living anatomy of the vessels and nerves Flashcards
palpate the subclavian pulse
in supraclavicular region - angle betwene clavical and SCM
palpate the axillary arteyr
on medial side of head of humerus, posterior ot tendon on hsort head of biceps
palpate brachial artery pulse
along middle third of humerus in medial bicipital groove behind the medial border of the biceps
at cubital fossa - on medial side of the tendon of the biceps on a fully extended elbow
what structures are at risk during venepuncture of the medial cubital vein *
the tendon of the biceps brachii muscle
the brachial artery
the median nerve
demonstrate the dorsal venous arch, basilic and cephalic veins on dorsum of hand and wrist
palpate the cubital lymph nodes
around the epicondyle, medial to the basilic vein
hold wrist to be examined in corresponding hand
using other hand grasp behind the olecranon with your fingers
your thumb should reach across the crease of the elbow to palpate the inner aspect of the arm just above the medial epicondyle of humerus
palpate the axillary lymph nodes
main groups are pectoral (anterior), humoral (lateral), subscapular (posterior), central and apical
hold their R forearm in your hand and take the weight - this relaxes the axillary muscles
with palm facing towards you palpate the lateral edge of the pec major - pectoral nodes
turn palm medially and with fingertips at apex of axilla palpate against the wall of the thorax using pulps of fingers - central nodes
facing your palm away fro you, feel inside of lateral edge of lat dorsi - posterior nodes
palpate inner aspect of arm in axilla - humeral
reach up towards apex of axilla
why wont loss of a single spinal root cause sensory loss in that dermatome
adjacent dermatomes overlap it
why would damage to a peripheral nerve affect more than 1 dermatome or myotome
they carry nerve components from several spinal segments or roots
what is the significance of the anterior and posterior axial lines
dermatomes dont cross the axial lines
what are the regions of the dermatomes for the upper limb
c4 - shoulder
5 lateral side of arm
6 lateral side fo forearma dn thumb
7 middle and ring finger
8 medial side of hand, forearm and little finger
t1 - medial side of upper forearm and arm
t2 - axilla
is it possible to detect any sensory loss in a single dermatome and why
no - the innervation of the dermatomes overlaps also different peripheral nerves supply one dermatome so loss of 1 peripheral nerve doesnt mean you wont feel anything in that dermatome
describe sensory innervation testing of the dermatome
demonstrate to the subject on a normal area of skin by touching with a blunt end of a pencil or cotton wool
then ask pt to close eyes while you examine individual dermatome areas methodically
ask if pt could feel touch as normal, dull or none at all
repeat on opposite limb and compare the dermatomes
in clinical practice use a sharp pin for crude touch and a cotton wool for light touch
what is the effect if the whole brachial plexus C5-T1 is damaged
the whole limb will be completely paralysed with complete sensory loss
there will also be horner’s syndrome due to loss of sympathetic supply to the head which comes form T1
which of the upper limb muscles are paralysed in the c5 6 roots lesion
Supra & infraspinatus (lateral rotators of shoulder),
deltoid (abductor),
biceps,
brachialis,
brachioradialis (elbow flexors),
supinator and wrist extensors (weak) - radial nerve effected
where would you expect sensory loss in erb’s
lateral aspect of forearm - lateral cutaneous nerve from musculocutaneous nerve
over sargeant’s patch - loss of axillary nerve
dorsal of hand - radial nerve ?
which muscles will be paralysed in klumpke’s
FC ulnaris, FD profundus (little and ring finger), lumbricals of (little and ring finger), and all interossei.
