MIDTERM Flashcards
A football player receives a blow to the side wall of chest, what complications could happen?
The long thoracic nerve can be caused which will put the serratus anterior out of business and cause winged scapula since serrates anterior can no longe hold shoulder
What structures are found in the axilla?
Brachial plexus
Axillary artery and vein
What are the branches of the Axillary artery?
Screw the lawyer, save the patient
Superior thoracic artery
Thoracoacromial artery
Lateral Thoracic artery
Subscapular artery
Anterior humeral circumflex artery
Posterior humeral circumflex artery
Where does axillary artery become brachial artery?
distal border of teres major
What are the terminal branches of the brachial plexus?
Median
Radial
Ulnar
Musculocutaneous
Axillary
What is the function of the axillary sheath?
acts as a conduit from vertebral column to arm, forearm. hand
What is contained in the axillary sheath?
Axillary artery and its branches
Axillary vein
Brachial Plexus
______ becomes axillary artery at the lateral border of the first rib
Subclavian
What are branches of the Thoracoacromial artery?
Cadavers are dead people
Clavicular
Acromial
Deltoid
Pectoral
What does the Lateral Thoracic artery supply?
Serratus anterior
Lateral Breast
Fracture of surgical neck of humerus can cause ?
Damage to axillary nerve and posterior humeral circumflex artery
If the axillary artery is cut and ligated, blood flow will reverse in what artery?
Blood flow will reverse in the subscapular artery
Ligation should be performed proximal to the subscapular artery
BRACHIAL PLEXUS IS A NETWORK OF NERVES DERIVED FROM ______ SPINAL NERVES THAT SUPPLY THE UPPER EXTREMITY
C5-T1
If you fracture the clavicle, you must worry about damage to?
Axillary vessels
Brachial plexus
_________ and _________ cords of the brachial plexus are anterior to the axillary artery
Lateral and medial cords are anterior to axillary artery
What part of the brachial plexus is supraclavicular?
Roots
Trunks
Divisions
What part of the brachial plexus in infraclavicular?
Cords
Branches
What brachial plexus cord does the Thoracodorsal nerve (middle subscapular nerve) come from?
Posterior cord
Thoracodorsal nerve (middle subscapular nerve) innervates which muscle?
Latissimus dorsi
The big M of the brachial plexus is which cords?
The big M is comprised of the lateral and medial cords and their branches
Which terminal branches of the brachial plexus come from the lateral cord?
Musculocutaneous nerve
Median nerve
Which terminal branches of the brachial plexus come from the posterior cord?
Axillary nerve
Radial nerve
Which terminal branches of the brachial plexus come from the medial cord?
Median nerve
Ulnar nerve
What does the Musculocutaneous nerve innervate?
Flexor compartment of arm
Biceps brachii
Coracobrachialis
Brachialis
Musculocutaneous nerve continues as Lateral Cutaneous Nerve of forearm for sensory innervationof lateral forearm
Damage to musculocutaneous nerve results in?
Sensory loss to the lateral forearm
Great weakness of forearm and arm flexion
What does the axillary nerve innervate?
Deltoid
Teres minor
Skin over deltoid
What structures run through the quadrangular space?
Axillary nerve
Posterior humoral circumflex artery
Damage to axillary nerve results in?
Weakness in abduction, flexion, extension, and lateral rotation of arm
Sensory loss over the lateral shoulder
What does the radial nerve innervate?
Extensor compartment of arm and forearm
Triceps brachii
Skin of the posterior forearm
Where is the radial nerve found?
Radial (spiral) groove of the shaft of the posterior humerus
Triangular interval
What structures are found in the triangular interval?
Radial nerve
Profunda brachii artery
If deep branch of radial nerve is damaged, what happens?
Wrist drop
If superficial branch of radial nerve is damaged, what happens?
Lose sensation over the skin of posterior forearm
What does median nerve innervate?
Muscles of anterior forearm (except for flexor carpi ulnaris and ulnar half of flexor digitorum profundus)
What artery does the median nerve run with?
