MSK Upper Limb Clinical Flashcards
Fracture of the clavicle: Common site of fracture Common causes Presentation Potential nerve damage
Common site of fracture: junction between the medial two thirds and lateral third
Common causes: force transmitted up arm through FOOSH, or falling directly on shoulder
Presentation: medial fragment displaced superiorly due to sternocleidomastoid, lateral fragment displaced inferiorly due to weight of upper limb and medially due to pec major
Nerve damage: may get suprascapular nerve injury -> paralysis to lateral rotators (rotator cuff) -> unopposed medial rotation of arm -> waiters tip
Fracture of the scapula:
Common causes
Presentation
Treatment
Causes: road traffic accidents, crushing injury, sports injury
Presentation: pain/tenderness over area, possible brachial plexus injury
Treatment: requires little treatment due to protection by surrounding muscles (rotator cuff)
Fracture to the surgical neck of the humerus:
Common causes
Presentation
Causes: common in old people with osteoporosis, FOOSH (transmitted force), direct blow to area
Presentation: axillary nerve damage as it wraps around the surgical neck. Causes paralysis of teres minor and deltoid so patient cant abduct arm, and causes loss of sensation over regimental badge area.
Posterior circumflex humeral artery damage
Avulsion fracture of the greater tubercle of the humerus:
Common causes
Presentation
Common causes: fall in the acromion, fall on an abducted arm. Rotator cuff muscles (exc. subscapularis) tear off a piece of the greater tubercle.
Presentation: subscapularis muscle still attached to humerus (lesser tubercle) so causes medial rotation of limb
Midshaft fracture of the humerus:
Common causes (transverse and spiral)
Presentation
Common causes: transverse fracture caused by direct blow to arm, spiral fracture caused by FOOSH
Presentation: proximal fragment pulled laterally due to deltoid muscle, radial nerve damage (runs in the radial groove) -> weakened extension and wrist drop due to paralysis of extensor muscles in posterior forearm
Profunda brachii artery damage as it lies in the radial groove
Supracondylar fracture of the humerus:
Description
Common causes
Presentation
Transverse fracture spanning between the 2 epicondyles of the humerus
Common causes: fall on flexed elbow
Presentation: Displaced fragments may impinge/damage cubital fossa contents -> median or radial nerve damage -> hand of benediction (median) and wrist drop (radial). Damage to brachial artery causes volkmanns ischaemic contracture (uncontrolled flexion of hand as flexor muscles become fibrotic and short)
Medial epicondyle fracture:
Common causes
Presentation
Common causes: fall on flexed elbow, direct blow to medial epicondyle, hitting your funny bone
Presentation: ulnar nerve damage -> tingling/paraesthesia in medial palmar surface of hand and ulnar claw
Colles fracture of the radius:
Description
Common causes
Presentation
Fracture to the distal radius causing a posterior displacement -> dinner fork deformity
Most common type of radial fracture
Common causes: FOOSH (force transmitted from scaphoid/lunate to radius)
Presentation: dinner fork deformity as distal fragments displaced posteriorly
Smiths fracture of the radius:
Description
Common causes
Presentation
Anterior displacement of the distal fragment of the radius
Common cause: fall on the back of the hand
Presentation: anterior displacement of distal fragment
Scaphoid fracture:
Common causes
Presentation
Causes: blow to the wrist, FOOSH
Presentation: localised pain/tenderness in anatomical snuffbox
Radial artery damage -> disrupts blood supply to scaphoid (its blood supply runs distal to proximal) -> avascular necrosis -> future arthritis
Radial nerve damage- no wrist drop as the forearm extensor muscles are still innervated
Boxers fracture:
Description
Common causes
Presentation
Description: fracture to neck of 5th metacarpal (occasionally 4th too)
Common causes: clenched fist when striking a hard object
Presentation: shorter finger as distal fragments are pushed proximally, snapping/popping, swelling, bruising, pain, misalignment of digit
Bennets fracture:
Description
Causes
Presentation
Description: fracture to base of 1st metacarpal
Common causes: hyperabduction of thumb, punching hard object, bike falls (thumb still extended around handle bars)
Presentation: instability of CMC joint (cant pinch, grasp, oppose thumb), pain/weakness/swelling
