clinical correlations of upper limb Flashcards
intercostal cutaneous brachial nerves
T1-T3
referred pain angina pectoris
T1-4, T5
pain from the thorax down the left upper limb
dermatomes of the upper limb T1-T3
Dupuytren’s contracture
thickening and contracture of longitudinal connective tissue bundles of palmar aponeurosis
draws fingers into palm
subacromial/subdeltoid bursitis
inflammation accompanied by pain and swelling within a confined synovial space or bursa
decrease in the amount of fluid
Olecranon bursitis
inflammation of olecranon bursa
ganglion cyst
inflammation/cyst formation of tendon sheaths at the extensor surface
DeQuervains’ disease tenosynovitis (synovial and tendon inflammation)
infammation of synovial sheath surrounding the extensor pollicis brevis and abductor policis longus tendons
Trigger finger
inflammation of synovial tendon sheaths of flexor tendon sheaths in the hand
finger doesn’t relax, stays in flexion
axilla problems
stretching of cords of the brachial plexus due to humeral dislocation
tumor
compression of the axillary artery to stop profuse bleeding distally
neoplastic lymph nodes due to breast carcinoma metastasis
Cubital fossa contents
Lateral to medial TAN
Tendons of biceps brachii
Brachial artery
Median nerve
improper use of needles can harm this area
trauma as well
radial (flexor pollicis longus sheath) and ulnar (common flexor) bursae
tenosynovitis
inflammation and distension of synovial tendon sheats
carpal tunnel
9 tendons
median nerve
deep palmar spaces
spread of infection through deep spaces of palm
clavicle ?
last bone to completely ossify (used in identifying skeletal remains to tell approximate age of individual)
most commonly broken
what happens with medial clavicular dislocation
results in pressure placed on the carotid sheath
this can lead to mechanical stimulation of cranial nerve 10 (vagus n) by the medial head of the clavicle this leads to decrease in heart rate and contractility since the vagus nerve innervates heart parasympathetically
acromioclavicular AC separation
involves stretching and or rupture of acromioclavicular and coracoclavicular ligaments
grade 1 AC separation
stretching AC ligaments
grade 2
torn AC ligaments with stretched CC ligament
grade 3
Torn AC and CC with 3-5 times increased coracoclavicular space
grade 4 and 5
even more increase in coracoclavicular space
grade 6 complete
complete rupture of both ligaments with inferior clavicular displacement
Frozen shoulder
Adhesive capsulitis
thickened, fibrotic, inflamed, shrunk capsule
scapular motion, no glenohumeral motion
shoulder doesn’t move (decreased) in all ranges of motion
can be from arthritis, bursitis, tendonitis, inactivity, postsurgical complication
supraspinatous tendon
most often injured rotator cuff muscle b/c its position
also suscpetible to erosion via osteocytes which grow down from arthritic AC joint
supraspinatous is the initiator of abduction
what are the causes of rotator cuff injuries
lift too much or catching a heavy falling object
repetitive overhead motion activities
calcific tendonitis of the supraspinatous tendon
erosion and inflammation of the suprspinatous tendon via osteophytes which grow down from the inferior surface of the AC joint
ruptured tendon of the long head of the biceps
intracapsular tendon becomes inflamed and erodes over time
bicipital tendinitis
inflammation of the synovial sheath surrounding the tendon of the long head of the biceps within the intertubercular groove
can lead to dislocation of the long head of the biceps from the groove
posterior shoulder dislocation
5 percent of dislocations
done by “sliding into second base”
greater tubercule and head of humerus prominent posterior
coroacoid process prominent anteriorly
cannot rotate humerus laterally
arm held in adduction
anterior shoulder dislocation
95 percent of shoulder dislocations
head of humerus prominent anteriorly, slides into axilla
parasthesias involved include axillary and musculocutaneous
lose the shoulder contour
humerus is slightly abducted
pinprick the proximal shoulder area near deltoid and the lateral forearm
testing the axillary and musculocutaneous (lateral antebrachial cutaneous)
humero-ulnar dislocation
movement of the radius and ulna posteriorly relative to the distal end of the humerus
ulnar n. may be stretched
radial head subluxation
“nursemaid”
distal movement of the radial head from undercover the annular ligament of the radius
occurs more often in children
fall on outstretched hand
youth
-displacement of distal radial epiphysis
adolescent
-clavicular fracture
adult
-Colle’s fracture
Colle’s fracture
fracture to the distal radius approximatley 1 inch proximal to the radiocarpal joint
causes “silver fork” deformity
dont’ set this properly you can end up with avascular necrosis of the scaphoid
scaphoid fracture
most often fractured carpal bone
deep to snuff box
lunate problems??