Brachial artery
What does the ulnar nerve innervate?
Flexor carpi ulnaris
Ulnar half of flexor digitorum profundus in the forearm
Ulnar nerve runs along_____
medial epicondyle
Which compartment of the arm are the flexors found in and what nerve are they innervated by?
Anterior
Musculocutaneous nerve
Biceps brachii action
Flexion of forearm at elbow
Supination
Brachialis action
flexes forearm
Coracobrachialis action
flexes arm
helps biceps brachii
What compartment of the arm are the extensors found in and what’s it innervated by?
Posterior
Radial nerve
What does the hinge joint of elbow consist of and its action?
trochlea and trochlear notch
flexion/extension
What does the gliding joint of elbow consist of and its action?
Capitulum and radial head
pronation/supination
What are the 3 ligaments of the elbow joint?
Annular ligament
Medial (ulnar) collateral ligament
Lateral (radial) collateral ligament
What are 2 functions of the annular ligament of elbow?
Hold radial head in place
Allows for pronation and supination
What nerve does a surgeon need to be careful of when performing surgery in the axilla region?
Thoracodorsal nerve
IS the radius and ulna crossed in pronation or supination?
The distal radius rolls over the ulna and proximal radius turns in pronation
DAMAGE TO WHAT NERVE AND AT WHAT SPINAL LEVEL WILL RESULT IN WINGED SCAPULA?
LONG THORACIC NERVE
C5, C6, C7
WHAT HAPPENS TO FUNCTION IN A PATIENT WITH WINGED SCAPULA ?
LOSS OF LONG THORACIC NERVE WILL MAKE THE PATIENT UNABLE TO ABDUCT ARM ABOVE 90 DEGREES BECAUSE OF LOSS OF THE SERRATUS ANTERIOR
WHAT STRUCTURES CAN GET DAMAGED IN A FRACTURE OF SURGICAL NECK OF HUMERUS?
AXILLARY NERVE
POSTERIOR HUMORAL CIRCUMFLEX ARTERY
WHAT HAPPENS TO FUNCTION IN A PATIENT WITH AXILLARY NERVE DAMAGE?
WEAKNESS IN ABDUCTION, FLEXION, EXTENSION, AND LATERAL ROTATION OF ARM
SENSORY LOSS OVER THE LATERAL SHOULDER
HOW MAY A PATIENT PRESENT WHEN THEY HAVE AXILLARY NERVE DAMAGE?
FLATTENED DELTOID
INABILITY TO ABDUCT SHOULDER PAST 15 DEGREES
REDUCED OR LOSS OF SENSATION OVER DELTOID AND LATERL ARM
WHAT CAUSES ERB’S PALSY?
DAMAGE TO UPPER ROOTS (C5 AND C6) OF BRACHIAL PLEXUS
INCREASED ANGLE BETWEEN NECK AND SHOULDER
FALLING ON HEAD AND SHOULDER OR IF INFANT’S HEAD PULLED ON FORCEFULLY
HOW DOES ERB’S PALSY PRESENT?
UPPER EXTREMITY IS MEDIALLY ROTATED AND PARALYZED EXCEPT FOR FINGERS
LOSS OF SENSATION ON LATERAL ASPECT OF UPPER LIMB
WAITERS TIP POSITION
WHAT IS KLUMPKES PALSY CAUSED FROM?
DAMAGE TO LOWER ROOTS (C8 AND T1) OF BRACHIAL PLEXUS
EXCESSIVE UPWARD PULL OF UPPER LIMBS
GRABBING A TREE BRANCH TO BREAK A FALL OR PULLING ON INFANTS ARM DURING DELIVERY
HOW DOES KLUMPKES PALSY PRESENT?
SHORT INTRINSIC HAND MUSCLES ARE PARALYZED
CLAW HAND
WHAT CAUSES SATURDAY NIGHT PALSY?
