MSK Clinical Conditions Flashcards
What is thoracic outlet syndrome?
The apex of the axilla region is an opening between the clavicle, first rib and the scapula. In this apex, the vessels and nerves may become compressed between the bones – this is called thoracic outlet syndrome.
What is axillary lymph node enlargement in women an indicator of?
Non-specific indicator of breast cancer
What are some common causes of thoracic outlet syndrome?
Common causes of TOS are trauma (e.g fractured clavicle) and repetitive (seen commonly in occupations that require lifting of the arms)
How does an individual with thoracic outlet syndrome present?
Individual often presents with pain in the affected limb, (where the pain is depends on what nerves are affected), tingling, muscle weakness and discolouration
About how much of the lymph from the breast drains into the axillary lymph node?
Approximately 75% of lymph from the breast drains into the axilla lymph nodes
Why might the lymph in the axillary lymph node be biopsied?
Approximately 75% of lymph from the breast drains into the axilla lymph nodes, so can be biopsied if breast cancer is suspected
If breast cancer is confirmed in a patient who has excessive lymph in their axillary lymph node what is the first step in their treatment?
If breast cancer is confirmed, the axillary nodes may need to be removed to prevent the cancer spreading. This is known as axillary clearance.
During axillary clearance, what nerve may be damaged and what is the result of this?
Long thoracic nerve
Winged scapula
What is the clinical relevance of the cubital fossa and blood pressure?
Brachial artery
The brachial pulse can be felt by palpating immediately medial to the biceps tendon in the cubital fossa. When measuring blood pressure, this is also the location in which the stethoscope must be placed, to hear the korotkoff sounds
What is the clinical relevance of the cubital fossa and venepuncture?
The median cubital vein is located superficially within the roof of the cubital fossa. It connects the basilic and cephalic veins, and can be accessed easily – this makes it a common site for venepuncture
What is a supraepicondylar fracture?
It is a transverse fracture, spanning between the two epicondyles.
When does a supraepicondylar fracture occur?
A supraepicondylar fracture occurs by falling on a flexed elbow
How does a supraepicondylar fracture affect the cubital fossa?
The displaced fracture fragments may impinge and damage the contents of the cubital fossa.
What happens as a result of a supraepicondylar fracture?
Direct damage, or post-fracture swelling can cause interference to the blood supply of the forearm from the brachial artery. The resulting ischaemia can cause Volkmann’s ischaemic contracture –
What artery is damaged in a supraepicondylar fracture?
Brachial artery
What is Volkmann’s ischaemic contracture and what causes it?
Uncontrolled flexion of the hand, as flexors muscles become fibrotic and short
Ischaemia as a result of a supraepicondylar fracture can cause it
What nerves may be damaged in a supraepicondylar fracture?
Median and radial nerve
What is the carpal tunnel syndrome?
Compression of the median nerve within the carpal tunnel can cause carpal tunnel syndrome (CTS). It is the most common mononeuropathy and can be caused by thickened ligaments and tendon sheaths
What is the cause of carpal tunnel syndrome?
Mostly unknown (idiopathic) Trauma Rheumatoid arthritis Acromegaly Myxoedema Pregnancy
Others are diabetes neoplasm amyloidoses
If untreated, what will carpal tunnel syndrome cause?
Weakness and atrophy of the thenar muscles
How will a patient with carpal tunnel syndrome present?
Numbness, tingling and pain in the distribution of the median nerve.
The pain will usually radiate to the forearm.
Symptoms are often associated with waking the patient from their sleep and being worse in the mornings.
What two tests can be performed during physical examination, when suspecting carpal tunnel syndrome?
Tapping the nerve in the carpal tunnel to elicit pain in median nerve distribution (Tinel’s Sign)
Holding the wrist in flexion for 60 seconds to elicit numbness/pain in median nerve distribution (Phalen’s manoeuvre)
What treatment is available for carpal tunnel syndrome?
Treatment involves the use of a splint, holding the wrist in dorsiflexion overnight to relieve symptoms. If this is unsuccessful, corticosterioid injections into the carpal tunnel can be used. In severe case, surgical decompression of the carpal tunnel may be required.
What pulse can be palpated in the anatomical snuff box?
The radial pulse can be palpated in some individuals by placing two fingers on the proximal portion of the anatomical snuffbox.
What carpal bone is most prone to fracture within the anatomical snuff box?
Scaphoid bone
What two bones articulate in the anatomical snuff box to form the wrist joint?
The scaphoid and the radius
What can cause a fracture to the scaphoid bone?
A blow to the wrist (e.g falling on a outstretched hand) where the scaphoid takes most of the force
What is the main indication of a fracture to the scaphoid bone?
Localised pain in the anatomical snuffbox
Why is a scaphoid fracture sometimes considered a clinical emergency?
The scaphoid has a unique blood supply, which runs distal to proximal. A fracture of the scaphoid can disrupt the blood supply to the proximal portion – this is an emergency. Failure to revascularise the scaphoid can lead to avascular necrosis, and future arthritis for the patient.
How common are fractures to the scapula?
Relatively uncommon
Trauma to which region of the body is seen with a fractured scapula?
Chest trauma
In what incidents are fractured scapulae most commonly seen?
High speed road collisions
Crushing injuries
Sports injuries
Why does a fractured scapula not necessarily require an intervention?
The fractured scapula does not require much intervention, as the tone of the surrounding muscles holds the pieces in place for healing to occur.
What may be caused by damage to the long thoracic nerve?
Winged scapula- the scapula protrudes out of the back when pushing with the arm
Paralysis of serratus anterior muscle
What may cause damage to the long thoracic nerve?
Trauma to the shoulder, repetitive movements involving the shoulder or by structures becoming inflamed and pressing on the nerve Surgical procedures (such as axillary clearance) where damage to LTN may occur
What function of the clavicle contributes to it being one of the most fractured bones?
It transmit forces from the upper limb to the axial skeleton
How can a fracture to the clavicle occur?
Fractures commonly result from a fall onto the shoulder, or onto an outstretched hand
What is the most common fracture site on the clavicle?
The most common point of fracture is the junction of the medial 2/3 and lateral 1/3.
After a fracture to the clavicle, how do the muscles solace the clavicle?
After fracture, the lateral end of the clavicle is displaced inferiorly by the weight of the arm, and medially, by the pectoralis major. The medial end is pulled superiorly, by the sternocleidomastoid muscle
What nerves may be damaged when the clavicle is fractured and what muscle does this nerve innervate?
The suprascapular nerves (medial, intermedial and lateral) may be damaged by the upwards movement of the medial part of the fracture.
These nerves innervate the lateral rotators (suprapinatus, infraspinatus and teres minor) of the upper limb at the shoulder
How may an individual with a fracture to their clavicle present and why?
Waiters tip position
Damage to suprascapsular nerve
These nerves innervate the lateral rotators of the upper limb at the shoulder – so damage results in unopposed medial rotation of the upper limb – the ‘waiters tip’ position.
Medial fragment pulled superiorly by sternocleidomastoid muscle
Trapezius can’t pull lateral fragment superiorly due to weight of upper limbs so shoulder drops
Adduction muscles (pec major) pull lateral fragment medially
What is a fracture of the surgical neck?
When a fracture occurs at the surgical neck of the humerus (most common site of fracture in humerus)
When can a surgical neck fracture of the humerus occur?
this occurs by a direct blow to the area, or by falling on an outstretched hand
What nerve is at most risk of damage in a surgical neck fracture of the humerus?
Axillary nerve
What artery is at most risk of damage in a surgical neck fracture of the humerus?
Posterior circumflex humeral artery (branch of axillary artery)
Damage to the axillary nerve in a surgical neck fracture of the humerus will affect which muscles and what movement?
Deltoid
Teres minor
Patient unable to abduct arm
Damage to the axillary nerve in a surgical neck fracture of the humerus will affect which region of skin?
The axillary nerve also innervates the skin over the lower deltoid (known as the regimental badge area), and so sensory innervation here could be lost.
What is a mid shaft fracture of the humerus?
When a fracture occurs in the shaft region of the humerus
Most commonly in region of radial groove
What nerve and artery can be damaged in a mid shaft fracture and why?
Radial nerve
Profunda brachii artery
These are tightly bound to the radial groove
What muscles does the radial nerve innervate in the forearm and how are these affected in a mid shaft fracture?
The radial nerve innervates the extensors of the wrist. In the event of damage to this nerve, the extensors will be paralysed. This results in unopposed flexion of the wrist occurs, known as ‘wrist drop’
How will a patient with damage to their radial nerve present?
Wrist drop- since extensor muscles of forearm are no longer innervated
Sensory loss over dorsal surface of hand and proximal ends of lateral 3 and a half fingers dorsally
What are the two most common distal humeral fractures?
Supraepicondylar fractures
Medial epicondyle fractures
What nerve can become damaged in a medial epicondyle fracture?
Ulnar nerve
When the ulnar nerve is damaged (as in medial epicondyle fracture) how will a patient present?
Claw hand
A deformity known as ulnar claw is the result. There will be a loss of sensation over the medial 1 and 1/2 fingers of the hand, on both the dorsal and palmar surfaces.
What can cause a fracture of the ulna bone?
Fracture occurs as a result of the ulna being hit by an object
What region of the ulna is the most common site for fracture?
The shaft
How will an ulna shaft fracture affect the appearance of the forearm?
Normal muscle tone will pull the proximal ulna posteriorly
When a fracture in the ulnar has occurred why is it necessary to check for a fracture in the radius bone?
Ulna and radius bone are attached by the interosseous membrane.
The force of a trauma to one bone can be transmitted to the other via this membrane.
Thus, fractures of both the forearm bones are not uncommon.
Polo mint analogy
What is a monteggia fracture of the Ulna bone and what causes it?
Monteggia’s Fracture – Usually caused by a force from behind the ulna. The proximal shaft of ulna is fractured, and the head of the radius dislocates anteriorly at the elbow.
What is a Galeazzi’s fracture of the ulna bone?
Galeazzi’s Fracture – A fracture to the distal radius, with the ulna head dislocating at the distal radio-ulnar joint.
What is a Colles fracture of the radius?
The most common type of radial fracture.
Fracture of distal 2cm of radius.
The structures distal to the fracture (wrist and hand) are displaced POSTERIORLY
What can cause a Colles fracture of the radius?
A fall onto an outstretched hand causing a fracture of the distal radius.
How would a patient who has suffered a Colles fracture present?
It produces what is known as the ‘dinner fork deformity’
Describe fractures of the radial head
This is characteristically due to falling on an outstretched hand. The radial head is forced into the capitulum of humerus, causing it to fracture.
What is a smiths fracture of the radius?
A fracture caused by falling onto the back of the hand.
Fracture to distal 2cm of radius
It is the opposite of a Colles’ fracture, as the distal fragment is now placed ANTERIORLY
What two carpal bones are the most commonly fractured?
Lunate and scaphoid
What is the most common cause of a carpal fracture?
Falling on an outstretched hand
What is the main clinical observation of a scaphoid bone fracture?
Pain/ tenderness in anatomical snuffbox
What artery is at risk of damage in a scaphoid bone fracture?
Radial artery
What nerve is at risk of damage in a scaphoid bone fracture?
Radial nerve
In a scaphoid fracture, what can occur as a result of radial artery damage?
Avascular necrosis as blood supply is cut off to a proximal part of bone
When can a lunate fracture occur?
A lunate fracture occurs when falling on a outstretched hand causes hyperextension at the wrist.
What nerve is at risk of damage in a lunate bone fracture?
Median nerve
What is the carpal tunnel syndrome?