most often dislocated carpal bone
can impinge carpal tunnel
force on the middle finger pushing down onto carpals
Avascular necrosis of scaphoid bone
non-union of distal fragment of scaphoid with proximal fragment
distal portion contains nutrient artery entrance site and therefore fracture may leave the proximal fragment without a blood supply
(Skier’s thumb) Game Keeper’s thumb
rupture of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb
if you abduct the thumb passively then it just goes without resistance
compression site of axillary artery
proximal humerus medial surface
compression sites of brachial artery
medial to anterior humerus from above downward
ulnar artery compression sites
distal anterior wrist lateral to pisiform
radial artery compression sites
distal anterior radius “snuff” box
1st dorsal digital space
what is the thoracocdorsal anastomed with ?
transverse cervical artery
what does the suprascapular artery anastomose with
suprascapular artery anastomomes with circumflex scpaular artery
what does the acromial branch of the thoracoacromial trunk anastomes with
the anterior circumflex humeral artery
what if you have a blockage proximal to the thoracromial trunk ?
don’t anastome with anything??
true or false
arteries have valves
false
they don’t have valves so they can redirect their flow
what does the radial recurrent anastome with?
the radial collateral artery
where are the perforating arteries sitting?
going from superficial to deep from palmar to dorsal
Raynaud’s disease
increased sympathetic innervation to distal blood vessels
results in increased vasoconstriction with concomitant decrease in vascular flow
finger tips coldest- hand looks blue
anxiety and cold weather make this worse
danger lies in necrosis of fingers due to reduced perfusion
how can you fix raynaud’s
cervicodorsal preganglionic sympathectomy can be performed to induce vasodilation
deep thrombosis
clot formation within a vessel
can result from trauma (fracture, deep contusion)
spontaneous due to reduced physical activity or weakened muscular fascia resulting in diminshed musculovenous pump
superficial veins
cephalic vein (start on dorsal lateral surface of forearm) basilic vein (starts on dorsal medial surface of hand)
access for surgical procedures
venapuncture , transfusion
lymphangitis
inflammation of lymph vessels
red streaks (visible as this)
those from thumb and index finger follow the course of the CEPHALIC vein to inferior clavicular nodes
those from the medial three fingers follow the course of the BASILIC vein to cubital and lateral axillary lymph nodes
why do infections happen on dorsum of hand?