Shoulder joint dislocation:
Direction of most common type of dislocation
Causes
Nerve damage
Most common type: anterior-inferior (direction of head of femur) as it is the weakest part of the capsule
Causes: excessive extension and lateral rotation of humerus -> head of humerus driven infero-anteriorly and the fibrous layer of the joint capsule and glenoid labrum may be removed in the process
Hard blow to the humerus when joint is fully abducted- inferior displacement of head of humerus (tears inferior part of capsule)
Superior dislocation
Elbow joint dislocation: How is an elbow dislocation clinically described? Most common type Common causes Ligament damage Nerve damage
Clinically described based on position of ulna and radius, not humerus
Most common: posterior dislocation
Common cause: Falls on hand with flexed elbow ->Distal end of humerus driven through anterior side of capsule (weakest part)
Ulnar collateral ligament torn with potential ulnar nerve damage
Pulled elbow/ nursemaid elbow/radial head subluxation
Commonly affects children under 5
Radius partially slips out of the radial annular ligament at the elbow
Common causes: child being lifted by its arm (arm stretched), or other similar motions
Tennis elbow
Lateral epicondylitis (inflammation of periosteum of lateral epicondyle) Lateral epicondyle is a common origin of the wrist extensor muscles in the forearm-> tennis players experience pain here due to repetitive extension of the wrist when backhanding (overuse strain)
Golfers elbow
Medial epicondylitis
Medial epicondyle is a common tendon origin of the wrist flexor muscles in the forearm
Golfers experience pain and inflammation here due to over use of the flexor muscles (overuse strain)
Rotator cuff tendinitis
Inflammation of the rotator cuff muscle tendons due to overuse causes degenerative changed to occur in the subacromial bursa and the subraspinatis tendon
Painful arc syndrome
a sign of rotator cuff tendinitis.
Pain on abduction between 50 and 130 degrees as the inflamed supraspinatus tendon is impinged by the acromion
Carpal tunnel syndrome: Description Causes Presentation Tests Treatment
Compression of median nerve and 9 tendons (4FDP, 4FDS, 1FPL) within the carpal tunnel
Many causes: idiopathic, trauma, RA, pregnancy, neoplasia, diabetes
Presentation: numbness/paraesthesia and pain in distribution of median nerve (lateral palm and lateral 3.5 digits and nail beds).
If untreated it will cause weakness and atrophy of the thenar muscles
Tests: Phalens (hold wrist in flexion for 60sec to elicit numbness, pain in median distribution) and tinnels (tap nerve in the carpal tunnel to elicit pain in median nerve distribution)
Treatment: splint, corticosteroid injections, surgical decompression (cut into flexor retinaculum)
Erbs palsy: Area of brachial plexus Nerves affected Muscles affected Motor effects Sensory effects Characteristic signs Causes
Upper brachial plexus injury (C5/C6) -> musculocutaneous (biceps brachii, brachialis, coracobrachialis), axillary (deltoid, teres minor), suprascapular (supraspinatus and infraspinatus) and nerve to subclavius (subclavius) affected
Movement losses: abduction at shoulder, lateral rotation at shoulder, supination of forearm, flexion at shoulder
Sensory losses: down lateral side of arm (axillary&musculocutaneous)
Characteristics: waiters tip (medial rotation by unopposed action of pec major, and pronation of forearm due to loss of biceps brachii)
Causes: difficult birth (injury given to baby) or blow to shoulder
Klumpke palsy Area of brachial plexus affected Nerves affected Muscles affected Motor effects Sensory effects Characteristic signs Causes
Lower brachial plexus injury (mainly T1)- ulnar and median nerve affected
All small intrinsic muscles of the hand are affected (extrinsic muscles of the forearm are innervated by same nerve but different roots so unaffected)
No movement losses
Loss of sensation along medial side of arm
Characteristic sign: ulnar claw (hyperextension at MCP joint and flexion at IP joint)
Causes: excessive abduction of arm (person catching a branch as they fall from a tree)
Subcutaneous bursitis
Inflammation of subcutaneous bursa, found between olecranon and overlying connective tissue
Subtendinous bursitis
Inflammation of subtendinous bursa, found between olecranon and tendon of triceps brachii, due to repeated flexion and extension at elbow