The carpal tunnel contains many tendons and the median nerve
Compression of the median nerve within the carpal tunnel can cause carpal tunnel syndrome (CTS).
It is the most common mononeuropathy.
What is the cause of carpal tunnel syndrome?
Its exact cause is not known, but it is thought to be due to thickening of the ligaments and synovial tendon sheaths of the tendons, brought on by overuse or increased pressure on this wrist.
What are the typical symptoms of carpal tunnel syndrome?
Pins and needles in the sensory distribution of the median nerve
Weakness of thenar muscles
The patients history will comment on numbness, tingling and pain in the distribution of the median nerve. The pain will usually radiate to the forearm. Symptoms are often associated with waking the patient from their sleep and being worse in the mornings.
How can a patient with Carpal tunnel syndrome be treated?
Treatment involves the use of a splint, holding the wrist in dorsiflexion overnight to relieve symptoms.
If this is unsuccessful, corticosterioid injections into the carpal tunnel can be used.
In severe case, surgical decompression of the carpal tunnel may be required- cutting into the flexor retinaculum, relieving the pressure
What are the two most common fractures of the metacarpal bones?
Boxers fracture
Bennetts fracture
What is Bennett’s fracture of the metacarpal bones and what is it caused by?
Caused by hyperabduction of the thumb, fracture normally occurs close to the carpometacarpal joint
What is the Boxers fracture of the metacarpal bones and what is it caused by?
Usually caused by a clenched fist striking a hard object.
It is a fracture of the neck of the 5th and occasionally the 4th metacarpal bones. The fingers look shorter as the distal fragments are pushed proximally.
What’s the best way to test the accessory nerve?
By testing how well the trapezius is functioning- Can be achieved by getting the patient to elevate their shoulder against resistance
What muscle does the accessory nerve supply?
The trapezius muscle
In what position does the tendon of the supraspinatus muscle and the coraco-acromial arch rub together? And what bursa normally reduces this friction?
When the arm is abducted, the tendon of the supraspinatus muscle ‘rubs’ against the coraco-acromial arch.
The friction is reduced by the subacromial bursa.
What can cause the painful arc syndrome?
Under repetitive use and abduction, there are degenerative changes in both the subacromial bursa and the supraspinatus tendon.
What is the characteristic sign of painful arc syndrome?
The chracteristic sign is the ‘painful arc’ – pain in the middle of abduction, where the affected area comes into contact with the acromion
What can cause the humerus to irritate the coraco-acromial arch and in turn what else can this cause?
Repetitive use of the rotator cuff muscles can cause the head of the humerus and the muscles to irritate the coraco-acromial arch, which in turn causes inflammation of the rotator cuff. Over a long period of time this can develop into rotator cuff tendonitis.
How common is the rupturing of a tendon in the body?
A complete rupture of any tendon in the body is rare.
How common is the rupture of the biceps brachii tendon?
the long head of the biceps brachii is one of the more common tendons to rupture
What sign would a patient who has a ruptured biceps brachii tendon present with and what other symptoms?
This produces a characteristic sign on flexing the elbow – a bulge where the muscle belly is, called the ‘Popeye Sign’. The patient would not notice much weakness in the upper limb due to the action of the brachialis and supinator muscles.
What is lateral epicondylitis?
Lateral epicondylitis (or tennis elbow) refers to inflammation of the periosteum of the lateral epicondyle.
What is the peak age of onset of lateral epicondylitis?
40-50 years old
What is lateral epicondylitis also known as?
Tennis elbow
What is the cause of lateral epicondylitis?
It is caused by repeated use of the superficial extensor muscles, which strains their common tendinous attachment to the lateral epicondyle.
Tennis players
What is wrist drop a clinical sign of?
Radial nerve injury
In which two regions does radial nerve damage most commonly occur?
Axilla – injured via humeral dislocations or fractures of the proximal humerus.
Radial groove of the humurus - injured via a humeral shaft fracture.
What happens to all of the muscles of the posterior extensor compartment of the forearm when the radial nerve is damaged and how does this cause wrist drop?
These muscles are paralysed
Flexor muscles of anterior forearm are unaffected since they are supplied by the median and ulnar nerve
Therefore the tone of the flexor muscles produces unopposed flexion at the wrist joint and consequently wrist drop
What is the most common cause of axillary nerve injury?
Anterior dislocation of the humerus at the glenohumeral joint, or a fracture of the humerus at the surgical neck.
Injury to the Axillary nerve affects which muscles and movement?
Paralysis of the deltoid and teres minor muscles. This renders the patient unable to abduct the affected limb.
Which branch of the axillary nerve will be non-functional and thus which area of skin will lose sensation in axillary nerve injury?
A branch of the axillary nerve, the lateral cutaneous nerve of arm will be non functional, resulting in loss of sensation over the regimental badge area.
What is a characteristic clinical side of axillary nerve damage?
In long standing cases, the paralysed deltoid muscle rapidly atrophies, and the greater tuberosity can be palpated in that area.
What is the most common cause of musculocutaneous nerve damage?
An injury to the musculocutaneous nerve is relatively uncommon, as it is well protected within the axilla. The most common cause is a stab wound to the axilla region.
Injury to the musculocutaneous nerve affects which muscles and movements?
The coracobrachialis, biceps brachii and brachialis muscles are paralysed. Flexion at the shoulder is weakened, but can still occur due to the pectoralis major. Flexion at the elbow is also affected, but can still be performed because of the brachioradialis muscle. Also, supination of the affected limb is greatly weakened, but is produced by the supinator muscle.
Which area of skin loses innervation when the musculocutaneous nerve is damaged?
Loss of sensation over the lateral side of the the forearm.
If untreated what can carpal tunnel syndrome cause?
If left untreated, CTS can cause weakness and atrophy of the thenar muscles.
What two tests for carpal tunnel syndrome can be performed in physical examination?
Tests for CTS can be performed during physical examination:
Tapping the nerve in the carpal tunnel to elicit pain in median nerve distribution (Tinel’s Sign)
Holding the wrist in flexion for 60 seconds to elicit numbness/pain in median nerve distribution (Phalen’s manoeuvre)
In what to places can the median nerve be damaged?
At the elbow
At the wrist
How can median nerve damage at the elbow occur?
Supracondylar fracture of the humerus
Injury to the median nerve at the elbow joint can affect which muscles and movements?
The flexors and pronators in the forearm are paralysed, with the exception of the flexor carpi ulnaris and medial half of flexor digitorum profundus. The forearm constantly supinated, and flexion is weak (often accompanied by adduction, because of the pull of the flexor carpi ulnaris).
Flexion at the thumb is also prevented, as both the longus and brevis muscles are paralysed.
The lateral two lumbrical muscles are paralysed, and the patient will not be able to flex at the MCP joints or extend at IP joints of the index and middle fingers.
Which area of skin loses innervation when the median nerve is damaged at the elbow joint and wrist?
Lack of sensation over the areas that the median nerve innervates.
What is a characteristic sign of median nerve damage at the elbow joint and wrist?
The thenar eminence is wasted, due to atrophy of the thenar muscles. If patient tries to make a fist, only the little and ring fingers can flex completely. This results in a characteristic shape of the hand, known as hand of benediction
How can median nerve damage occur at the wrist joint?
Lacerations just proximal to the flexor reticaculum
In median nerve injury at the wrist joint which muscles and movements are affected?
Thenar muscles paralysed, as are the lateral two lumbricals. This affects opposition of the thumb and flexion of the index and middle fingers.
In what four regions can radial nerve damage occur?
In the Axilla
In the Radial Groove
Deep Branch of Radial Nerve
Superficial Branch of the Radial Nerve
How can damage to the radial nerve occur in the axilla region?
Dislocation of humerus at the glenohumeral joint or fractures of proximal humerus. Can also happen via excessive pressure on the axilla, e.g. a badly fitting crutch.
In radial nerve injury in the axilla region which muscles and movements are affected?
Triceps brachii and muscles in posterior compartment are paralysed. The patient is unable to extend the forearm, wrist and fingers. Unopposed flexion of wrist occurs, known as wrist drop.
Which area of skin loses sensation when the radial nerve is damaged in the axilla region?
All four cutaneous branches of the radial nerve are affected. There will be a loss of sensation over the lateral and posterior upper arm, posterior forearm, and dorsal surface of the lateral three and a half digits.
How can damage to the radial nerve occur in the radial groove?
Fracture of the shaft of the humerus – damaging the radial nerve when it is bound in the radial groove.
In radial nerve injury in the radial groove which muscles and movements can be affected?
The triceps brachii may be weakened, but is not paralysed. The deep branch of the radial nerve is affected, so the muscles in the posterior compartment of the forearm are paralysed. The patient is unable to extend the wrist and fingers. Unopposed flexion of wrist occurs, known as wrist drop.
Which area skin loses sensation when the radial nerve is damaged in the radial groove?
The cutaneous branches to the arm and forearm have already arisen. The superficial branch of the radial nerve will be damaged, resulting in sensory loss on the dorsal surface of the lateral three and half digits, and their associated palm area.
How can damage to the deep branch of the radial nerve occur?
Fractures of the radial head, or a posterior dislocation of the radius at the elbow joint.
In injury to the deep branch of the radial nerve which muscles and movements are affected?
Muscles in posterior compartment of the forearm are affected – except for the supinator and extensor carpi radialis longus. The extensor carpi radialis longus is a strong extensor at the wrist, and so wristdrop does not occur.
Which area of skin loses sensation when damage to the deep branch of the radial nerve occurs?
None, as it is a motor nerve.
How can damage to the superficial branch of the radial nerve occur?
Stabbing or laceration of the forearm.
In damage to the superficial branch of the radial nerve, which muscles and movements are affected?
None, as it is a sensory nerve.
Which area of skin loses sensation when the superficial branch of the radial nerve is damaged?
Loss of sensation over the lateral and posterior upper arm, posterior forearm, and dorsal surface of the lateral three and a half digits.
In what two regions can ulnar nerve damage occur?
At elbow
At wrist
How can damage to the ulnar nerve at the elbow occur?
The nerve is most vulnerable to injury at the medial epicondyle, so fracture of the medial epicondyle is the most common way of damaging the ulnar nerve
In damage to the ulnar nerve at the elbow which muscles and movement for affected?
Flexor carpi ulnaris and medial half of flexor digitorum profundus paralysed. Flexion of the wrist can still occur, but is accompanied by abduction. The interossei are paralysed, so abduction and adduction of the fingers cannot occur. Movement of the little and ring fingers is greatly reduced, due to paralysis of the medial two lumbricals.
Which area of skin loses sensation when the ulnar nerve is damaged at the elbow?
All sensory branches are affected, so there will be a loss of sensation over the areas that the ulnar nerve innervates.
What is a characteristic sign of ulnar nerve injury at the elbow?
Patient cannot grip paper placed between fingers.
How can damage to the ulnar nerve occur at the wrist?
Lacerations to the wrist
In ulnar nerve injury at the wrist which muscles and movements are affected?
The interossei are paralysed, so abduction and adduction of the fingers cannot occur. Movement of the little and ring fingers is greatly reduced, due to paralysis of the medial two lumbricals. The two muscles in the forearm are unaffected
Which area of skin loses sensation when ulnar nerve injury to the wrist occurs?
The palmar branch and superficial branch are usually severed, but the dorsal branch is unaffected. Sensory loss over palmar side of medial one and a half fingers only.
What is a clinical sign of ulnar nerve injury in the wrist?
Patient cannot grip paper placed between fingers. For long-term cases, a hand deformity called ‘Ulnar Claw’ develops
What does the ulnar claw look like?