DAMAGE TO RADIAL NERVE
CAN HAPPEN THROUGH EXCESSIVE PRESSURE ON AXILLA (CRUTCHES OR SLEEPING WITH ARM OVER CHAIR)
WRIST DROP
WHAT NERVE MAY GET DAMAGED IN BREAST SURGERY?
THORACODORSAL NERVE
A PATIENT WITH THORACODORSAL NERVE DAMAGE MAY HAVE DEFICITS IN FUNCTION IN WHAT AREAS?
A PATIENT WITH THORACODORSAL NERVE DAMAGE MAY HAVE WEAKNESS IN EXTENSION, MEDIAL ROTATION, AND ADDUCTION OF ARM
A PATIENT THAT CAN NOT WIPE THEMSELVES IS EXAMPLE OF WHAT TYPE OF DAMAGE?
THORACODORSAL NERVE DAMAGE
what does hypesthesia mean?
reduced sensation
What does the interosseous membrane that is between the radius and ulna divide?
Anterior (flexor) and posterior (extensor) compartments
What nerves are found in the flexor compartment (anterior forearm) ?
Median and Ulnar nerves
What nerves are found in the extensor compartment (posterior forearm)?
Radial nerve
Radius articulates with the ________ of the humerus and the _______ of the ulna
Capitulum of humerus
Radial notch of the ulna
What inserts on the radial tuberosity of the radius?
Tendon of the biceps brachii
What part of radius is prone to fracture?
Styloid process on the distal end of radius
What part of the ulna is prone to fracture?
Styloid process of the ulna on distal end
What can cause a fracture of the styloid process of the ulna?
Falling on outstretched hand
Why is it necessary to have collateral circulation at elbow?
Because when you flex the elbow, you kink brachial artery
What does brachial artery split into?
Ulnar and radial arteries
During supination, the radius and ulna are _______
parallel
What nerve separates the superficial and deep layers of the anterior forearm (flexor compartment)?
Median
What muscles are found in the flexor compartment (anterior forearm)
Any muscle starting with flexor or pronator
Palmaris longus
Brachioradialis *** located in extensor compartment but is a flexor muscle
All of the flexor muscles of the forearm are innervated by the Median nerve except which muscles?
Flexor carpi ulnaris (Ulnar nerve)
Brachioradialis (Radial nerve)
The portion of the Flexor Digitorum Profundus that controls the medial 2 digits (Ulnar nerve)
Lateral 2 digits controlled by median nerve
Pronator teres action
pronates and flexes forearm
Flexor carpi radialis action
flexes and abducts wrist (radial deviation)
Palmaris longus action
flexes wrist
Flexor carpi ulnaris action
flexes and adducts wrist (ulnar deviation)
Brachioradialis action
flexes elbow
Flexor digitorum superficialis action
flexes wrist, PIP and MP joints of median 4 digits
Flexor digitorum profundus action
flexes wrist, DIP,PIP, and MP
Flexor pollicus longus action
flexes thumb
Pronator quadratus action
pronates forearm
what nerve runs through the carpal tunnel?
Median nerve
Median nerve enters forearm alongside ________ artery
Brachial artery
How does patient with median nerve injury at elbow present?
Hand of Benediction (Ape hand)
cannot oppose thumb
loss of pronation
sensory loss
What is Hand of Benediction?
Attempted formation of a fist results in 4th and 5th flexed (intact ulnar nerve) but first 3 fingers remain extended
What is ape hand
inability to abduct the thumb
What can result from median nerve injury at the wrist (in carpal tunnel)
Ape hand due to damage of the recurrent branch of the median nerve resulting in sensory loss, thenar eminence wasting and inability to abduct the thumb
Ulnar nerve runs along the medial edge of the forearm along with the _______
ulnar artery
Ulnar nerve innervates which muscles of the anterior compartment of forearm?
Flexor carpi ulnaris
Portion of the flexor digitorum profundus that controls medial 2 digits
How does patient with ulnar nerve damage at elbow present?