most lymph vessels from the fingers pass to the dorsum of the hand and then ascend the forearm
lymphadenitis
inflamed lymph nodesas a direct result of lymphangitis
breast lymph drainage
75 percent to axillary lymph nodes
25 percent is conducted to parasternal nodes which are internal to the thorax (more difficult to detect) paralleling the internal throacic artery
contralateral drainage exists between the breasts
Tendons relfexes
test integrity of segmental regions of spinal cord
biceps reflexes
C5, C6
Triceps reflexes
C7, C8
Erb-Duchenne’s palsy
injury to C5 and C6 at the brachial plexus level (deltoid, supraspinatous, infraspinatous, teres minor, biceps)
b/c bicep tone is decreased don’t have supination
injure by increase angle between head and shoulder
loss of flexors of the forearm and lateral rotators of the humerus
medial rotators take over, limb held in “waiter’s tip” position
Klumpke’s palsy
C8 and T1 injury
loss of intrinsic muscle of the hand
CLAW HAND–> b/c C8 and T1 go to the hand
due to loss of muscle which provide balance between powerful extensor and flexor muscles of the fingers (lumbricals and interossi)
this injury is caused due to catching one’s self in a hanging position while falling
Winged scapula
injury to long thoracic nerve
decreased ability to fully abduct the hand (decreased scapular rotation component)
loss of integrity of platform of upper limb from which to operate (loss of scapular fixation)
Injury to axillary nerve
injury to nerve as it passes around humerus in quadrangular space
happens due to poor crutch placement , downward glenohumeral dislocation, fracture of surgical neck of humerus
axillary supplies deltoid and teres minor
wasting of the deltoid contour
decreased abduction and flexion of the arm
loss of cutaneous sensation over lower 1/2 of deltoid
radial nerve injury
injury to nerve can occur as it exits the axilla or winds around the humerus in the “spiral groove”
all extensors are lost
wrist drop - acute
flexion contractures - chronic
examples of how to injure the radial nerve
poor crutch placement
falling asleep with arm over back of chair
fracture of the upper humerus
downward dislocation of glenohumeral joint
musculocutaneous nerve injury
results in: flaccid flexor compartment minimal flexion at the shoulder no flexion at the elbow (loss of forearm flexion) reduced supination
loss of cutaneous sensation to lateral forearm
median nerve injury
slide 77
mostly flexor muscles
ulnar nerve injury
slide 79
partial claw
ulnar nerve lesion have to use pincher and can’t use adduction griop
what can an injury at the elbow due to medial supracondylar humeral fracture or numero-ulnar dislocation result in?
Ape Hand
-appearance due to decreased wrist flexion and supination of the hand (both pronators paralyzed)
thumb in neutral position (laterally rotated and adducted)
wasting of the thenar eminence
wrist drop
happens due to injury of the radial nerve
ACUTE loss results in this due to loss of innervation of all extensors
flexion contractures
chronic loss of radial nerve (secondary to injury) results in this type of flexion contractures of flexors of the upper limb with complete loss of limb function
what are the cord levels of musculocutaneous
C5, C6, C7
what are the cord levels of axillary
C5, C6
what are the cord levels of Median nerve
C6-T1, sometimes C5
how does carpal tunnel syndrome happen?
Increased activity of wrist resulting in edema, compression and inflammation of median n.
symptoms of carpal tunnel (x5)
paresthesias of lateral 3 1/2 fingers
weakness upon flexion, abduction and opposition of thumb
wasting of thenar eminence
loss of fine motor control of 2nd and 3rd digits due to paralysis of 1st and 2nd lumbricals
loss of opposition; loss of grasp reflex
median claw
can be from injury of median nerve
loss of fine motor control of 2nd and 3rd digitis due to paralysis of 1st and 2nd lumbricals
what can falling on an outstretched hand potentially do?
injure the recurrent branch of the median nerve
struther’s canal
look it up
guyon’s tunnel
look it up
Injury within the canal of struther’s
occurs posterior to the medial humeral epicondyle (fracture/dislocation)
symptoms include weakness upon flexion and adduction of the wrist with paresthesias to the ring and little finger
injury within Guyon’s tunnel
occurs at the wrist medial to the flexor retinaculum beneath the pisohamate ligament (spans the hamulus of the hamate to the pisiform)
occurs as a result of cuts or falls on the outstretched palms
deficits seen with injury that is within Guyon’s tunnel
paresthesias to the ring and little finger
wasting of the hypothenar eminence and interosseous spaces (tunneling)
ulnar claw appearance of hand (4th and 5th digits)
loss of adduction of the thumb (Froment’s sign- adductor pollicis)
ulnar claw?
due to injury of the ulnar nerve (4th and 5th digits)
