Clinical Topics Flashcards
DVT
Deep Venous Thrombosis
Use of general anesthesia (muscle relaxant drugs) or prolonged sitting
- slows down the blood flow in the deep veins
- result in pooling of the blood
- leads to a high risk of clot formation
Potential Collateral Circulation
alternate channels that ensure the blood supply to structures distal to the blockage
-
require time to open adequately
- insufficient to compensate for a sudden or acute incident
Gradual occlusion of the main vessel = activation of the collateral circulation
Compartment Syndrome
excessive pressure builds up inside an enclosed space in the body
bleeding from a fractured bone or swelling after a crush injury
- tough walls of fascia cannot easily expand
- pressure rises inside compartemnt
Tx fasciotomy
Impingement Syndrome of Supraspinatus
if supraspinatus tendon is thickened by an inflammatory or degenerative process,
- difficulty sliding in the canal
f there’s nodular swelling
- can get stuck in the canal
Rotator Cuff Syndrome (Tendonitis/Impingement)
very common shoulder injury
- from repetitive use or direct trauma
- head of humerus compresses against coraco-acromial arch
- rupture of supraspinatus tendon
- loss of abduction 0-15
Calcific Supraspinatus Tendinitis & Subacromial bursitis
subacromial painful arc syndrome
Subacromial bursitis
- calcium deposition into the supraspinatus tendon
- irritates the overlying subacromial bursa
excruciating pain during abduction of the arm
adducted the patient is pain-free
abduct the shoulder
- pain occur during 60-120° of abduction
- supraspinatus tendon is in direct contact with the acromion and coraco-acromial arch
Axillar nerve injury
usually injured by
- fracture of surgical neck of humerus
- dislocation of glenohumeral joint
- compression from incorrect use of crutches
Result
- Inability to abduct the arm (15-90 degrees)
- Loss of sensation over lateral aspect of proximal of arm
-
deltoid atrophy
- flattened shoulder look
Suprascapular Nerve Palsy
relatively uncommon
nerve entrapment or injury caused by
- repetitive overhead motion
- Compressive by cyst
occurs in
- Suprascapular notch (both infra/supraspinatus)
- spinoglenoid notch (infraspinatus effected)
results
- weakness or Atrophy
- loss of initiation of abduction (supraspinatus)
- loss of lateral rotation (infraspinatus)
Winged scapula
Paralysis of serratus anterior
- a result of damage to long thoracic nerve
Results
- unable to do any pushing action
- limited to no abduction
Breast Cancer
Cancer in Cooper’s Ligament
- large dimples
Cancer in subareolar region
- retracted nipple
Cancer of Dermal Lymphatics
- orange peel texture
- little pore at copper ligament attachment sites
Screen using Mammogram
- looking for regions of ill-defined dense (high in fatty elements) masses
Metastases of Breast Cancer
Breast cancer spreads via the lymphatics of the breast
Sentinel Node
- first lymph node to receive lymph drainage from breast
- tested through injection of a dye
Post-Mastectomy
- lymphedema in the upper extremities
- swelling with no pitting
Gynecomastia
breast hypertrophy in males after puberty
- triggered by a decrease in amount of testosterone present compared to estrogen
- achieved through
- Reduced androgen production (hypogonadism)
- Androgen resistance (testicular feminization)
- Increased estrogen secretion
Dislocation of the SC joint
very rare
Caused by
- a fall on the shoulder or outstretched hand
Anterior dislocation is more common than posterior
- posterior dislocation is life-threatening
Dislocation of the AC joint
Caused by
- hard fall on the shoulder
- severe blow to the back
Result
- AC and the coracoclavicular ligaments are torn
- shoulder separation (acromion sits below clavicle)
Dislocation of the glenohumeral Joint
Caused by
- abduction (90°) and excessive extension and lateral rotation
- head of the humerus is driven antero-inferiorly
- fibrous capsule and glenoid labrum stripped
- hard blow to the humerus when fully abducted
- tilts the head of the humerus inferiorly onto the inferior weak part of capsule
Results
- Injury to the axillary nerve
- stretching of radial nerve and posterior cord of brachial plexus
Adhesive Capsulitis
(frozen shoulder)
Fibrosis and inflammation of the joint capsule, bursae, rotator cuff muscles and/or deltoid
Cause
- spontaneous onset
- common in middle-aged DM pts
- may be due to prolonged immobilization
Results
- progressive pain and stiffness
- No tenderness
- ROM are limited
inferior vena cava blockage
lateral thoracic vein + superficial epigastric vein join to form the thoraco-epigastricvein which providescollateralroute during blockage
Brachial plexus block
Injection of anesthetic solution into the axillary sheath
- interrupts conduction
