MSK HARC Lectures Flashcards
Brachial plexus is divided into 5 sections what are they?
Roots, Trunks, Divisions, Cords and Branches
What is the origin of the brachial plexus?
Anterior primary rami of C5-T1 spinal nerves
Can be prefixed (C4) or post-fixed (T2)
Where are the Roots, Trunks, Divisions, Cords and Branches
What are the two major nerves involved in the brachial plexus ROOTS?
Dorsal scapular n. :Innervates levator scapulae and rhomboids (major and minor)
Long thoracic n.: Innervates serratus anterior
What are the two major nerves imvolved in the brachial plexus TRUNKS?
Suprascapular n. : Innervates supraspinatus and infraspinatus
Nerve to subclavius :Innervates subclavius
BP: Trunks split in two, forming _______ and ________ divisions
- Divisions come together in a specific way to form the cords of the brachial plexus
- ___nerves come from the divisions.
BP: Trunks split in two, forming anterior and posterior divisions
- Divisions come together in a specific way to form the cords of the brachial plexus
- No nerves come from the divisions.
BP
Three cords
Position determined by relationship with _______ _______
______ formed by the anterior divisions from upper and middle trunks
_______ formed by posterior divisions from all trunks
________ formed by anterior divisions from lower trunk
Three cords
Position determined by relationship with axillary artery
Lateral formed by the anterior divisions from upper and middle trunks
Posterior formed by posterior divisions from all trunks
Medial formed by anterior divisions from lower trunk
What are the nerves involved with BP cords?
Lateral pectoral n. • Innervates pectoralis major
Thoracodorsal n. • Innervates latissimus dorsi
Subscapular nerves Upper * & lower * • Innervates subscapularis and teres major (lower only)
Medial pectoral n. • Innervates pectoralis major and minor
Medial. cutaneous n. of the arm • Sensory to the arm
Medial. cutaneous n. of the forearm • Sensory to the forearm
BP Branches NERVES
Musculocutaneous n. • Lateral cord continuation
Axillary n. • Branch of posterior cord
Radial n. • Posterior cord continuation
Median n. • Medial & lateral cord branch union
Ulnar n. • Medial cord continuation
What suppplies musculocataneous nerve
and what is it sensory to?
- C5, C6 & C7
- Supplies anterior arm musculature
- Sensory to the forearm via lateral cutaneous nerve
What doe sthe axillary nerve suppply
and what is it sensory to>
- Supplies Deltoid and Teres Minor
- Sensory to shoulder • Deltoid badge
WHat are the landmarks for axillary nerve?
Landmarks
- Quadrangular Space
- Surgical neck of the humerus
Radial Nerve
Supply?
Sensory to?
Landmarks?
- Supplies posterior arm and forearm • Extensors
- Landmarks • Lower triangular space • Radial groove of the humerus
- Sensory to arm, forearm and hand
Which nerve supplies these muscles?
Radial- triceps
Brachioradialis- musculotaneous
Median nerve
Supply
Landmarks
Sensorty to?
- C5, C6, C7, C8 & T1
- Supplies anterior forearm & hand
- Landmarks • Cubital fossa • Carpal tunnel
- Sensory to lateral hand
Ulnar nerve
Supply?
Landmarks
Sensory ?
- C8 & T1 •Supplies anterior forearm & hand • Majority of intrinsic hand muscles
- Landmarks • Posterior groove of medial epicondyle • Ulnar tunnel
- Sensory to medial hand
How to remember the nerve roots?
Causes of brachial plexus injuries?
Caused by trauma or obstetric complication
- Violent traction injuries around shoulder and cervical spine
- Traffic collisions, knife and gunshot wounds
How are BP injuries classified?
root avulsion, stretch or rupture of plexal segments
Localised or whole plexus lesions
How are BP injuries presented?
- Presentation depends on severity
- Sensory loss, weakness, pain & paralysis
What is erbs palsy?
- Erb’s palsy (Upper trunk injury)
- Damage at Erb’s point • C5 & C6 form the upper trunk
- Loss of shoulder movements and elbow flexion - ‘Waiter’s tip’ position
- Unopposed medial shoulder rotators, wrist flexion and pronators
- Finger movements intact; T1 preserved
- Injured by sudden increase of angle between neck and shoulder
What is Klumpke’s paralysis
(Lower trunk injury)
- Damage at C8 and/or T1
- C8 & T1 form the lower trunk
- Loss of intrinsic hand muscle and long finger flexor movements
- Hand paralysis and loss of forearm and hand sensation medially
- Abduction injuries
- Falling from height and grabbing on causing upwards pull on the lower trunk
- Obstetric complications
What is Flail limb?