what is the difference between a true claw and a claw like hanf
true claw - median and ulnar nerves affected so all digits and muscles are affected - hyperextension of the MCP joints and flexion ai IP joints
claw like - either ulnar or median nerves are affected
in klumpke’s palsy is it a true claw or claw like
true claw - both median and ulnar nerves are affected
where would you expect sensory loss in c8 t1 lesion - klumpke’s
hand - areas supplied by median and ulnar nerve
the medial forearm and arm
what does the presence of a reflex activity indicate
integrity of the nerve pathway (lower motor neuron) of the particular spinal segment
what does the biceps tendon reflex test
the musculocutaneous nerve
explain how to do the biceps tendon reflex
ask the subject to rest comfortably, sitting/lying supine with elbow semi-flexed and hand pronated
place examiners thumb on biceps tendon and tap briskly with knee hammer on nail bed of thumb
if reflex arc is intact there will be a brisk contraction of the biceps causing flexion of the forerm at the elbow joint
compare with contralateral limb
describe the triceps tendon reflex
ask subject to rest comfortably - sitting or lying supine with elbow semi-flexed and hand pronated - the examiner should support the elbow with 1 hand
tap the triceps tendon directly with the tendon hammer
if the reflex arc is in tact there will be a brisk contraction of the triceps causing extension of the forearm
compare with contralateral limb
surface mark upper limb arteries
subclavian artery runs towards axilla in root of neck - becomes teh axillary artery as passes over 1st rib
brachial artery - on medial side of the arm between the biceps brachii and triceps brachii , then goes anterior to the humeus, medial to the biceps tendon, divides at teh radial neck into ulnar and radial artery
ulnar - medial side of forearm, then lateral to the pisiform, then forms the superficial palmar arch and deep palmar arch - superficial palmar arch gives of common palmar digital arteries then palmar digital arteries
radial artery - goes from flexor limb surface on lateral aspect of arm, thorugh the snuff box to the posterior of the arm then between the metacarpels of the thumb and index finger, then form deep plamar arch - gives rise to deep metacaroal arteries
surface mark the axillary nerve
how would you test integrity of the axillary nerve
weak abduction from 15-90degrees
loss of sensation on the sargeants patch
what joints would be affected if radial nerve is damaged in the axilla by an ill fitting crutch
elbow - triceps
wrist - supinators and wrist extensors
where will sensory loss be from damage to the radial nerve
dorsum of hand and lateral digits
sensory loss from the ulnar nerve damage
palmar aspects of the medial 1 and a half digits
how would you test the integrity of the musculocutaneous nerve
flexion of the elbow joint
sensation down lateral aspect of forearm
what motor deficits would you expect to see if median nerve is damaged
loss of func of most anterior foreaem muscles, and the LOAF muscles in hand
so weak pronation of forearm
weak wrist flexion adn abduction
paralysis of thenar eminence
weak flexion of lateral digits
clinical signs of carpal tunnel syndrome
pain and pins and needles in distribution of median nerve
weakness and loss of bulk of thenar muscles
how do you best demonstrate clawing due to an ulnar lesion
when the subject is asked to straighten all of their fingers
the IPJ of little and ring cannot straighten, the others can = claw like hand
if try to make a fist the little and ring fingers cant flex properly while other 3 fingers form a tight fist = claw like
how is clawing due to median nerve lesion better demonstrated
when patient is asked to form a tight fist with all fingers = partly extended index and middle fingers - hand of benediction
the MPJs of index and middle are hyperextended and loss of flexion in proximal IPJ (digitorum superficialis) and in distal IP joints (FDP)
there is loss of thenar muscles so the thumb cannot oppose
mark the veins
presentation of erb’s
Arm adducted, medially rotated, pronated forearm with flexed wrist known as Waiter’s tip position.
presentation of klumpke’s
Hand will show clawing 4th & 5th digit when at rest or extending all fingers. Thumb inabilty to adduct (adductor policis paralysed). Sensory loss to ulnar side of fore arm and hand.
Difficulty in straightening all fingers= 4th & 5th fingers are over extended at MCP. But at distal interphalageal jts, due to the paralysis of lumbricals and interossei they can’t be straightend. Assumes semi flexed position due to action FD superficialis
Difficulty in making a fist= because flexion of 4th & 5th digits incomplete at distal interphalageal jts. The MCP joints hyperextended due to unopposed action of extensor digitorum.
how do you determine the prognosis of klumpke’s palsy
test for elevation of teh scapula, if nerves to rhomboids and elevator scapulae are intact then the lesion is distal = good prognosis, if roots were damaged, they wouldnt be able to bring medial borders of the scapula together
if horner’s syndrome - means sympathetic component of T1 is affected = bad prognosis
what is the discrepancy with the term roots
spinal root comes out of spinal cord
root of brachial plexus is the primary ramus of the spinal nerve