Hyper-extension of the metacarpophalangeal joints of the little and ring fingers – this is because of the paralysis of the medial two lumbricals, and the now unopposed action of the extensor muscles
Flexion at the interphalangeal joints of the little and ring fingers- because of the unopposed action of FDP (only visible when injury is at wrist and FDP is still functional)
If the lesion has occurred close to the elbow, this might not be evident as the flexor digitorum profundus will be paralysed and so little and ring fingers cannot flex
Described Erbs Palsy
Upper Brachial Plexus Injury – Erb’s Palsy
How it commonly occurs: Usually occurs as a result of a difficult birth or a blow to the shoulder.
Nerves affected: Nerves derived from solely C5 or C6 roots; musculocutaneous, axillary, suprascapular and nerve to subclavius.
Muscles paralysed: Supraspinatus, infraspinatus, subcalvius, biceps brachii, brachialis, coracobrachialis, deltoid and teres minor.
Motor functions: The following movements are lost or greatly weakened – abduction at shoulder, lateral rotation of arm, supination of forearm, and flexion at shoulder.
Sensory Functions: Loss of sensation down lateral side of arm, which covers the sensory innervation of the axillary and musculcutaneous nerves.
Characteristic signs: Affected limb hangs limply, medially rotated by unapposed action of pectoralis major, forearm is pronated because of loss of biceps brachii. This is known as ‘waiter’s tip’.
Describe klumpke palsy
Lower Brachial Plexus Injury – Klumpke Palsy
How it commonly occurs: Excessive abduction of the arm e.g person catching a branch as they fall from a tree.
Nerves affected: Nerves derived from T1 – ulna and median nerves.
Muscles paralysed: All the small muscles of the hand (The flexors muscles in the forearm are supplied by the ulna and median nerves, but are innervated by different roots)
Sensory: Loss of sensation along medial side of arm.
Characteristic signs: Hand is clawed, hyperextension occurs at the metacarpophalangeal joints, and flexion occurs at the interphalangeal joints.
Compare the ulnar claw and hand of benediction
Ulnar claw
Nerve: Lesion of ulnar nerve at wrist
Typical presentation: Appears in long-standing cases of nerve damage
Digits affected: Little and ring fingers
Muscles paralysed: medial two lumbricals
Movements involved: unopposed extension at the MCP joints; unopposed flexion at the IP joints
Hand of benediction:
Nerve: Lesion of the median nerve at the elbow or wrist
Typical presentation: Appears when the patient attempts to make a fist
Digits affected: Middle and index fingers
Muscles paralysed: lateral half of flexor digitorum profundus
Movements involved:inability to perform flexion at the MCP joints of the middle and index fingers
What is an aneurysm of the axillary artery?
Where the proximal portion of the axillary artery may dilate – this is called an aneurysm
How does an aneurysm of the axillary artery affect surrounding structures? And what symptoms would this give?
The dilated portion of the artery could put pressure on the brachial plexus. This would manifest clinically as pain and loss of sensation in the cutaneous distribution of the affected nerve.
Give three examples of people prone to axillary aneurysms
Patients with high blood pressure
Patients with Marfan’s
Baseball pitchers – thought to be due to the speed and force of the their arm movement
Why is occlusion or laceration of the brachial artery considered a clinical emergency?
The arm has relatively good anastomotic supply which protects it from temporary or partial occlusion of the brachial artery. However, if the artery is completely blocked, or severed, it is a medical emergency.
The resulting ischaemia of the forearm can cause necrosis and paralysis of the muscles in the forearm. The affected muscles are replaced to some degree by scar tissue, and shorten considerably. This can cause a characteristic flexion deformity, caused Volkmann’s contracture.
Where is the main site for taking blood and why?
The main site for taking blood is the median cubital vein. This is because it is easily accessible, and the vein is relatively superficial.
How are shoulder dislocations described clinically? In relation to what?
Clinically, dislocations at the shoulder are described by where the humeral head lies in relation to the infraglenoid tubercle.
What type of shoulder dislocation is most common?
Anterior dislocations are the most prevalent, although posterior dislocations can sometimes occur.
What is superior movement of the humerus in the shoulder joint prevented by?
Superior movement of the humeral head is prevented by the coraco-acromial arch.
What is anterior dislocation of the shoulder joint usually caused by?
An anterior dislocation is usually caused by excessive extension and lateral rotation of the humerus.
In a dislocation of the shoulder joint what happens to the humeral head?
The humeral head is forced anteriorly and inferiorly – into the weakest part of the joint capsule.
When the joint capsule of the shoulder capsule is damaged in dislocation what is the effect on future dislocations?
Tearing of the joint capsule is associated with an increased risk of future dislocations.
What nerves can be damaged in dislocation of the shoulder joint? What muscles and sensory innervations does this consequently affect?
The axillary nerve runs in close proximity to the shoulder joint, and can be damaged in the dislocation.
Injury to the axillary nerve causes paralysis of the deltoid, and loss of sensation over regimental badge area.
A dislocation can also stretch the radial nerve, as it is tightly bound in the radial groove.
Why are rotator cuff muscles common sites of injury?
The rotator cuff muscles have a very important role in stabilising the glenohumeral joint. They are often under heavy strain, and therefore injuries of these muscles is relatively common.
What is tendonitis?
Tendonitis refers to inflammation of the muscle tendons
What is the usual cause of tendonitis?
Usually due to overuse
Over a long period of time what can be the effect of tendonitis on surrounding structures of she shoulder joint?
Over time, this causes degenerative changes in the subacromial bursa, and the supraspinatus tendon. This increases friction between the structures of the joint.
What is the characteristic sign of rotator cuff tendonitis?
The characteristic sign of rotator cuff tendonitis is the ‘painful arc’ – pain in the middle of abduction, where the affected area comes into contact with the acromion.
What is subcutaneous bursitis of the elbow joint?
Repeated friction and pressure on the bursa can cause it become inflamed. Because this bursa lies relatively superficially, it can also become infected (e.g cut from a fall on the elbow), and this would also cause inflammation
*Subcutaneous: Found between the olecrannon and the overlying connective tissue.
What is subtendinosus bursitis of the elbow joint?
This is caused by repeated flexion and extension of the forearm, commonly seen in assembly line workers. Usually flexion is more painful as more pressure is put on the bursa.
*Subtendinosus: Found between the olecrannon and the tendon of the triceps brachii, reducing friction between the two structures during extension and flexion of the arm.
Describe a dislocation of the elbow joint? (Pulled elbow) Bone, capsule, ligament and nerve damage?
An elbow dislocation usually occurs when a young child falls on a hand with the elbow flexed. The distal end of the humerus is driven through the weakest part of the joint capsule, which is the anterior side. The ulnar collateral ligament is usually torn and there can also be ulnar nerve involvement
Most elbow dislocations are posterior, and it is important to note that elbow dislocations are named by the position of the ulna and radius, not the humerus.
Describe tennis elbow (Epicondylitis)
Tennis players experience pain in the lateral epicondyle from the common extensor origin
Tennis players can develop an overuse strain of the common tendon – which results in pain and inflammation around the area of the lateral epicondyle.
Describe folders elbow (Epicondylitis)
Golfers experience pain in the medial epicondyle from the common flexor origin.
Golf players can develop an overuse strain of the common tendon – which results in pain and inflammation around the area of the medial epicondyle.
How does a supraepicondylar fracture occur?
A supraepicondylar fracture occurs by falling on a flexed elbow
What is a supraepicondylar fracture?
It is a transverse fracture, spanning between the two epicondyles.
What neurovasculature can be damaged in a supraepicondylar fracture and what are some consequences of this?
Direct damage, or swelling can cause the interference to the blood supply of the forearm via the brachial artery. The resulting ischaemia can cause Volkmann’s ischaemic contracture – uncontrolled flexion of the hand, as flexors muscles become fibrotic and short. There also can be damage to the medial, ulnar or radial nerves.
When can anterior dislocation of the lunate carpal bone occur?
This can occur by falling on a dorsiflexed wrist.
What is the effect of an anterior dislocation of the lunate on surrounding structures?
The lunate is forced anteriorly, and compresses the carpal tunnel, causing the symptoms of carpal tunnel syndrome.
What are some consequences of an anterior dislocation of the lunate?
Paresthesia in the sensory distribution of the median nerve
Weakness of thenar muscles
The lunate can also undergo avascular necrosis, so immediate clinical attention to the fracture is needed
Why are fractures of the femur a good predictor of mortality?
Within a year of a femoral fracture (also known as a broken hip) 1/3 of the people will die
Describe an intrascapular fracture of the femur
Fracture within the capsule of the hip joint
Distal fragment is pulled upwards and rotated laterally
Damage to femoral circumflex artery = avascular necrosis
Shorter length legs, toes pointing laterally
More commonly in elderly women
Minor trip/ stumble
Describe an extracapsular fracture of the femur
Fracture of femur, outside the capsule
Blood supply to head of femur remains intact- so avascular necrosis does not occur
Leg shortens and is laterally rotated
Describe a femoral shaft fracture
Uncommon
Require a lot of force- traumatic vehicular accident
Spiral fracture- fragments overriding, pulled by the attached muscles- leg shortening
Injury to surrounding tissues
Femoral nerve palsy
Damage to femoral artery
Describe a fracture to the proximal end of the Tibia
Uncommon
Middle aged and elderly
If fibula is not fractured it will support the tibia and displacement of the fragments will be minimal
Proximal end of tibia- condyle fracture, trauma, vehicular accident, injury to ligament of knee
Describe a fracture the the distal end of the tibia
Uncommon
Middle aged and elderly
If fibula is not fractured it will support the tibia and displacement of the fragments will be minimal
Medial malleolus fracture
Ankle twisted inwards (over inversion)
Spiral fracture (talus against medial malleolus)
Describe a fracture to the fibula
At ankle- lateral malleolus fracture
More commonly caused by external rotation of ankle forcing talus against the fibula (=spiral fracture)
Can also be caused by the foot twisting outwards (eversion) forcing talus against fibula (=transverse fracture)
How can femoral nerve damage be tested for using the quadriceps femoris muscle?
Ask the patient to lie down in a supine position with the knees slightly flexed
Ask the patient to extend their leg and resist the movement- contraction of quadriceps femoris should be visible
Describe the injuries to adductor muscles in the medial compartment of the thigh
Strain to adductor muscles= groin strain
Proximal part of the muscles are most usually affected tearing near their bony attachments in the pelvis
Groin injuries usually occur in sports that require explosive movements or extreme stretching
Treatment of any muscle strain should utilise the RICE protocol
Rest, Ice, Compression, Elevation
Where can the femoral pulse be palpated?
Passes midway between the public symphysis and ASIS along the inguinal ligament
Pulse- blood reaches the lower extremity
How is the femoral triangle important on coronary angiography?
Femoral artery within the femoral triangle is catheterised with a long thin tube
Tube is navigated up the external iliac artery, common iliac artery, aorta and into the coronary vessels
Radioactive dye ejected into the coronary vessels and any wall thickening or blockages can be visualised
What is a femoral hernia?
Condition where part of an organ is displaced and protrudes through the wall of the cavity containing it- here part of the bowel pushes into the femoral canal under the inguinal ligament = lump/ bulge
Describe a fracture to the metatarsals
Blow to the foot- usually when a heavy object drops onto the foot
Stress fracture- incomplete fracture caused by repeated stress to the bone- common in athletes and frequent to MTs 2 3 and 4
Excessive inversion of foot- fibular is brevis muscle can pull off the base of MT 5
Describe a fracture to the talus bone
Neck- during excessive dorsiflexion of the foot with the neck pushed into the tibia
Body- jumping from a height
In a talar fracture the two malleolus of the leg bones act to hold the fragments together so there is little displacement
Avascular necrosis results
Describe fracture to the calcaneus
Most commonly fracture when jumping from a height
Talus one is driven into the calcaneus bone crushing it
Radiograph- calcaneus appears shorter and fatter
Damage to the superior gluteal nerve affected which muscles?