- Damage across C5-T1
- Most common BP injury
- Significant trauma is main cause
- Linked to MND and ALS when non-traumatic
- Complete loss of upper limb mobility and sensation
- Severe muscular atrophy
- Surgical repair difficult
Is this Erbs, Klumpke’s or Flail
Flail
Is this Erbs, Klumpke’s or Flail
Klumpke’s
Is this Erbs, Klumpke’s or Flail
Erbs
What is the difference between surgical neck humerus fracture and humeral shaft fracture?
Surgical neck of humerus fracture
- Damage to axillary n. and circumflex humeral arteries
- Loss of deltoid and teres minor function
- Abduction above 15 degrees lost
- Weak flexion, extension and rotation of the shoulder
Humeral shaft fracture
- Damage to radial n.
- Loss of extension at elbow, wrist, hand and fingers
- Spiral fracture most common – torsion induced injury
What is joint dislocation?
- No contact between the articular surfaces of the joint.
- “Shoulder dislocation” - Antero-inferior dislocation of the glenohumeral joint with sub-coracoid displacement
- “Shoulder separation” – Superior dislocation of the acromioclavicular joint
• Subluxation is a partial dislocation in which some _______ contact is maintained.
• Subluxation is a partial dislocation in which some articular contact is maintained.
- Classic lesion presentation for three nerves
- Radial nerve
- Median nerve
- Ulnar nerve
- Radial nerve - Wrist drop (extensor loss)
- Median nerve - Ape hand/median claw
- Ulnar nerve - Ulnar claw
What are the thee common locations fro radial nerve lesion?
- Axilla compression
- Humerus spiral groove fracture
- Forearm compression (PIN syndrome)
What are the two common locations for Ulnar nerve lesion?
- Ulnar (epicondylar) groove
- Ulnar tunnel (medial wrist)
What are the two common locations for Median nerve lesion?
- Cubital fossa (elbow)
- Carpal Tunnel (wrist)
General rules
Gluteal region - The _________ muscles are relatively large and play an active role in hip _______ and _______. The deep muscles are much smaller and collectively known as the _____ _______ ______ for the primary movement they enable at the hip
General rules
Gluteal region - The superficial muscles are relatively large and play an active role in hip extension and abduction. The deep muscles are much smaller and collectively known as the deep lateral rotators for the primary movement they enable at the hip
The thigh - The ________ muscles enable hip ______ and knee ________; the ________ r muscles enable hip _______ and knee _____, and the medial muscles are hip adductors. Note that the body’s strongest hip flexor is the combined _________ muscle, located in the posterior abdominal wall
The thigh - The anterior muscles enable hip flexion and knee extension; the posterior muscles enable hip extension and knee flexion, and the medial muscles are hip adductors. Note that the body’s strongest hip flexor is the combined iliopsoas muscle, located in the posterior abdominal wall
The leg (knee to foot) - Most of the leg muscles cross the ____ joint to act on the foot. As a rule, the anterior muscles are ________. The two lateral muscles _____ the foot. The superficial and deep posterior muscles, although separated by a layer of deep fascia, function mainly to __________ the foot. ________ some muscles cross the knee joint to flex this joint
The leg (knee to foot) - Most of the leg muscles cross the ankle joint to act on the foot. As a rule, the anterior muscles are dorsiflexors. The two lateral muscles evert the foot. The superficial and deep posterior muscles, although separated by a layer of deep fascia, function mainly to plantarflex the foot. Posteriorly some muscles cross the knee joint to flex this joint
Nerve Supply to Lower Limb
L2 to L4
Enters femoral triangle passing deep to inguinal ligament
Motor to anterior compartment (and pectineus)
Anterior cutaneous to front of thigh and knee
Long cutaneous nerve to supply skin as far as medial side of foot
Is this femoral, sciatic and obturator?