- produce anesthesia
Erb-Duchenne palsy
Caused by
- excessive increase in the angle between the neck and the shoulder
- Birth injury
- Fall on the shoulder
Results in
- avulsion of the C5, C6 roots
- loss of sensation of lateral aspect of arm
- arm adducted and medially rotated
- forearm extended and pronated
- waiter tip hand
Klumpke’s paralysis
Caused by
- the undue abduction of arm
- grasp something to break a fall
- Birth injury: baby’s upper limb is pulled excessively during delivery
Results
- avulsion of roots T1 and C8
- Claw hand + ape thumb
Thoracic outlet syndrome
Caused by
- compression of subclavian vessels and brachial plexus
- vascular compression less common than neurologic compression
Pain
- neurologic: paresthesia of the neck, shoulder, arm, and hand
- vascular: coldness, weakness, fatigability of the hand and arm
Biceps tendinitis
Caused by:
- Inflammation of the tendon result from repetitive micro-trauma
Result
- tenderness in the bicipital groove
- Resisted elbow flexion
- resisted shoulder flexion
- resisted supination with elbow flexed
Rupture of the tendon of long head of biceps brachii
Caused by
- Biceps tendinitis
- tendon is torn from its attachment to the supraglenoid tubercle
Result
- Popeye sign
- biceps muscle belly forms a ball near center of the arm
Distal biceps tendon rupture
Caused by
- Injuries to the distal biceps tendon
- Unanticipated loading of the tendon (catching something thats falling)
Result
- avulses from its radial tuberosity insertion
Median nerve injury/paralysis
Apelike thumb & hand of benediction deformity
Ulnar nerve injury
Caused by
- Fracture of the medial epicondyle of the humerus
- Cubital tunnel syndrome (entrapment syndrome)
Paralysis of
- Flexor carpi ulnaris,
- medial half of flexor digitorum profundus
ulnar claw hand deformity
Radial nerve injury
Caused by
- Contusion of the arm
- Fracture of the shaft of the humerus
Results
- Loss of extension of the wrist & MCP joints
- Wrist drop deformity
- Triceps brachii spared extension of elbow is possible
Volkmann’s Ischemic Contracture
Caused by
- contractures of muscles of forearm
- due to fractures of distal end of humerus or fractures of radius and ulna
- reduces the blood flow to the flexors and extensor muscles
Result
- ischemic necrosis
- muscles are replaced by fibrous tissue
TRAUMATIC INJURY TO BRACHIAL ARTERY
Caused by
- penetrating or blunt trauma
- arterial tap perforation
Results in
- ischemia and severe disability if anastomoses around elbow are inadequate
Pronator Syndrome (median nerve entrapment)
Caused by
- compressed of median nerve as it passes between two heads of pronator teres
- pain upon pronation
Dupuytren’s contracture
Caused by
- Gradual thickening and fibrosis of palmar aponeurosis
Results
- progressive shortening of the palmar fascia
- affects 4th + 5th digits
Tx
- surgical removal of palmar aponeurosis
Allen Test
test the patency of the radial and ulnar arteries
- occluding both radial and ulnar arteries at the wrist by direct pressure
- asked pt to open their hand (should be white)
- release pressure over one of two artery
- hand should turn pink (blood flow return)
- repeat test with other artery
If the palm does not become pink this signifies an occlusion of the released artery
Ulnar Canal Syndrome (Handlebar neuropathy)
Caused by
- compression of the ulnar nerve at wrist in Guyon Canal
Results
- Weakness and clawing of the 4th and 5th digits
Carpal Tunnel Syndrome
Caused by
- Any lesion that reduces the size of the tunnel
- increases the size of some the tendons
Results
- Compression of the median nerve
- Paresthesia (tingling), hypoesthesia, and anesthesia
stenosing tenosynovitis
(Trigger Finger)
Caused by
- inflammation and fibrosis of the flexor tendon sheath
- inflammation narrows the space within the sheath
- nodule may be present
results
- One of the fingers gets stuck in a bent position
- finger may straighten with a snap
Lateral epicondylitis
(tennis elbow)
most commonly involved is extensor carpi radialis brevis
Caused by
- weakened from overuse, microscopic tears
- inflammation
- repeated, forceful contraction of the wrist extensor, with repeated pronation + supination
Results
- severe inflammation and pain
Posterior interosseous nerve entrapment syndrome
Caused by
- Radial nerve entrapment in radial tunnel btw brachialis and brachioradialis
Results
- both motor and sensory deficits
- pain
- weakness of finger
- decreased wrist extension
Posterior interosseous nerve syndrome
caused by
- entrapment nerve passes between the two heads of supinator
- repetitively pronate and supinate of arm
Results
- gradual onset of weakness of muscles
- motor but no sensory deficits
Ganglion or Synovial Cyst of Wrist