Gluteus medius and minimus
How does damage to the superior gluteal nerve affect the functioning of the gluteus medius and minimus?
Gluteus medius and minimus have an important role in stabilising the pelvis during walking
Whilst standing- gluteus medius and minimus contract when the contralateral leg is raised preventing the unsupported pelvis from dropping
Damage or lesion t the superior gluteal nerve- causes muscles to become paralysed/ unsteady pelvis/ positive trendlenburg test (lifts left foot unable to maintain pelvic tilt, downward tilt of pelvis and iliac crest on left side falls) / gluteal gait- characteristic walk
What is considered the landmark muscle of the gluteal region?
Piriformis muscle
As it travels through the greater sciatic foramen, the piriformis divides the gluteal region into the inferior and superior part
Determines names of vessels and nerves in this region
Superior gluteal nerve and vessels emerge in gluteal region superior to piriformis
Inferior gluteal nerve and vessels emerge in gluteal region inferior to piriformis
Describe an intrascapular fracture to the neck of the femur
Broken hip
40yos - falls, women, brittle bones- osteoporosis
Laterally rotated limb
Arteries from the medial circumflex humeral artery are torn and so avascular necrosis of the femoral neck and head can occur
Describe a trochanteric fracture (extracapsular) of the femur
Less risk of osteonecrosis/ avascular necrosis
Usually treated with a dynamic hip screw
What happens in a surgical hip replacement?
A plastic socket is cemented to the hip bone to replace the acetabulum, whilst a stainless steel femoral stem and head replaces the femur
Performed after a traumatic injury or degenerative disease of joint
1/3 of the people die within a year after a hip replacement
Describe a congenital dislocation of the femoral head
More common in girls- (x8) ~1.5 / 100 births
During development femoral head is not placed within the acetabulum - dislocated joint
Symptoms- inability to abduct at hip joint, affected limb is shorter, positive trendlenburg sign
Predisposes patient to arthritis in later life
Describe an acquired dislocation of the femoral head
Quite uncommon (due to strength and stability of the joint)
Traumatic accidents
Posterior: more common, femoral head forced posteriorly and tears through inferior and posterior part of joint capsule (weakest), shortened and medially rotated limb; SCIATIC nerve can be damaged (posterior to HJ) = paralysis of hamstring muscles and muscles distal to the knee (all supplied by the sciatic nerve)
Anterior: more rare; extension, abduction and lateral rotation causes this; femoral head ends up anterior and inferior to acetabulum and pulls acetabulum labrum with it
What is arthritis?
Inflammation of joints in the synovium
Damaged cartilage
Usually pain early on due to information
Becomes a mechanical process later – mechanical grinding
May result in joint replacement
Previous joint injury predisposes condition (congenital dislocation at hip joint)
X-ray – reduction in joint space from loss of cartilage – very painful; overgrowth of bone/ bony spurs; increased density and cortical bone (whiter)
What is rheumatoid arthritis?
Problem starts in synovium
Essentially inflammatory
Joint cartilage is destroyed
Problem then becomes mechanical
Describe a herniated intervertebral disc
In herniation of intervertebral disc, nucleus pulposus ruptures breaking through the outer layer
Occurs in a lateral and posterior direction, putting pressure on the spinal-cord, resulting in a variety neurological and muscular symptoms
What is kyphosis?
Excessive thoracic curvature causing a hunchback deformity
What is lordosis?
Excessive lumbar curvature causing a sway back deformity
What is scoliosis?
A lateral curvature of the spine usually of unknown cause
What is cervical spondylosis?
A decrease in the size of intervertebral foramina, usually due to degeneration of the joints of the spine
The smaller the size of the intervertebral foramina puts pressure on the exiting nerve causing pain
What are the two major causes of swelling in the popliteal fossa?
Bakers cyst
Popliteal aneurysm
What is bakers cyst?
Inflammation and swelling of semimembranosus bursa
Arises in conjunction with arthritis of knee (OA or RA)
Usually resolved – this can rupture and produce symptoms similar to DVT
What condition can bakers cyst produce symptoms like if it ruptures?
Deep vein thrombosis
What is a popliteal aneurysm?
Popliteal fascia (roof) is tough and nonextensible – so an aneurysm or popliteal artery can compress the tibial nerve (leg anaesthesia/ loss of leg motor function) Detected by obvious palpable pulsation of popliteal fossa- abnormal arterial sounds
How can an injury to the collateral ligaments of the knee occur?
Caused by a force being applied to the side of the knee when a foot is placed on the ground
How can damage be assessed?
By asking the patient to medially and laterally rotate the leg whilst holding the leg at knee joint (with a flexed knee)
Pain on medial rotation – damage to medial (tibial) ligament
Pain on lateral rotation – damage to lateral (fibular) ligament
How can damage to the anterior cruciate ligament occur?
Torn by hyper extension of the knee joint or application of a large force to the back of the knee with the joint partly flexed
How can anterior cruciate ligament damage be tested for?
Anterior draw test – Pull tibia forward and if it moves this implies the ligament has been torn
How can damage to the posterior cruciate ligament occur?
Dashboard injury – when the knees flexed and large force is applied to the shins pushing the tibia posteriorly or by hyperextension of the knee joint or damage to upper part of the tibial tuberosity
How can posterior cruciate ligament damage be tested for?
Posterior draw test – knee in flexed position, push posteriorly – if it moves this implies that the ligament has been torn
What is the unhappy triad of knee injuries?
Tearing of anterior crucial ligament – medial shift of unstable femur
Tearing of tibial (medial) collateral ligament
Medial meniscus can also be torn due to the tibial collateral ligament attachment
What is housemaids knee?
Friction between skin and patella causes bursitis of prepatellar bursa causing inflammation and producing a swelling on anterior side of knee
What is Clergyman’s knee?
Friction between the skin and tibia can cause the infrapatellar bursa to become inflamed- bursitis
Tilers roofers builders
What can cause Muscle strain of posterior muscles of the thigh?
Excessive stretch or tear of hamstring muscle fibres
Athletes (running/kicking sports)
What is a consequence of muscle strain in the posterior muscle compartment of the thigh?
Damage to muscle fibres is likely to rupture surrounding blood vessels – Haematoma – contained by overlying fascia lata
What is the best advice given to someone with muscle strain?
RICE- rest, ice, compression, elevation
Describe an avulsion fracture of the ischial tuberosity
Hamstring muscles tear off a piece of the ischial tuberosity
Sports – requiring rapid contraction and relaxation of muscles – sprinting, football, hurdling
What is lymphangitis in the upper limb?
An infection in the upper limb can cause the axillary nodes to enlarge and become tender and inflamed
Usually involves the humeral group of nodes
Lymphangitis is characterised by the development of warm, red, tender streaks in the skin of the limb
What is axillary clearance and the clinical relevance of it?
Removal of the axillary lymph nodes
In breast cancer- important to determine the degree to which the cancer has metastasised, lymph collects in axilla region (pectoral lymph odes drain to apical and central lymph nodes), remove any cancer cells which may have metastasised to axillary lymph nodes
In removal, you must be careful of damaging long thoracic nerve (winged scapula) and thoracodorsal nerve (Weakened medial rotation and adduction of the arm)
What is a fracture dislocation of the proximal humeral epiphysis and what causes it?
Separation of humeral epiphysis in a child or adolescent
A direct blow or indirect injury of the shoulder of a child or adolescent may produce this, because the joint capsule of the glenohumeral joint reinforced by the rotator cuff (tendons of the SITS muscles), is stronger than the epiphyseal plate
In severe fractures the shaft of the humerus is markedly displaced, but the humeral head remains in its normal relationship with the glenoid cavity of the scapula
Describe the significance of compression of the axillary artery
Compression of the third part of the axillary artery against the humerus may be necessary when profuse bleeding occurs (e.g.resulting from a stab or bullet wound in the axilla)
If compression is required at a more proximal site, the axillary artery can be compressed at its origin (as the subclavian artery crosses the first rib) by exerting downward pressure in the angle between the clavicle and the inferior attachment of the sternocleidomastoid muscle
Where can the axillary artery be palpated?
In the inferior part of the lateral wall of the axilla
What is an aneurysm of the axillary artery?
The first part of the axillary artery may enlarge and compress the trunks of the brachial plexus, causing pain and anaesthesia in the areas of skin supplied by the affected nerves. They may occur in baseball pitchers and football quarterbacks because of their rapid and forceful arm movements.
Describe some effects of axillary vein injuries
Wounds in the axilla often involve the axillary vein because of its large size and exposed position. When the arm is fully abducted, the axillary vein overlaps the axillary artery anteriorly. A wound in the proximal part of the axillary vein is particularly dangerous, not only because of the profuse bleeding but also because of the risk of formation of air emboli in the blood.
What is the role of the axillary vein in the subclavian vein puncture?
Subclavian vein puncture, in which a catheter is placed into subclavian vein, has become a common clinical procedure.
The axillary vein becomes the subclavian vein as the first rib is crossed. Because the needle is advanced medially to enter the vein as it crosses the rib, the vein actually punctured in a subclavian vein puncture is the terminal part of the axillary vein.
However, the needle tip proceeds into the lumen of the subclavian vein almost immediately. Thus it is clinically significant that the axillary vein lies anterior and inferior (superficial) to the axillary artery, and the part of the brachial plexus that begin to surround the artery at this point.
What is bicipital myotactic reflex?
Biceps reflex is one of the several deep tendon reflexes that are routinely tested during physical examinations. The relaxed limb is passively pronated and partially extended at the elbow. Examiners thumb is firmly placed on the biceps tendon and the reflex hammer is briskly tapped at the base of the nail bed of the examiners thumb. A normal (positive) response is an in voluntary contraction of the biceps, felt as a momentarily tensed tendon, usually with a brief jerk like flexion of the elbow.
A positive response confirms the integrity of the musculocutaneous nerve and the C5 and C6 spinal cord segments. Excessive, diminished or prolonged responses may indicate central or peripheral nervous system disease or metabolic disorders
What is biceps tendinitis?
Tendon of the long head of biceps is enclosed by a synovial sheath, and moves back and forth in the intertubercular sulcus (bicipital groove) of the humerus.
Wear and tear of this mechanism can go shoulder pain.
Inflammation of the tendon, usually a result of repetitive microtrauma, is common in sports involving throwing and use of a racquet
What is the dislocation of the tendon of the long head of the biceps brachii?
Tendon of the long-head of the biceps can be partially or completely dislocated from the intertubercular sulcus in the humerus. This painful condition may occur in young persons during traumatic separation of the proximal epiphysis of the humerus. The injury also occurs in older persons with the history of biceps tendinitis. Usually a sensation of popping or catching os felt during arm rotation.
Describe the rupture of the tendon of the long head of biceps brachii
Rupture of the tendon usually results from wear and tear of an inflamed tendon as it moves back and forth in the intertubercular sulcus of humerus. This injury usually occurs in individuals older than 35 years. Typically the tendon is torn from its attachment to the supraglenoid tubercle of the scapula. The rupture is commonly dramatic and is associated with a snap or pop. The detached muscle belly forms a ball near the centre of the distal part of the anterior aspect of the arm (Popeye deformity)
Rupture of the biceps tendon may result from forceful flexion of the arm against excessive resistance as occurs in weightlifters. However, the tendon rupture is more often as the result of prolonged tendinitis that weakens it. Rupture results from repetitive overhead motions, such as occurs in swimmers and baseball pitchers, that tear the weakened tendon in the intertubercular sulcus.