femoral
Nerve Supply to Lower Limb
L2 to L4
Enters medial compartment of thigh through obturator canal
Supplies most of adductor muscles and skin on the medial aspect of thigh
Posterior branch – Obturator externus, adductor brevis and part of adductor magnus
Anterior branch – Adductor longus, gracilis, adductor brevis, contribution to pectineus
is this femoral obturator or sciatic
obturator
Nerve Supply to Lower Limb
L4 to S3
Exits pelvis through greater sciatic foramen to enter posterior compartment of thigh between ischial tuberosity and the greater trochanter
Supplies all muscles in posterior compartment of thigh (lies on adductor magnus)
Branches into tibial and common fibular nerve
Tibial (motor) supplies posterior compartment and sole of foot
Common fibular (motor) supplies anterior and lateral compartments and continues into same for foot
Is it femoral obturator or sciatic
sciatic
Contraction of gluteus______ and ______ on stance side prevent pelvic drop on swing side
Contraction of gluteus medius and minimus on stance side prevent pelvic drop on swing side
What is Trendelenburg Gait?
Trendelenburg gait is an abnormal gait resulting from a defective hip abductor mechanism. The primary musculature involved is the gluteal musculature, including the gluteus medius and gluteus minimus muscles. The weakness of these muscles causes drooping of the pelvis to the contralateral side while walking
Patient uses circumduction to compensate
Trendelenburg gait
causes?
Caused by muscular dystrophy, myopathy, muscle atrophy, congenital hip dysplasia, pelvic fracture
Surgery to correct alignment, physio to strengthen
What is the largest snyovial joint in the body?
Knee joint
Patella helps decrease leverage and increase tendon wear
TRUE or FALSE
FALSE
Patella helps increase leverage and decrease tendon wea
what is the q angle of the knee?
The Q-angle is the angle formed by the intersection of lines drawn from the anterior superior iliac spine to the center of the patella and from the center of the patella to the tibial tubercle
What is a foot drop?
Foot drop is a muscular weakness or paralysis that makes it difficult to lift the front part of your foot and toes. It’s also sometimes called drop foot. It can cause you to drag your foot on the ground when you walk. Foot drop is a sign of an underlying problem rather than a condition itself
what is Tibial nerve entrapment
Tarsal tunnel syndrome is a condition in which the tibial nerve is being compressed. This is the nerve in the ankle that allows feeling and movement to parts of the foot. Tarsal tunnel syndrome can lead to numbness, tingling, weakness, or muscle damage mainly in the bottom of the foot.
what is calcaneal tendon rupture?
The Achilles tendon is a strong fibrous cord that connects the muscles in the back of your calf to your heel bone. If you overstretch your Achilles tendon, it can tear (rupture). Achilles (uh-KILL-eez) tendon rupture is an injury that affects the back of your lower leg
What is Plantar Fasciitis
Straining and inflammation of the plantar aponeurosis
Weakness and overstretch so cannot support longitudinal arch
Frequently due to standing, walking, obesity, tight Achilles
Pain and tenderness of the sole of the foot and medial aspect
Inflammation causes most of the pain, mediated
Can cause ossification in the posterior attachment causing a calcaneal spur
Stretching, pain relief, orthotics to treat
What is hallux valgus often referred to as?
Which joint is affected?
bunion
The first metatarsophalangeal joint is affected
What is hammer toe?
A hammertoe has an abnormal bend in the middle joint of a toe. Mallet toe affects the joint nearest the toenail. Hammertoe and mallet toe usually occur in your second, third and fourth toes. Relieving the pain and pressure of hammertoe and mallet toe may involve changing your footwear and wearing shoe inserts
Contracture occurring in second to fifth toes. Usually due to muscle/tendon imbalance. Poor fitting shoes again. Causes irritation against shoes which develop corns. Inheritance similar to bunions
What are claw toe?
Claw toe is a common foot deformity in which your toes bend into a claw-like position, digging down into the soles of your shoes and creating painful calluses. People often blame claw toe on wearing shoes that squeeze your toes, such as shoes that are too short or high heels
Claw toes are likely to affect all four toes of a foot at once, rather than one at a time
TRUE OR FALSE
FALSE
What is a congential clubfoot?
Clubfoot describes a range of foot abnormalities usually present at birth (congenital) in which your baby’s foot is twisted out of shape or position. In clubfoot, the tissues connecting the muscles to the bone (tendons) are shorter than usual
Which nerve innervates rectus femoris?
Femoral
Which condition is shown in the image?
Genu valgum
. What condition could the injury below most likely cause?
Foot drop
