living anatomy of the vessels and nerves

Question 1

palpate the subclavian pulse

Answer 1

in supraclavicular region - angle betwene clavical and SCM

Question 2

palpate the axillary arteyr

Answer 2

on medial side of head of humerus, posterior ot tendon on hsort head of biceps

Question 3

palpate brachial artery pulse

Answer 3

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

Question 4

what structures are at risk during venepuncture of the medial cubital vein *

Answer 4

the tendon of the biceps brachii muscle

the brachial artery

the median nerve

Question 5

demonstrate the dorsal venous arch, basilic and cephalic veins on dorsum of hand and wrist

Question 6

palpate the cubital lymph nodes

Answer 6

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

Question 7

palpate the axillary lymph nodes

Answer 7

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

Question 8

why wont loss of a single spinal root cause sensory loss in that dermatome

Answer 8

adjacent dermatomes overlap it

Question 9

why would damage to a peripheral nerve affect more than 1 dermatome or myotome

Answer 9

they carry nerve components from several spinal segments or roots

Question 10

what is the significance of the anterior and posterior axial lines

Answer 10

dermatomes dont cross the axial lines

Question 11

what are the regions of the dermatomes for the upper limb

Answer 11

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

Question 12

is it possible to detect any sensory loss in a single dermatome and why

Answer 12

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

Question 13

describe sensory innervation testing of the dermatome

Answer 13

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

Question 14

what is the effect if the whole brachial plexus C5-T1 is damaged

Answer 14

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

Question 15

which of the upper limb muscles are paralysed in the c5 6 roots lesion

Answer 15

Supra & infraspinatus (lateral rotators of shoulder),

deltoid (abductor),

biceps,

brachialis,

brachioradialis (elbow flexors),

supinator and wrist extensors (weak) - radial nerve effected

Question 16

where would you expect sensory loss in erb’s

Answer 16

lateral aspect of forearm - lateral cutaneous nerve from musculocutaneous nerve

over sargeant’s patch - loss of axillary nerve

dorsal of hand - radial nerve ?

Question 17

which muscles will be paralysed in klumpke’s

Answer 17

FC ulnaris, FD profundus (little and ring finger), lumbricals of (little and ring finger), and all interossei.

Question 18

what is the difference between a true claw and a claw like hanf

Answer 18

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

Question 19

in klumpke’s palsy is it a true claw or claw like

Answer 19

true claw - both median and ulnar nerves are affected

Question 20

where would you expect sensory loss in c8 t1 lesion - klumpke’s

Answer 20

hand - areas supplied by median and ulnar nerve

the medial forearm and arm

Question 21

what does the presence of a reflex activity indicate

Answer 21

integrity of the nerve pathway (lower motor neuron) of the particular spinal segment

Question 22

what does the biceps tendon reflex test

Answer 22

the musculocutaneous nerve

Question 23

explain how to do the biceps tendon reflex

Answer 23

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

Question 24

describe the triceps tendon reflex

Answer 24

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

Question 25

surface mark upper limb arteries

Answer 25

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

Question 26

surface mark the axillary nerve

Question 27

how would you test integrity of the axillary nerve

Answer 27

weak abduction from 15-90degrees

loss of sensation on the sargeants patch

Question 28

what joints would be affected if radial nerve is damaged in the axilla by an ill fitting crutch

Answer 28

elbow - triceps

wrist - supinators and wrist extensors

Question 29

where will sensory loss be from damage to the radial nerve

Answer 29

dorsum of hand and lateral digits

Question 30

sensory loss from the ulnar nerve damage

Answer 30

palmar aspects of the medial 1 and a half digits

Question 31

how would you test the integrity of the musculocutaneous nerve

Answer 31

flexion of the elbow joint

sensation down lateral aspect of forearm

Question 32

what motor deficits would you expect to see if median nerve is damaged

Answer 32

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

Question 33

clinical signs of carpal tunnel syndrome

Answer 33

pain and pins and needles in distribution of median nerve

weakness and loss of bulk of thenar muscles

Question 34

how do you best demonstrate clawing due to an ulnar lesion

Answer 34

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

Question 35

how is clawing due to median nerve lesion better demonstrated

Answer 35

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

Question 36

mark the veins

Answer 36

Question 37

presentation of erb’s

Answer 37

Arm adducted, medially rotated, pronated forearm with flexed wrist known as Waiter’s tip position.

Question 38

presentation of klumpke’s

Answer 38

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.

Question 39

how do you determine the prognosis of klumpke’s palsy

Answer 39

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

Question 40

what is the discrepancy with the term roots

Answer 40

spinal root comes out of spinal cord

root of brachial plexus is the primary ramus of the spinal nerve