What is hemostasis?
Stopping bleeding through manual or surgical control of blood flow.
Where is the best place to compress the brachial artery to control haemorrhage?
Medial to the humerus near the middle of the arm
Why is it okay for the brachial artery to be clamped in the elbow region?
Because the arterial anastomoses around the elbow provide functionally and surgically important collateral circulation and so the brachial artery maybe clamped distal to the origin of the deep artery of the arm without producing tissue damage.
The anatomical basis for this procedure is that the ulnar and radial arteries will still receive sufficient blood through the anastomoses around the elbow
When the brachial archery is lacerated, how long until volkmann ischaemic contracture occurs?
Muscles and nerves can tolerate up to 6 hours of ischaemia
What is elbow tendinitis or lateral epicondylitis?
Elbow tendinitis (tennis elbow) is a painful musculoskeletal condition that may follow repetitive use of superficial extensor muscles of the forearm. Pain is felt over the lateral epicondyles and radiates down the posterior surface of the forearm. People with elbow tendinitis often feel pain when they open a door or lift a glass. Repeated forceful flexion and extension of the wrist strain the attachment of the common extensor tendon, producing inflammation of the periosteum of the lateral epicondyle.
What is another name for tennis elbow?
Elbow tendinitis on lateral epicondylitis
What is another name for elbow tendinitis or lateral epicondylitis?
Tennis elbow
What is mallet or baseball finger?
Sudden severe tension on a long extensor tendon may avulse part of its attachment to the phalanx. The most common result of the injury is a mallet or baseball finger. This deformity results from the distal interphalangeal joint suddenly being forced into extreme flexion (hyperflexion) when, for example, a baseball is miscaught or a finger is jammed into the base pad. These actions avulse the attachment of the tendon to the base of the distal phalanx. As a result, the person cannot extend the distal interphalangeal joint. The resultant deformity bears some resemblance to a mallet
Describe a fracture to the olecranon
Fracture of the olecranon, called a the fractured elbow by laypersons, is common because the olecranon is subcutaneous and protrusive. The typical mechanism of injury is a fall on the elbow combined with sudden powerful contraction of the triceps brachii. The fractured olecranon is pulled away by the active and tonic contraction of the triceps and the injury is often considered to be an avulsion fracture. Because of the traction produced by the tonus of the triceps on the olecranon fragment, pinning is usually required. Healing occurs slowly and often a caste has to be worn for an extended period of time
What is the synovial cyst of the wrist?
Sometimes a non-tender cystic swelling appears on the hand, most commonly on the dorsum of the wrist. Usually the cyst is the size of a small grape but it varies and maybe as large as a plum. Then thin-walled cyst contains clear mucinous fluid. The cause of this cyst is unknown, but it may result from mucoid degeneration. Foexion of the wrist makes the cyst enlarge, and it may be painful. Clinically, this type of swelling is called a ganglion (anatomically = collection of nerve cell bodies). Synovial cysts are closed to and often communicate with the synovial sheaths on the dorsum of the wrist. The distal attachment of the extensor carpi radialis brevis tendon to the base of the third metacarpal is another common site for such as this. A cystic swelling of the common flexor synovial sheath on the anterior aspect of the wrist can enlarge enough to produce compression of the median nerve by narrowing the carpal tunnel – carpal tunnel syndrome. This syndrome produces pain and paraesthesia in the sensory distribution of the median nerve (lateral palm, lateral 3 1/2 digits and nail beds) and clumsiness of finger movements
What is pronator syndrome?
Pronators syndrome, a nerve entrapment syndrome, is caused by compression of the median nerve near the elbow. The nerve may be compressed between the heads of the pronator teres as a result of trauma, muscular hypertrophy or fibrous bands. Individuals with this syndrome are first seen clinically with pain and tenderness in the proximal aspect of the anterior forearm, and hypesthesia (decreased sensation) of Palmer aspects of the radial 3 1/2 digits and adjacent palm. Symptoms often follow activities that involve repeated pronation.
What is cubital tunnel syndrome?
The ulnar nerve maybe compressed (ulnar nerve entrapment) in cubital tunnel formed by the tendinous arch joining the humeral and ulnar heads of the attachment of the FCU. The signs and symptoms of cubital tunnel syndrome are the same as in ulnar nerve lesion in the ulnar groove on the posterior aspect of the medial epicondyle of the humerus
What is Dapuytren contracture of palmar fascia?
Disease of the palmar fascia resulting in progressive shortening, thickening and fibrosis of the palmar fascia and aponeurosis. The fibrous degeneration of the longitudinal bands of the palmar aponeurosis on the medial side of the hand pulls the fourth and fifth digits into partial flexion at the metacarpophalangeal and proximal interphalangeal joints.
Men > 50 years old
Unknown cause- hereditary predisposition?
Disease first manifests as painless nodular thickenings on the palmar aponeurosis that adhere to the skin. Gradually, progressive contracture of the longitudinal band produces raised ridges in the palmar skin that extend from the proximal part of the hand to the base of the fourth and fifth fingers.
Treatment usually involves surgical excision of all fibrotic parts of the palmar fascia to free the fingers
Why are hand infections common in the dorsum of the hand?
Palmar fascia is thick and strong whereas dorsal fascia is thinner and so hand infections usually appear there
Describe some hand infections
Palm- has potential fascial spaces which can become infected and determine the extent and direction of the spread of pus from the infections.
Depending on the site of infection, pus will accumulate in the Thenar, hypothenar, mid palmar or adductor compartments.
Antibiotic therapy has made infections that spread beyond one of these fascial compartments rare; however an untreated infection can spread proximally from the midpalmar space through the carpal tunnel into the forearm, anterior to the pronator quadratus and it’s fascia
What is tenosynovitis?
Inflammation of the tendon and synovial sheath of a digit (usually contained within each digit by the synovial sheath unless it is severe)
What is the result of a laceration to a palmar arch?
Bleeding is usually profuse when the palmar arches are lacerated. It may not be sufficient to ligate only one forearm artery when the arches are lacerated, because these vessels usually have numerous communications in the forearm and hand and thus bleed from both ends. To obtain a bloodless surgical operating field for treating complicated hand injuries it may be necessary to compress the brachial artery and its branches proximal to the elbow (using a pneumatic tourniquet). This procedure prevents blood from reaching the ulnar and radial arteries through the anastomoses around the elbow
What is Raynauds syndrome?
Pain, Paraesthesia
Abnormal vasoconstriction- no blood supply, pale fingers, hypoxia, blue fingers, blood supply returns= reactive hyperaemia (metabolites)
Cold weather and extreme emotion
What is ulnar canal syndrome?
compression of the ulnar nerve may occur at the wrist where it passes between the pisiform and the hook of hamate. The depression between these bones is converted by the Pisohamate ligament into an osseofibrous tunnel, ulnar canal (Guyon canal).
Ulnar canal syndrome is manifested by hypoaesthesia in the medial one and a half fingers, and weakness of the intrinsic muscles of the hand.
Clawing of the fourth and fifth fingers (hyperextension at the metacarpophalangeal joints with flexion at the proximal interphalangeal joint) may occur but in contradistinction to proximal ulnar injury – their ability to flex is unaffected, and there is no radial deviation of the hand
What is handlebar neuropathy?
People who ride long distances on bicycles with their hands in an extended position against the handgrips but pressure on the hooks of Hamates, which compresses their ulnar nerves.
Results in sensory loss on the medial side of the hand and weakness of the intrinsic hand muscles
What is dermatoglyphics?
The science of studying bridge patterns of the palm, is a valuable extension of the conventional physical examination of people with certain congenital anomalies and genetic diseases.
For example people with trisomy 21/down syndrome have dermatoglyphics that are highly characteristic.
In addition they often have a single transverse palmar crease (simian crease); however approximately 1% of the general population has this crease with no other clinical features of the syndrome
Describe dislocation of the sternoclavicular joint
The rarity of dislocation of the sternoclavicular joint attests to its strength, which depends on its ligaments, it’s disc and the way forces are generally transmitted along the clavicle. When a blow is received to the acromion of the scapula or when a force is transmitted to the pectoral girdle during a fall on the outstretched hand, the force of the blow is usually transmitted along the length of the clavicle, along its axis.
The clavicle may fracture near the junction of its middle and lateral thirds, but it is rare for this sternoclavicular joint to dislocate. Most SC dislocations occur in person less than 25 years of age which result from fractures through the epiphyseal plate because the Epiphyses at the sternal end of the clavicle does not close until 23 to 25 years of age
Describe ankylosis of the sternoclavicular joint
Movement of the sternoclavicular joint is critical to movement of the shoulder. When ankyloses (stiffening or fixation) of the joint occurs, or is necessary surgically, a section of the centre of the clavicle is removed, creating a pseudo joint or flail joint to permit scapular movement
Describe the dislocation of the acromioclavicular joint
Although it’s extrinsic coracoclavicular ligament is strong, the AC joint itself is weak and easily injured by a direct blow. In contact sports such as football soccer hockey or the martial arts it is not uncommon for dislocation of the A/C joint to result from a hardball on the shoulder on outstretched happening. Dislocation of the A/C joint can also occur when an ice hockey player is driven into the boards or when a person receives severe blow to the superolateral part of the back
Also called a shoulder separation
Severe when both the AC and coracoclavicular ligaments are torn- causes shoulder to separate from the clavicle and fall because the weight of the upper limb
Rupture of the coracoclavicular ligament allows the fibrous layer of the joint capsule to be torn so that The acromion can pass inferior to the acromial end of the clavicle. Dislocation of the AC joint makes the acromion more prominent, and the clavicle may move superior to this process
What is calcific supraspinatus tendinitis?
Inflammation and calcification of the subacromial bursa which results in pain tenderness and limitation of movement of the glenohumeral joint
Also known as Calcific scapulohumeral bursitis
Deposition of calcium in the supraspinatus tendon is common – causes increased local pressure that often causes excrutiating pain during abduction of the arm (50-130° because during this arc the supraspinatus tendon is in intimate contact with the inferior surface of the acromion) – the pain may radiate as far as the hand
Calcium deposit may irritate overlying subacromial bursa – produce inflammatory reaction known as subacromial bursitis
Usually in males aged 50+ after unusual or excessive use of the glenohumeral joint
May cause acute capsulitis and frozen shoulder
Describe rotator cuff injuries
The musculotendinous rotator cuff is commonly injured during repetitive use of the upper limb above the horizontal (during throwing and racket sports, swimming and weight lifting).
Recurrent inflammation of the rotator cuff, especially the relatively avascular area of the supraspinatus tendon, is a common cause of the shoulder pain and results in tears of the musculotendinous rotator cuff.
Repetitive use of the rotator cuff Muscles (by baseball pitchers) may allow the humeral head and rotator cuff to impinge on the coracoacromial arch producing irritation of the arc and inflammation of the rotator cuff. As a result, degenerative tendinitis of the rotator cuff develops. Attrition of the supraspinatus tendon also occurs.
To test for degenerative tendinitis of the rotator cuff, the person is asked to lower the fully abducted arm slowly and smoothly. From approximately 90° abduction, the limb will suddenly dropped to the side in an uncontrolled manner if the rotator cuff (especially it supraspinatus part) is disease and/or torn.
Rotator cuff injuries may also occur during the strain of the muscles, for example, when an older person strains to lift something, such as a window that is stuck. This strain may rupture previously degenerated musculotendinous rotator cuff. A fall on the shoulder may also tear previously degenerated rotator cuff. Often the intrascapular part of the tendon of the long head of biceps brachii becomes frayed (even worn away), leaving it adherent to the intertuberculus sulcus- shoulder stiffness occurs as a result.