Claw hand (can’t abduct and adduct fingers)
Claw hand develops over time
Hypeextension of MP joint
Flexion of PIP joint
Static Sign unlike Hand of Benediction
can’t flex DIP joints, ring and little fingers
What artery runs through snuffbox?
Radial artery
The radial artery becomes the __________ arch?
Deep palmar arch
Ulnar artery becomes the ________ arch
superficial palmar arch
What is the Allen’s test?
Allen’s test allows testing of circulatory status of radial and ulnar arteries. Occlude both arteries by pressure and then ask patient to make a fist until palmar surface is white. Releasing pressure on either radial or ulnar artery will reveal whether the opposite artery is providing adequate circulation to hand
All extensor muscles of forearm are innervated by?
any muscle that starts with extensor, supinator, and the abductor pollicis longus
Radial nerve
Extensor carpi radialis longus action
extend abduct wrist (radial deviation)
Extensor carpi radialis brevis action
extend and abduct wrist (radial deviation)
Extensor digitorum action
partially extend all but thumb
final extension of fingers by lumbrical and interosseous muscles
Extensor carpi ulnaris action
extend and adduct wrist (ulnar deviation)
extensor digiti minimi action
extend little finger
Extensor indicis action
extend index finger (along with extensor digitorum)
Extensor pollicis longus action
extend thumb (IP joint)
Extensor pollicis brevis action
extend thumb
Abductor pollicis longus action
abduct thumb
Supinator
supinates forearm
which are stronger? Supinator or pronator
Supinators are stronger than pronators
The superficial branch of radial nerve innervates?
skin of posterior forearm and parts of dorsum of hand
The deep branch of the radial nerve innervates ?
muscles in the posterior compartment of forearm (extensors)
What are signs of radial nerve injury?
wrist drop
cannot extend elbow
loss of sensation on posterior forearm and dorsum of hand
What structure in dorsum of hand holds all tendons in position as they pull on insertions?
extensor retinaculum
What is compartment syndrome?
Muscles of forearm are grouped into tight fascial compartments and if there is swelling the compartment blood supply can be cut off
What type of fractures are scaphoid bones prone to ?
avascular fractures
Identify the bones of wrist on xray
Which bones of the wrist transmit force from the hand?
scaphoid and lunate
Where is interphalangeal joint (IP) found?
thumb
What is the function of the palmar aponeurosis?
Lies right under skin and protects all underneath structures from crushing injuries
Prevents long tendon from bowing out when constricted strongly
Carpal tunnel is formed by ______
flexor retinaculum
What nerve is found in the carpal tunnel?
Median nerve which breaks into branches called the recurrent nerve
Sensory branches of the median nerve innervate?
thumb second digit, third digit and half of fourth digit
What is carpal tunnel syndrome?
Inflammation of the flexor retinaculum sheath due to repeated movement in the carpal tunnel, fluid retention, fractures, infection or trauma to wrist
this results in decrease in size of tunnel and compression of the median nerve leading to tingling, lack of sensation (except for palm),
wasting of thenar muscles and lack of opposition
If the recurrent median branch of median nerve is affected in carpal tunnel syndrome, what happens?
Ape hand
How do you test for carpal tunnel syndrome?
Phalen’s maneuver
test for median nerve compression
raise arms to shoulder level and bring dorsum of hand together and hold wrist forced flexion 30-60 seconds. Positive phalens get tingling and numbness
What is tendonitis/synovitis?
sterile inflammation of the tendon or synovial sheath that is a result of overuse
What is Tenosynovitis
infection of both the digital synovial sheath and the tendon causing inflammation
usually confined to one digit
Which muscle is the only muscle to flex DIP joint
Flexor digitorum profundus
Flexor digitorum profundus action
flexes DIP, PIP, MP joint and wrist
What is special about how the Flexor Digitorum Superficialis attaches ?