non-tender cystic swelling on dorsal wrist
contains clear mucinous fluid
Flexion causes cyst to enlarge and cause pain
De Quervain’s tenosynovitis
(texting thumb)
Caused by
- Inflammation of abductor pollicis longus, extensor pollicis brevis and synovial sheath
Results
- server pain against resistance or adduction
Affects women more often than men
Mallet or Baseball Finger
Caused by
- Sudden severe tension on a long extensor tendon
- distal interphalangeal joint suddenly being forced into extreme flexion
Results
- avulse the attachment of the tendon to the base of distal phalanx
- hanging finger tip
Swan Neck or Boutonniere
deformities of the rheumatoid hand
Cubital Valgus vs Varus
carrying angle of the arms
Cubital Valgus greater than 15 degrees
Cubital Varus less than 5 degrees
Subcutaneous bursitis
Caused by
- Falls on the elbow
- infection of the skin covering the olecranon
- repeated excessive pressure and friction
Results
- inflammation
- pain
Subtendinous olecranon bursitis
Caused by
- excessive friction between the triceps tendon and olecranon
- repeated flexion–extension
Results
- pain is most severe during flexion
- pressure exerted on the bursa by the triceps tendon
Posterior Dislocation of the elbow
Caused by
- fall on hands when elbows flexed
- distal end of the humerus is driven through the weak anterior part of the joint capsule
Result
- radius and ulna dislocate posteriorly
- ulnar collateral ligament torn
- Injury to ulnar nerve
- fracture of the head of the radius, coronoid process, or olecranon process
traction apophysitis
Young Athlete’s Elbow Injury
Caused by
- repetitive action such as throwing a ball
Results
- medial elbow pain in young athletes
elbow area is the last epiphyseal center to close
Medial Epicondylitis
(golfer’s elbow)
Caused by
- overuse of wrist flexors + forearm pronator
- micro-tearing of flexor carpi radialis and pronator teres
Results
- medial elbow pain
Subluxation of the radial head
(Nursemaid’s Elbow/ Pulled elbow)
common and painful injury of small children
Caused by
- arm is jerked upward with the forearm pronated
- radial head slips out of the annular ligament
Results
- the ligament may become trapped between the radial head and the capitulum
Tx
- Supinating the forearm and flexing the elbow
Colles fracture
most common fracture of the forearm in people 50+
Caused by
- complete transverse fracture of the distal radius
- trying to break a fall by outstretching the upper limb
Results
- dinner fork deformity
Fracture of the scaphoid
common in young adult
prolonged healing time due to the poor blood supply to the proximal part of the scaphoid
Avascular necrosis may occur
Anterior dislocation of the lunate
uncommon but severe
Caused by
- fall on the extended wrist
Results
- displaced lunate may compress the median nerve
- lead to carpal tunnel syndrome
- poor blood supply may lead to avascular necrosis
Epiphyseal injury
common in children
Caused by
- fall on hand with transmitted force to the radius
Results
- fracture + separation of distal radial epiphysis
Hamate fracture
Caused by
- the handle of a golf club, tennis racquet or baseball bat
Results
- wrist pain, weakness
- Injury to deep branch of ulnar nerve
Peripheral neuropathy
Nerve transections vs Compression
Nerve transections = Acute loss of function
Compression neuropathy = Gradual loss of function
Principles of localization of the Site of nerve injury
- What is the motor function?
- Is it present?
- What is the Sensory Function?
- Is it present?
Suprascapular Nerve Compression
Ganglion Cyst
entrapped it passes through the suprascapular foramen to reach the supraspinous fossa
Long thoracic nerve injury
winged scapula
loss of serratus anterior function
Axillar nerve injury
Crutch Palsy
Fracture of the surgical neck of the humerus
Dislocation of the glenohumeral joint
Compression from the incorrect use of crutches
Musculocutaneous nerve injury
as pierces coracobrachialis may become entrapment
Ulnar nerve injury
Klmupke’s Claw Hand
Partial Claw Hand
Caused by
- Fracture of the medial epicondyle of the humerus
- Cubital tunnel syndrome (entrapment)
- Ulnar (Guyon) canal syndrome (entrapment)
- Handle-bar neuropathy (compression)
- Fracture of the hook of hamate
Median nerve injury
Caused by
- Supracondylar fracture
- Pronator Syndrome (entrapment)
- Carpal tunnel syndrome (entrapment)
- Stab or iatrogenic (surgical damage) wounds in the palm of recurrent branch of median nerve
Radial nerve injury
Caused by
- axilla by crutches (compression)
- Contusion of the arm
- Fracture of the mid-shaft of the humerus
- Radial canal entrapment (between brachialis and brachioradialis)
- passes between the two head of supinator muscle (deep branch or posterior interosseous)