Because they fuse, the integrity of the fibrous layer of the joint capsule of the glenohumeral joint is usually compromised when the rotator cuff is injured. As a result the articular cavity communicates with the subacromial bursa. Because the supraspinatus muscle is no longer functional with a complete tear of the rotator cuff, the person cannot initiate abduction of the upper limb. If the arm is passively abducted 15° or more the person can usually maintain or continue abduction using the deltoid.
May cause acute capsulitis and frozen shoulder
Describe dislocations of glenohumeral joints
Because of its freedom of movement and instability, the glenohumeral joint is commonly dislocated by direct or indirect injury. Because the presence of the Coracoacromial arch and support of the rotator cuff are effective in preventing upward dislocation, most dislocations of the humeral head occur in a downward (inferior) direction.
However, they are described clinically as anterior all (more rarely) posterior dislocations, indicating whether the humeral head has descended anterior or posterior to the infraglenoid tubercle and long head of the triceps. The head ends up lying anterior or posterior to the glenoid cavity.
Can cause axillary nerve injury.
May cause acute capsulitis / frozen shoulder
Describe an anterior dislocation of the glenohumeral joint.
Occurs most often in young adults, particularly athletes
It is usually caused by excessive extension and lateral rotation of the humerus
The head of the humerus is driven inferoanteriorly and the fibrous layer of the joint capsule and Glenoid Labrum May Be Stripped from the Anterior Aspect of the Glenoid Cavity in the Process
A hard blow to the humerus when the glenohumeral joint is fully abducted tilts the head of the humerus inferiorly onto the inferior weak part of the joint capsule – made tear the capsule and dislocate the shoulder so that the humeral head comes to lie inferior to the glenoid cavity and anterior to the infraglenoid tubercle.
The strong flexor and adductor muscles of the glenohumeral joint usually subsequently pull the humeral head and anterosuperiorly into the subcoracoid position - unable to use the arm the person commonly supports it with their other hand
Describe an inferior dislocation of the glenohumeral joint
Occurs after an avulsion fracture of the greater tubercle of the humerus
Owing to the absence of the upward and medial pull produced by muscles attaching to the tubercle
What is a adhesive capsulitis of the glenohumeral joint?
Also known as frozen shoulder
Caused by Adhesive fibrosis and scarring between the inflamed joint capsule of the glenohumeral joint, rotator cuff, subacromial bursa and deltoid
Seen in individuals aged 40-60 years of age
A person with this condition has difficulty abducting the arm and can obtain apparent abduction of upto 45° by elevating and rotating the scapula
Due to lack of movement of shoulder joint strain is placed on the AC joint which may be painful during other movements- shrugging, elevation of shoulder
Glenohumeral dislocations, Calcific supraspinatus tendinitis, partial tearing of rotator cuff and bicipital tendinitis may initiate acute capsulitis
Describe a tear of the glenoid labrum
Tearing of the fibrocartilaginous glenoid labrum, commonly occurs in athletes who throw a baseball or football and in those who have shoulder instability and subluxation of the glenohumeral joint. The tear often results from sudden contraction of the biceps or forceful subluxation of the humeral head over the glenoid labrum. Usually a tear occurs in the anterosuperior part of the labrum. The typical symptom is pain while throwing especially during the acceleration phase. A sense of popping or snapping may be felt in the glenohumeral joint during abduction and lateral rotation of the arm
Describe an avulsion of the medial epicondyle of the humerus?
Can result from a fall that causes severe abduction of the extended elbow- an abnormal movement of this articulation
The resulting traction on the ulnar collateral ligament pulls the medial epicondyle distally
The anatomical basis of the avulsion is that the epiphyses of the medial epicondyle may not fuse with the distal end of the humerus until age 20- Usually fusion is complete radiographically at age 14 in females and age 16 in males
Traction injury of the ulnar nerve is a frequent complication of the abduction type of avulsion of medial epicondyle of the humerus. the anatomical basis for stretching of the ulnar nerve is that it passes posterior to the medial epicondyle before entering the forearm.
Describing dislocation of the elbow joint
Posterior dislocation of the elbow joint may occur when children fall on their hands with their elbows flexed.
Dislocations of the elbow may also result from hyperextension or blow that drives the ulna posterior or posteriolateral.
The distal end of humerus is driven through the weak anterior part of the fibrous layer of the joint capsule as the radius and ulna dislocate posteriorly.
The ulnar collateral ligament is often torn and an associated fracture of the head of the radius, coronoid process or olecranon process of the ulna may occur.
Injury to the ulnar nerves may occur, resulting in numbness of the little finger and weakness of flexion and abduction of the wrist
Describes subluxation and dislocation of the Radial head
Preschool children, particularly girls are vulnerable to transient subluxation of the head of the radius – nursemaid elbow/ pulled elbow
A child is suddenly lifted by the upper limb while the forearm is pronated
The child may cry out, refuse to use the limb and protect their limb by holding it with the elbow flexed and the forearm pronated.
Sudden pulling of the upper limb tears the distal attachment of the annular ligament, where it is loosely attached to the neck of the radius.
The Radial head then moves distally partially out of the socket formed by the annular ligament.
The proximal part of the torn ligament may become trapped between the head of the radius and the capitulum of the humerus.
The source of pain is the pinched annular ligament
Treatment of the subluxation consists of supination of the child’s forearm while the elbow is flexed
A tear in the annular ligament heals when the limb is placed in a sling for two weeks
What is Bull Riders thumb?
Bull riders thumb refers to a sprain of the radial collateral ligament, and an avulsion fracture of the lateral part of the proximal phalanx of the thumb.
This injury is common in individuals who ride mechanical bulls
What is skiers thumb?
Skiers thumb refers to the rupture or chronic laxity of the collateral ligament of the first MP joint
The injury results from hyperabduction of the MP joint of the thumb, which occurs when the thumb is held by the ski pole while the rest of the hand hits the ground or enters the snow.
In severe injuries the head of the metacarpal has an avulsion fracture.
Describe compartment syndrome in the lower limb
Trauma to muscles or vessels within the compartments (e.g. Anterior, medial and posterior of thigh) from burns, sustained intense use of muscles or blunt trauma may produce haemorrhage, oedema and inflammation of the muscles.
Because the septa and deep fascia of the leg forming the boundaries of the leg compartments are strong, the increased volume consequent to any of these processes increases intracompartmental pressure- may become high enough to compress structures
Compression of the vessels of the muscles and nerves (vasa nervorum) are vulnerable to compression
Structures distal to the compressed area become compressed and ischaemic and permanently injured
Loss of distal leg pulses, lowering of distal temperature of tissues, is and obvious sign of arterial compression
A fasciotomy (incision of overlying fascia or septum) may be performed to relieve the pressure in compartments concerned
What is a varicose vein?
A vein that has dilated so much that the cusps of their valves do not close (valves don’t function properly/ are incompetent) and so blood flows inferiorly/ distally
Where are varicose Veins common?
Posterio medial parts of lower limb- great saphenous vein and it’s tributaries
What are some characteristics of deep vein thrombosis?
Swelling, warmth and erythema (inflammation and infection)
What is an important cause of deep vein thrombosis?
Venous stasis
What are some causes of venous stasis?
Incompetent loose fascia that fails to resist muscle expansion, diminishing the effectiveness of the musculovenous pump External pressure on the Veins from bedding during a prolonged hospital stay or from a tight caste or bandage Muscular inactivity (e.g. during an overseas aircraft flight)
What is thrombophlebitis?
DVT with inflammation around the involved veins
What can DVT lead to?
A large thrombus that breaks free from a lower limb vein may travel to a lung forming a pulmonary thromboembolism (obstruction of a pulmonary embolism)
A large embolism may obstruct a pulmonary artery causing death
Why is the great saphenous vein sometimes used for coronary arterial bypasses?
It is readily accessible
A sufficient distance occurs between the tributaries and the perforating veins so that usable lengths can be harvested
It’s wall contains a higher percentage of muscular and elastic fibres than do other superficial veins
What are saphenous vein grafts used for?
To bypass obstructions in blood vessels (e.g. An intracoronary thrombus)
How are saphenous veins orientated when used for a bypass?
The vein is inverted so that the valves do not obstruct blood flow in the venous graft
Why is there no adverse effect on the lower limb after removal of the great saphenous vein for a bypass?
Because there are many other leg veins, removal of the great saphenous vein rarely produces a significant problem in the lower limb or seriously affects circulation, provided the deep veins are intact
In fact, the removal of the vein may facilitate the superficial to deep drainage pattern to take advantage of the musculovenous pump
What is saphenous vein cutdown?
The procedure where the great saphenous vein can be located by making a skin incision anterior to the medial malleolus
Procedure used to insert a cannula for prolonged administration of blood, plasma expanders, electrolytes or drugs
What nerve can be damaged when handling the great saphenous vein and why? What will the patient complain of with this damage?
Saphenous nerve which accompanies the great saphenous vein anterior to the medial malleolus
Patient may complain of pain with numbness along medial border of the foot
What may cause enlargement of the superficial inguinal lymph nodes?
Abrasions and minor sepsis, caused by pathogenic micro organisms or their toxins in the blood or other tissues
Why are enlarged inguinal lymph nodes easy to palpate?
Because they are located in subcutaneous tissue
Why must the trunk inferior to the umbilicus, including the perineum, as well as the entire lower limb be examined when inguinal lymph nodes are enlarged?
To determine the cause of enlargement, check for uterine cancer (which could have metastasised to inguinal lymph nodes)
What cancer is enlargement of inguinal lymph nodes an indicator of?
Uterine cancer
Some lymphatic drainage from the uterine fungus may flow along lymphatic accompanying the round ligament of the uterus through the inguinal canal to reach the superficial inguinal lymph node
Describe regional nerve blocks of the lower limb
Interruption of the conduction of impulse in peripheral nerves (nerve block) may be achieved by making perineural injections of anaesthetics close to the nerves whose conductivity is to be blocked
The femoral nerve (L2-L4) can be blocked 2 cm inferior to the inguinal ligament, approximately a fingers breadth lateral to the femoral artery
Paraesthesia (tingling, tickling, burning) radiates to the knee and over the medial side of the leg if the saphenous nerve (terminal branch of the femoral) is affected
What does a peripheral nerve sensitising and area of skin normally represent?
More than one segment of the spinal cord
Describe hip and thigh contusions
Sports broadcasters and trainers refer to a hip pointer, which is a contusion of the iliac crest that usually occurs at its anterior parts. This is one of the most common injuries to the hip region, usually occurring in association with collision sports, such as the various forms of football, ice hockey, and volleyball.
Contusions caused bleeding from ruptured capillaries and infiltration of blood into the muscles, tendons and other soft tissues. The term hip pointer may also refer to avulsion of bony muscle attachments for example of the sartorius or rectus femoris to the anterior superior and inferior iliac spines, respectively, of the hamstrings from the ischium. However these injuries should be called avulsion fractures.
Another term commonly used is Charley horse, which may refer either to the cramping of an individual thigh muscle because of ischaemia or to contusion and rupture of blood vessels sufficient enough to form a haematoma. The injury is usually the consequence of tearing of the fibres of the rectus femoris; sometimes the quadriceps tendon is also partially torn. The most common sites of thigh haematoma is in the quadriceps. Charley horse is associated with localised pain and/or muscle stiffness and commonly follows direct trauma.
What is a psoas abscess?