Flexor Digitorum Superficialis splits and inserts on each side of the middle phalanx
Flexor digitorum superficialis action
flexes PIP, MP joint and wrist
What are the three long flexor tendons?
Flexor Digitorum Profundus
Flexor Digitorum Superficialis
Lumbricals
Where do Lumbricals insert?
Lumbricals insert on the radial side of profundus tendon (no direct bone attachment)
what are vincula
synovial folds containing small blood vessels to long flexor tendons
What is the function of the lumbricals?
fine finger movements
The lateral two lumbricals are innervated by?
Median nerve
The medial two lumbricals are innervated by?
ulnar nerve
Interosseus muscles of hand (located between metacarpals) are innervated by?
ulnar nerve
What is the function of the palmar interossei muscles of hand?
Palmar Interossei muscles adduct 2, 4, 5 digits (toward middle finger) PAD
What is function of Dorsal Interossei muscles of hand?
Dorsal interossei muscles abduct 2, 4, 5 digits (away from middle finger) DAB
The intrinsic muscles (aka THENAR muscles) of the deep thumb are innervated by?
recurrent branch of the median nerve
Damage to recurrent branch of median nerve causes?
loss of opposition (APE HAND)
What are the three muscles of thumb?
Abductor Pollicis Brevis
Flexor Pollicis Brevis
Opponens Pollici
What muscle is the ONLY muscle that opposes thumb?
Opponens Pollicis
Adductor pollicus action and innervation
Adduct and flex the thumb
Ulnar nerve
Hypothenar muscles are innervated by?
Ulnar nerve
IF THE UPPER LIMB HAS SUSTAINED TRAUMA, HOW DO TEST FOR SENSATION OF THE
MEDIAN NERVE
ULNAR NERVE
RADIAL NERVE
MEDIAN NERVE-PALMAR SURFACE OF INDEX FINGER
ULNAR NERVE-DORSAL SURFACE OF PINKY
RADIAL NERVE-DORSUM OVER THE FIRST INTEROSSEOUS
CUTANEOUS INNERVATIONS OF THE HAND
Claw hand is caused by what type of nerve damage?
Ulnar nerve damage
Benediction hand is from what type of nerve damage
median nerve damage at elbow
Ape hand caused by what type of nerve damage?
median nerve damage at wrist
thenar muscle paralysis
can be due to carpal tunnel
The superficial palmar arch (ulnar) and the deep palmar arch (radial) anastomose and provide collateral circulation. Allen’s test can be performed by occluding both radial and ulnar nerves. What constitutes a positive Allens test?
Positive Allen’s test-color of hand doesn’t return to normal within 5 seconds
Negative Allens test-color of hand returns to normal after 5 seconds
What is a Colles’ fracture?
Fracture of the ulnar styloid process and distal radius (DINNER FORK DEFORMITY)
common in women aged 50+
What can cause a scaphoid fracture?
Common in young adults usually with a fall onto an abducted and outstretched hand
Degeneration of bone may occur due to cut off blood supply from branch of radial artery
What ligaments are involved in shoulder separation?
acromioclavicular ligament
coracoclavicular ligament
muscles of the rotator cuff
Supraspinatus
Infraspinatus
Teres minor
Subscapularis
What is the sequence of muscle activation in abduction of the arm at the shoulder?
Supraspinatus initiates abduction
Deltoid brings arm to 90 degrees
Serratus anterior and Trapezius brings arm over 90 degrees
What type of action can cause shoulder dislocation?
Forced abduction and lateral rotation
What direction do shoulder dislocations most often occur?
Anterior dislocation
What is the function of the annular ligament in the elbow?
allows for pronation/supination as radius rotates in ligament
Holds the head of radius against ulna
Describe elbow dislocation
Head of radius slips out of the annular ligament (subluxation)
What type of nerve damage may occur with olecranon fracture?
Ulnar nerve damaged
Winged scapula and difficulty abducting arm above 90 degrees and pushing
No sensory loss
What nerve damaged?
