
- extensors take over, pronators take over, medially rotated
Klumpke’s Palsy I
- lower brachail plexus infjury of C8,T1
- can be due to delivering baby while pulling on hand, or when someone catches one self in a hanging position while falling
- results in loss of intrinsic muscles of hand (ulnar n) –> claw hand appearance due to loss of muscles which provide “balance” between powerful extensor and flexor muslces of fingers (i.e. lose lumbricals and interossei)
Klumpke’s Palsy I
- lower brachail plexus infjury of C8,T1
- can be due to delivering baby while pulling on hand, or when someone catches one self in a hanging position while falling
- results in loss of intrinsic muscles of hand (ulnar n) –> claw hand appearance due to loss of muscles which provide “balance” between powerful extensor and flexor muslces of fingers (i.e. lose lumbricals and interossei)
Winged Scapula
damage of long thoracic n. (C5,6,7)
- due to being hit on the side - knocks out serratus anterior
- results in decreased ability to fully abduct the limb (decreased scapular rotation)
- loss of integrity of platform of upper limb - no scapular fixation
Winged Scapula
damage of long thoracic n. (C5,6,7)
- due to being hit on the side - knocks out serratus anterior
- results in decreased ability to fully abduct the limb (decreased scapular rotation)
- loss of integrity of platform of upper limb - no scapular fixation
fracture at surgical neck of humerus, downward glenohumeral dislocation or poor crutch placement
- damage of axillary n. (C5,6) as it passes around humerus in quadrangular space
- knocks out the deltoid and teres minor
- results in wasting of deltoid contour, decreased abduction and flexion of the arm, loss of cutaneous sensation over lower 1/2 of deltoid
fracture at surgical neck of humerus, downward glenohumeral dislocation or poor crutch placement
- damage of axillary n. (C5,6) as it passes around humerus in quadrangular space
- knocks out the deltoid and teres minor
- results in wasting of deltoid contour, decreased abduction and flexion of the arm, loss of cutaneous sensation over lower 1/2 of deltoid
injury around spiral groove of humerus
- damage of the radial n (C5-T1)
- knocks out all of the extensors
- due to poor crutch placement, falling asleep with arm over back of chair, fracture of upper humerus, downward dislocation of glenohumeral joint
- results in “wrist drop” (acute loss)
- chronically results in flexion contractures of flexors of upper limb with complete loss of limb function
NOTE: the triceps will still work because their innervation comes out before the radial injury
rupture of coracobrachialis
results in injury of musculocutaneous n (C5,6,7)
- injury results in loss of forearm flexion and supination; loss of cutaneous sensation to lateral forearm
-
injuries in elbow due to medial supracondylar humeral fracture or humero-ulnar dislocation
- results in injury of median n (C6-T1, sometimes C5)
- “ape hand” appearance due to increased wrist flexion, supination of the hand (both pronators paralyzed), thumb in neutral position (laterally rotated and adducted) and wasting of thenar eminence, fingers appear long and strait
Carpal tunnel syndrome
- damage to median n (C6-T1)
- due to increased activity of wrist resulting in edema, compression and inflammation of median nerve
- could also be due to fall on oustretched palm (injure recurrent branch of median n.)
- symptoms: 1. paresthesias of lateral 3.5 fingers,
2-paresis upon flexion, abduction and opposition of thumb
3- wasting of thenar eminence
4- loss of fine motor control of 2nd,3rd digits due to paralysis of 1st and 2nd lumbricals (may results in “median claw”)
5- loss of oppostion: loss of grasp reflex
damage to funny bone: “canal of struther’s”
- fracture/dislocation posterior to the medial humeral epicondyle
- damage of ulnar n (C8,T1)
- results in weakness upon flexion and adduction of the wrist with paresthesias to the ring and little finger
Injury within “Guyon’s tunnel”
- damage to ulnar n (C8,T1)
- occurs as the result of a cut or fall on outstretched palm –> injury occurs at wrist medial to the flexor retinaculum beneath the pisohamate ligament
- results in 1. paresthesias to the ring and little finger, 2. wasting of the hypothenar eminence and interosseous spaces(tunneling) 3. “ulnar claw” - flexion of 4th and 5th fingers 4. loss of adduction of thumb (froment’s sign) 5. wrist flexion with radial deviation 6. pincer mechanism to grasp if ulnar is damaged