A retroperitoneal pyogenic infection in the abdomen or greater pelvis characteristically occurring in association with tuberculosis of the vertebrae: or secondary to regional enteritis of the ileum (Crohn disease) may result in the formation of a psoas abscess. When the abscess passes between the psoas and it’s fascia to the inguinal and proximal thigh regions, severe pain may be referred to the hip, thigh or knee joint.
A psoas abscess should always be considered when oedema occurs in the proximal part of the thigh. Such an abscess may be palpated or observed in the inguinal region, just inferior or superior to the inguinal ligament and maybe mistaken for an indirect inguinal hernia or femoral hernia, an enlargement of inguinal lymph nodes, or a saphenous varix. The lateral border of the psoas is commonly visible in radiographs of the abdomen; an obscured psoas shadow may be an indication of abdominal pathology.
Describe a person with paralysed quadriceps muscles
Patient cannot extend their leg against resistance and usually presses on the distal end of the thigh during walking to prevent inadvertent flexion of the knee joint.
Weakness of the vastus medialis or vastus lateralis, resulting from arthritis or trauma to the knee joint, can result in abnormal patellar movement and loss of joint stability
What is chondramalacia patellae?
Chondromalacia patellae (runners knee) is a common knee injury for marathon runners. Such over stressing of the knee region can also occur in running sports such as basketball. The soreness and aching around or deep to the patellar results from quadriceps imbalance. Chondromalacia patellae may also result from a blow to the patella or extreme flexion of the knee (during squatting when powerlifting)
Describe a fracture to the patella
Direct blow to the patella may fracture it into two or more fragments
Transverse patellar fractures may result from a blow to the knee or sudden contraction of the quadriceps (e.g. When one slips and attempts to prevent a backward fall). The proximal fragment is pulled superiorly with the quadriceps tendon, and the distal fragment remains with the patellar ligament
Describe abnormal ossification of the patellar bone
Patellar is cartilaginous at birth. It ossified during the 3rd to 6th years frequently from more than one ossification centre. Although the centres usually coalesce and form a single bone, they may remain separate on one or both sides giving rise to a bipartite or tripartite patella. An unwary observer might interpret the condition on a radiograph or CT as a patella fracture. Ossification abnormalities are nearly always bilateral; therefore diagnostic imaging should be examined from both sides.
If the defects are bilateral, the defects are likely ossification abnormalities
Describe the patellar tendon reflex
Tapping the patellar ligament with a reflex hammer usually elicits the patellar tendon reflex (knee jerk). This myotatic reflex is routinely tested during physical examination by having a person sitting with their legs dangling. If the reflex is normal a hand on the person Quadriceps should feel the muscle contract. This tendon reflex tests the integrity of the femoral nerve and the L2 to L4 spinal cord segments.
Diminution or absence of the patella tendon reflex may result from any lesion that interrupts the innervation of the quadriceps (e.g. Peripheral nerve disease)
Why can the gracilis muscle be removed without any noticable loss of its actions on the leg?
Because the gracilis is a relatively weak member of the adductor group of muscles.
Surgeons often transplant the gracilis or part of it with its nerve and blood vessels to replace the damaged vessel in the hand for example. Once the muscle is transplanted, it soon produces good digital flexion and extension.
Freed from its distal attachment, the muscle has also been relocated and repositioned to create a replacement for a non-functional external anal sphincter
What is groin pull?
Sports broadcasters referr to a pulled region or groin injury. These terms mean that a strain, stretching and probably some tearing of proximal attachments of the anteromedial thigh muscles have occurred. The injury usually involves the flexor and adductor thigh muscles. The proximal attachments of these muscles are in the inguinal region (groin), the junction of the thigh and the trunk.
Groin pulls usually occur in sports that require quick starts or extreme stretching.
Describe an injury to the adductor longus
Muscle strains of the adductor longus may occur in horseback riders and produce pain (riders strain). Ossification sometimes occurs in the tendons of these muscles because the horseback riders actively adduct their thighs to keep from falling from their animals. Ossification tendons are sometimes wrongly called riders bones
Why is the proximal part of the femoral artery good for clinical procedures? And what clinical procedures are these?
The initial part of the femoral artery, proximal to the branching of the profunda femoris artery, is superficial in position, making it especially accessible and useful for a number of clinical procedures
Describe palpation of the femoral pulse
With the person lying in a supine position, the femoral pulse may be palpated mid way between the ASIS and the pubic symphysis.
By placing the tip of the little finger on the ASIS and the tip of the thumb on the pubic tubercle, femoral pulse can be palpated the palm just inferior to the midpoint of the inguinal ligament by pressing firmly. Normally the pulse is strong; however, if the common or external iliac arteries are partially occluded, the post maybe diminished
Describe compression of the femoral artery
Compression of the femoral artery may also be accomplished in the region of palpation of the femoral artery, by pressing directly posteriorly against the superior pubic ramus, psoas major, and femoral head. Compression at this point will reduce blood flow through femoral artery and its branches such as the profunda femoris artery
Describe cannulation of the femoral artery
The femoral artery may be cannulated just inferior to the midpoint of the inguinal ligament. In left cardial angiography, a long, slender catheter is inserted into the artery and passed up the external iliac artery, common iliac artery and aorta to the left ventricle of the heart. The same approach is used to visualise the coronary arteries in coronary arteriography.
Blood can also be taken from the femoral artery for blood gas analysis (the determination of oxygen and Carbon dioxide concentrations and pressures with the pH of the blood by laboratory tests).
What artery is most vulnerable to traumatic injury such as laceration?
The superficial position of the femoral artery in the femoral triangle makes it vulnerable here.
In anterior thigh wounds what structures are usually damaged?
Femoral artery and vein because they lie close together
What may occur as a result of communication between injured vessels in the lower limb?
Arteriovenous shunt
Why are anastomoses important when an artery in the lower limb is ligated?
When it is necessary to ligate the femoral artery, anastamoses of branches of the Femoral artery with other arteries that cross the hip joint may supply blood to the lower limb
What is the cruciate anastomoses?
The cruciate anastomoses is a four way common meeting of the medial and lateral circumflex femoral arteries with the inferior gluteal artery superiorly and the first perforating artery inferiorly, posterior to the femur, occurring less often than its frequent mention implies
Is the femoral vein superficial or deep?
Deep - so it’s potent to know that thrombosis can form here!
Describe saphenous varix
Localised dilation of the terminal part of the great saphenous vein, called a saphenous varix may cause oedema in the femoral triangle. A saphenous varix may be confused with other groin swellings such as the psoas abscess; however varix should be considered when varicose veins are present in other parts of the lower limbs.
Describe the location of the femoral vein
Femoral vein is not usually palpable but its position can be located inferior to the inguinal ligament, by feeling the pulsations of the femoral artery, which is immediately lateral to the vein.
In thin people, the femoral vein may be close to the surface and may be mistaken for the great saphenous vein. It is important therefore to know that the femoral vein has no tributaries at this level except the great saphenous vein that joins it approximately 3 cm inferior to inguinal ligament. In varicose vein operations it is obviously important to identify the great saphenous vein correctly and not tie off the femoral vein by mistake.
Describe cannulation of the femoral vein
To secure blood samples and take pressure recordings from the chambers of the right side of the heart and/or from the pulmonary artery and to perform right cardiac angiography, a long, slender catheter is inserted into the femoral vein as it passes through the femoral triangle.
Under fluoroscopic control, the catheter is passed superiorly through the external and common iliac veins into the inferior vena cava and right atrium of the heart. Femoral venous puncture may also be used for the administration of fluids.
What is the femoral ring?
Weak area in the anterior abdominal wall that normally is a sufficient size to admit the tip of a little finger.
Describe femoral herniae
Usual originating site of a femoral hernia, a protrusion of abdominal viscera (often a loop of small intestine) through the femoral ring into the femoral canal.
A femoral hernia appears as a mass often tenders in the femoral triangle, infero-lateral to the pubic tubercle.
The hernia is bounded by the femoral vein laterally and the lacunae ligament medially.
The hernial sac compresses the contents of the femoral canal (loos connective tissue, fat and lymphatics) and distended the wall of the canal.
Initially the hernia is small because it is contained within the canal, but it can enlarge by passing inferiorly through the saphenous opening into the subcutaneous tissue of the thigh.
More common in females due to wider pelves
Strangulation of the femoral hernia may occur because of the sharp rigid boundaries of the femoral ring, particularly the concave margin of the lacunar ligament. Strangulation of the femoral hernia interferes with the blood supply to the herniated intestine. This vascular impairment may result in necrosis.
What is a replaced or accessory obturator artery?
And enlarged pubic branch of the inferior epigastric artery either takes the place of the obturator artery (replaced obturator artery) or joins it as an accessory obturator artery in approximately 20% of people.
This artery runs close to or across the femoral ring to reach the obturator foramen and could be closely related to the neck of a femoral hernia. Consequently, this artery could be involved in strangulated femoral hernia. Surgeons placing staples during endoscopic repair of both Inguinal and femoral hernias must also be vigilant concerning the possible presence of common arterial variants
What is trochanteric bursitis?
Inflammation of the trochanteric bursa which may result from repetitive action such as climbing stairs while carrying heavy objects, or running on a steeply elevated treadmill. These movements involve the gluteus maximus and move the superior tendinous fibres repeatedly back and forth over the bursae of the greater trochanter. Trochanteric bursitis causes deep diffuse pain in the lateral thigh region.
This type of friction bursitis is characterised by point tenderness over the greater trochanter; however, the pain radiates along the iliotibial tract that extends from iliac tubercle to the tibia. This thickening of the fascia lata receivers tenderness reinforcements from the tensor fascia Latae and the gluteus maximus muscles. The pain from and inflamed trochanteric bursa usually localised just posterior to the greater trochanter is generally elicited by manually resisting abduction and lateral rotation of the thigh while the person is lying on the unaffected side
What is ischial bursitis?
Recurrent micro trauma resulting from repeated stress (cycling, rowing, activities that involve repetitive hip extension while seated) may overwhelm the ability of the ischial bursa to dissipate applied stress. The recurrent trauma results in inflammation of the bursa.
Ischial bursitis is a friction bursitis resulting from excessive friction between the ischial bursae and the ischial tuberosities. Localised pain occurs over the bursae and the pain increases with movement of the gluteus maximus. Calcification may occur in the bursa with chronic bursitis . Because the ischial tuberosities bear the bodies weight during setting, these pressure points may lead to pressure sores in debilitated people, particularly paraplegic persons with poor nursing care.
Describe damage to the superior gluteal nerve
Maury to this nerve results in a characteristic motor loss, resulting in a disabling gluteus medius limp, to compensate for weakened abduction of the thighby the gluteus medius and minimus, and/or a gluteal gait a compensatory list of the body to the weakened gluteal side. This compensation places the centre of gravity over the supporting lower limb. Medial rotation of the thigh is also severely impaired. When a standing person is asked to lift one foot off the ground and stand on one foot, the gluteus medius and minimus usually contract as soon as the contralateral foot leaves the floor preventing tipping of the pelvis to the unsupported side.
When a person who has suffered a lesion to the superior gluteal nerve is asked to stand on one leg, the pelvis on the unsupported side descends, indicating that the gluteus medius and minimus on the supported side are weak and non-functional. This sign is referred to clinically as the positive Trendelenberg test.