Long thoracic nerve
Serratus anterior
Patient undergoes breast surgery and afterwards shows weakness in extension, medial rotation, and arm adduction
no sensory loss
What nerve damaged?
Thoracodorsal nerve
Latissimus dorsi
A patient presents with weakness in abduction of arm, weakness in flexion, extension, and lateral rotation of arm plus sensory loss over lateral shoulder
What nerve damage?
Axillary nerve
deltoid, teres minor, and skin over deltoid (lateral shoulder)
Axillary nerve comes from ________ cord and runs through _____________
Axillary nerve comes from posterior cord and runs through quadrangular space (surgical neck)
A patient presents with weakness in the flexion of the forearm, weakness in the flexion of arm and loss of sensation over the lateral forearm
What nerve damaged?
Musculocutaneous nerve
flexor muscles of the arm and skin of lateral forearm
Biceps brachii
Coracobrachialis
Brachialis
Musculocutaneous nerve comes from ______ cord and runs through __________
Musculocutaneous nerve comes from lateral cord and runs through coracobrachialis
If a patient present with:
cannot flex the distal IP joint of the ring and little fingers
cannot abduct and adduct fingers
cannot adduct thumb and has CLAW HAND
What nerve damaged?
Ulnar nerve
flexor carpi ulnaris
1/2 of flexor digitorum profundus
Ulnar nerve comes from_______ cord and runs behind _______
Ulnar nerve comes from medial cord and runs behind medial epicondyle of humerus
The deep branch of the ulnar nerve innervates?
hypothenar muscles
adductor pollicis
ulnar (medial) two lumbricals
all interosseous muscles
The superficial branch of ulnar nerve innervates?
skin
The median nerve innervates?
flexors of forearm
pronators of forearm
palmaris longus
thenar muscles
radial (lateral) two lumbricals
skin
what are the thenar muscles?
flexor polllicis brevis
abductor pollicis brevis
opponens pollici
How does the median nerve reach the thenar muscles?
through carpal tunnel
Median nerve comes from____ cord
Median nerve comes from medial and lateral cords
What happens if the recurrent branch of the median nerve is damaged?
cannot oppose thumb (APE hand)
What happens if median nerve is damaged in carpal tunnel?
Patient cannot oppose thumb and has median nerve sensory changes
What happens if median nerve damaged higher up than the recurrent median nerve and the carpal tunnel?
Ape hand
cannot pronate
cannot flex distal IP joints of index and middle fingers
weak flexion of the thumb and wrist
Hand of Benediction
If radial nerve is damaged up high, what signs?
cannot extend forearm (triceps)
loss of sensation over posterior arm and forearm (I THINK DORSUM OF HAND BUT CHECK
wrist drop
loss of extension of thumb and MP joints
Radial nerve comes from _______ cord and travel in _______
Radial nerve comes from posterior cord and runs in the radial groove along shaft of humerus
Superficial branch of the radial nerve runs through ________ and supplies
snuff box
sensation to hand
Deep branch of the radial nerve runs through _________ to innervate_________
Deep branch of the radial nerve runs through supinator to innervate extensor muscles of forearm
Damage to the deep branch of the radial nerve results in ?
wrist drop
unable extend thumb
unable extend MP joints
Umbilicus part of _______ dermatome
T10 dermatome
What vertebral level is the iliac crest found?
L4
HOW DOES APPENDICITIS PRESENT
PERIUMBILICAL/EPIGASTRIC PAIN WHICH GRADUALLY MIGRATES TO RLQ (TO MCBURNEY’S POINT WHERE THE APPENDIX IS FOUND)
Name the layers of oblique abdominal wall
skin
Camper fascia
Scarpa fascia
external oblique
internal oblique
transversus abdominis
transversals fascia
exztraperitoneal fat
parietal peritoneum
What is the largest and most superficial muscle of abdominal cavity?
External oblique muscle
External Oblique muscle is innervated by?
T7-T12
Muscle fibres of the external oblique muscle run in what direction?
hands in pocket