Other causes of this sign include fracture of the greater trochanter and dislocation of the hip joint
When the pelvis descends on the unsupported side the lower limb becomes in effect too long and does not clear the ground when the foot is brought forward in the swing phase of walking. To compensate the individual leans away from the unsupported side, raising the pelvis to allow adequate room for the foot to clear the ground as it swings forward. This results in a characteristic waddling or gluteal gait
Other ways to compensate is to lift the foot higher as it is brought forward (steppage gait), or to swing the foot outward, laterally (swing out gait)- these same gaits are ALSO adopted to compensate for foot drop due to damage to the common fibular nerve
Describe injury to the sciatic nerve
A pain in the buttocks may result from compression of the sciatic nerve by the piriformis (piriformis syndrome). Individuals involved in sports that require excessive use of the gluteal muscles and women are more likely to develop this syndrome. In approximately 50% of cases histories indicate trauma to the buttocks associated with hypertrophy and spasm of the piriformis. In the approximately 12% of people in whom the common fibular division of the sciatic nerve passes through the piriformis, this muscle may compress the nerve.
Complete section of the sciatic nerve is uncommon – however when it occurs the lower limb is useless because extension of the hip is impaired, as is flexion of the leg. All ankle and foot movements are also lost.
Incomplete section of the sciatic nerve may also involve the inferior gluteal and /or the posterior cutaneous femoral nerves. Recovery from a lesion of the sciatic nerve is slow and usually incomplete.
With respect to the sciatic nerve, the buttocks has a side of danger (MEDIAL SIDE). Wounds or surgery on the medial side of the buttocks may injure the sciatic nerve and it’s branches to the hamstrings (semitendinosus, semimembranosus and biceps femoris) on the posterior aspect of the thigh. Paralysis of these muscles results in an impairment of thigh extension and leg flexion.
Describe a popliteal abscess and tumour
Because the deep popliteal fascia is strong and limits expansion, pain from an abscess or tumour in the popliteal fossa is usually severe. Popliteal abscesses tend to spread superiorly and inferiorly because of the toughness of the popliteal fascia.
Why is the popliteal pulse hard to feel?
Because the popliteal artery is deep it may be difficult to feel the popliteal pulse. Palpation of this pulse is commonly performed with the person in the prone position with knee flexed to relax the popliteal fascia and hamstrings. Pulsations are best felt in the inferior part of the fossa where the popliteal artery is related to the tibia. Weakening or loss of the popliteal pulse is a sign of femoral artery obstruction
Describe injury to the tibial nerve
Injury to the tibial nerve is uncommon because of its deep and protected position in the popliteal fossa, however the nerve may be injured by deep lacerations in the fossa. Posterior dislocation of the knee joint may also damage the tibial nerve. Severance of the tibial nerve produces paralysis of the flexor muscles in the leg and the intrinsic muscles in the sole of the foot. People with a tibial nerve injury are unable to plantarflex their ankles or flex their toes.
Loss of sensation also occurs in the sole of the foot.
Describe injury to the common fibular nerve and foot drop
Because of its superficial position, the common fibular nerve is the most often injured nerve in the lower limb, mainly because it winds subcutaneously around the fibular neck, leaving it vulnerable to direct Trauma. This nerve may also be damaged during fracture of the fibular neck or severely stretched when the knee joint is injured or dislocated. Severance of the common fibular nerve results in flaccid paralysis of all the muscles in the anterior and lateral compartments of the leg (dorsiflexors of the ankle and evertors of the foot). The loss of dorsi flexion of the ankle causes foot drop which is further exacerbated by unopposed inversion of the foot. This has the effect of making the limb too long : the toes do not clear the ground during the swing phase of walking.
There are several other conditions which may result in a lower limb that is too long functionally - pelvic tilt and spastic paralysis or contraction of the soleus. There are at least three means for compensating for this problem:
1. Waddling gait- individual leans to the side opposite the long limb
2. Swing out gait- long limb is swung out laterally (abducted) to allow the toes to clear the ground
3. High stepping steppage gait- in which extra flexion is employed at the hip and knee to raise the foot as high as necessary to keep the toes from hitting the ground
Because the dropped foot makes it difficult to make the heel strike the ground as in normal gait, a steppage gait is commonly employed in the case of flaccid paralysis. Sometimes an extra kick is added as the free limb swings forward in an attempt to flip the forefoot upward just before setting the foot down.
The braking action normally produced by eccentric contraction of the dorsiflexors is also lost in flaccid paralysis foot drop. Therefore the foot is not lowered to the ground in a controlled manner after heel strike- instead the foot slaps the ground suddenly, producing a distinctive clop and greatly increasing the shock both received by the forefoot and transmitted up the tibia to the knee. Individuals with a common fibular nerve injury may also experience a variable loss of sensation on the anterolateral aspect of the leg and dorsum of the foot.
Describe deep fibular nerve entrapment
Excessive use of muscles supplied by the deep fibular nerve may result in muscle injury and oedema in the anterior compartment. This entrapment may cause compression of the deep fibular nerve and pain in the anterior compartment.
Compression of the nerve may occur where the nerve passes deep to the inferior extensor retinaculum and the extensor hallucis brevis. Pain occurs in the dorsum of the foot and usually radiates to the web space between the first and second toes.
Commonly called the SKI BOOT SYNDROME as ski boots are a common cause of this type of nerve entrapment.
Describe superficial fibular nerve entrapment
Chronic ankle sprains may produce recurrent stretching of the superficial fibular nerve, which may cause pain along the lateral side of the leg and the dorsum of the ankle and the foot. Numbness and Paraesthesia may be present and increase with activity.
What is a fabella in the gastrocnemius?
Close to its proximal attachment the lateral head of the gastrocnemius, may contain a sesamoid bone- fabella which articulates with the lateral femoral condyle. The fabella is visible in lateral radiographs of the knee in 3-5% of people.
What is calcaneal tendinitis?
Inflammation of calcaneal tendon constitutes 9-18% of running injuries. Microscopic tears of collagen fibres in the tendon, particularly just superior to its attachment to the calcaneus, result in tenditnitis, which causes pain during walking, especially when wearing rigid soled shoes. Calcaneal tendinitis often occurs during repetitive activities, especially in individuals who take up running after prolonged inactivity or suddenly increase the intensity of their training, but it may also result from poor footwear on training surfaces.
What usually causes a ruptures calcaneal tendon?
Poorly conditioned people with a history of calcaneal tendinitis
What is the presentation of an individual with a ruptured calcaneal tendon?
Injury experienced with an audible snap during a forceful push off(plantar flexion with the knee extended) followed immediately by sudden calf pain and sudden dorsi flexion of the plantar flexed foot.
In a completely ruptured tendon, a gap is palpable usually 1-5cm proximal to the calcaneal attachment.
The muscles affected are the gastrocnemius, soleus and plantaris.
Individuals cannot plantar flex against resistance (cannot raise the heel from the ground or balance on the affected side) and passive dorsi flexion (usually limited to 20 degrees from neutral) is excessive. Ambulation/ walking is only possible when the limb is laterally rotated rolling over the transversely placed foot during the stance phase without push off.
Bruising appears in the malleolar region and a lump usually appears in the calf owing to shortening of the triceps surae.
Describe the calcaneal tendon reflex
The ankle jerk reflex or triceps surae reflex is a calcaneal tendon reflex. It is a myotatic reflex elicited when the persons legs are dangling over the side of an examining table. The calcaneal tendon is struck briskly with a reflex hammer just proximal to the calcaneus. The normal result is plantar flexion of the ankle joint. The calcaneal tendon reflex tests the S1 and S2 nerve roots. If the S1 nerve root is injured or compressed the ankle reflex is virtually absent.
What is gastrocnemius strain?
Painful acute injury resulting from partial tearing of the medial belly of the gastrocnemius at or near its musculotendinous junction.
Often seen in individuals (>40)
It is caused by over stretching the muscle by concomitant full extension of the knee and dorsi flexion of the ankle joint.
Usually an abrupt onset of stabbing pain is followed by oedema and spasm of the gastrocnemius.
What is calcaneal bursitis?
Results from inflammation of the deep bursa of the calcaneal tendon located between the calcaneal tendon and the superior part of the posterior surface of the calcaeneus. Calcaneal bursitis causes pain posterior to the heel and occurs commonly during long distance running, basketball and tennis. It’s cause by excessive friction on the bursa as the tendon continuously slides over it.
What is an accessory soleus?
Present in approx. 3% of people. The accessory muscle usually appears as a distal belly medial to the calcaneal tendon.
May be associated with pain and oedema during exercise.
Describe the posterior tibial pulse
The posterior tibial pulse can usually be palpated between posterior surface of the medial malleolus and the medial border of the calcaneal tendon. Because the posterior tibial artery lies deep to the flexor retinaculum it is important when palpating this pulse to have the person invert the foot to relax the retinaculum. Failure to do so may lead to the erroneous conclusion that the pulse is absent.
Both arteries are examined simultaneously for equality of force.
This palpation is essential for examining patients with occlusive peripheral arterial disease- intermittent claudication (results from Ischaemia of leg muscles as a result of narrowing the arteries)
What is plantar fasciitis?
Inflammation of plantar fascia often caused by an overuse mechanism (or running Na high impact aerobics)
Causes pain on the plantar surface of the foot and heel - pain often most severe after sitting and when beginning to walk in the morning- usually dissipates after 5-10 mins rest and then recurs again following rest
Point tenderness is located at the proximal attachment of aponeurosis to medial tubercle of calcaneus and on the medial surface of this bone
Describe sural nerve grafts
Pieces of sural nerve are often used for nerve grafts in procedures such as repairing nerve defects resulting from wounds. The surgeon is usually able to locate this nerve in relation to the small saphenous vein. Because of variations in the level of formation of the sural nerve, the surgeon may have to make incisions in both legs and then select the better specimen.
Describe the plantar reflex
The plantar reflex L4, L5, S1 and S2 nerve roots is a myotatic (deep tendon reflex) that is routinely tested during neurologic examinations. The lateral aspect of the sole of the foot is stroked with a blunt object such as a tongue depressor, beginning at the heel and crossing to the base of the great toe. The motion is firm and continuous but neither painful nor ticklish. Flexion of the toes is a normal response. Slight fanning of the lateral four toes or dorsi flexion of the great toe is an abnormal response (BABINSKI SIGN), Indicating brain injury or cerebral disease, except in infants.
Because a corticospinal tracts are not fully developed in newborns, a BABINSKI sign is usually elicited and may be present in children until 4 years of age (except in infants with Brian injury or cerebral disease)
Describe medial nerve entrapment
Compressive it’d rotation of the medial plantar nerve as it passes deep to the flexor retinaculum or curves deep to the abductor hallucis may cause aching burning numbness and Paraesthesia on the medial side of the sole of the foot and in the region of the navicular tuberosity.
Medial plantar nerve compression may occur during repetitive eversion of the foot. Because of its frequency in runners these symptoms have been called JOGGERS FOOT
Describe palpation of the dorsalis pedis pulse
Evaluated during physical examination of pip herbal vascular system.
May be palpated with the feet slightly dorsi flexed. Pulses are usually easy to palpate because these dorsal arteries are subcutaneous and pass along a line from the extensor retinaculum to a point just lateral to the EHL tendons.
A diminished or absent dorsalis pedis pulse usually suggests vascular insufficiency resulting from arterial disease.
Some healthy adults and even children have congenitally non palpable dorsalis pedis pulses- in these cases the dorsalis pedis artery is usually replaced by an enlarged perforating fibular artery.
What are the 5 P signs of acute arterial occlusion?
Pain Pallor Paresthesia Paralysis Pulselessness
Describe haemorrhaging wounds of the sole of the foot
Puncture wounds of the sole of the foot involving the deep plantar arch and it’s branches usually result in severe bleeding, typically from both ends of the cut artery because of the abundant anastomoses. Ligation of the deep arch is difficult because of its depth and the structures that surround it.
Ankle sprain
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Potts fracture dislocation
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Trendlenburg gait
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Foot drop
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Antalgic gait
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Locating common fibular nerve in dissection
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