Upper Extremity Flashcards
segments of the arm
-4 segments
-shoulder- pectoral girdle
-arm- anterior and posterior
-forearm- anterior posterior
-hand- wrist palm, dorsum, digits
bones
-pectoral girdle
-upper extremity
-forearm
-wrist
pectoral girdle
-scapula
-clavicle
-6 muscles- movement of girdle and stabilization of the scapula
-elevation, depression, protraction (hunch), retraction
-serratus anterior, rhomboid major and minor, trapezius, subclavius, pectoralis minor, levator scapulae
fracture of clavicle
-direct fall on shoulder or indirect force
-sternocleidomastoid elevates medial part
-trap is unable to hold up the lateral part of clavicle bc the weight of the arm -> depressed
-may also be pulled medially bc of pectoralis major
-middle- MC fracture- thinnest
-any force can cause dislocation- ligaments
-MC displacement- proximal fragment displaces superior bc its pulled on by sternocleidomastoid
-lateral displacement- weight of arm pulls it down -> caudal displacement
-non-union of these fractures -> 15%*
clavicle defect
-dont mistake epiphysis at acromial end of clavicle for fracture
-fusion of ossification center fails -> bony defect on lateral side -> this is bilateral condition -> To differentiate between fracture graph both sides
fracture of scapula
-severe trauma
-MVA
-protected by muscles of both sides
fractures to humerus
-MC in elderly with osteoporosis
-proximal head fracture- osteoporotic/fragility fracture
-surgical neck
-even a fall on hand can cause
-direct blow- mid shaft transverse fracture
-supraepicondylar (supracondylar) fracture- distal humerus fracture -> usually in child falling on hand
-nerve injury with fracture:
-surgical neck- axillary**
-radial groove- radial nerve
-distal humerus- median nerve
-medial epicondyle- ulnar nerve
osteoporotic/fragility fractures
-distal radius fracture
-proximal head fracture of humerus (surgical neck)
-vertebral compression fracture
fractures of ulna and radius
-direct- transverse injury to both at same level
-interosseous membrane binds these bones -> dislocation of nearest joint with fracture
colles fracture
-complete fracture of distal 2cm radius
-MC forearm fracture
-comminuted
-forced dorsiflexion
-ulnar styloid is often avulsed (broken off)
-dinner fork deformity- distal radius fragment projects posteriorly -> creates dinner fork shape
-radius shortens
fracture of hand
-27 bones in hands, wrist, palm, digits
-scaphoid is MC- fall on palm with hand abducted
-may not show on imaging at first
-can cause avascular necrosis of proximal fragment of scaphoid -> degenerative joint disease of wrist
-hamate fracture- may damage ulnar artery/nerve
pelvic girdle innervation
-rhomboids- dorsal scapular
-levator scapulae- dorsal scapular
-pectoralis minor- pectoral nerves
-serratus anterior- long thoracic
-subclavius- subclavian nerve
-trapezius- accessory
pectoral gridle movement
-pectoralis minor- protraction
-subclavian- stabilizes and depresses
clavicle
-joins two different skeletal system
-appendicular and axial
-rigid support for scapula and free limb
-protection to neurovascular bundle
-transfer shock from upper limb to axial skeleton -> without this we would fracture with trauma to arm
structures neighboring clavicle
-above- thoracic inlet- vital structures pass behind
-thoracic outlet syndrome- compression of structures
shoulder separation
-tear or a stretching of ligaments around shoulder
-complete tear- surgical repair -> AC and CC rupture
-partial- immobility will heal MC
-affects the positioning of the structures
-clavicle displaces posterior over acromion
-clavicle displaces just under skin -> coracoidclavicular and acromioclavicular tear
-clavicle underneath coracoid (very rare)
-Acromioclavicular ligament and Coracoclavicular ligament
rotator cuff
-these muscles help humerus SIT in the glenoid fossa
-subscapularis
-infraspinatus
-teres minor
-supraspinatus
-humoral head- sits in glenoid fossa (made from scapula)
shoulder joints
-TRUE JOINTS (anatomical):
-sternoclavicular joint
-acromioclavicular joint
-glenohumeral joint
-FALSE JOINT (physiological):
-scapulothoracic joint- space between
-suprahumeral (subacromial)- space above humeral head
rotator cuff tear
-primary action is to balance the tension around glenohumeral joint
-glenohumeral joint is very flat -> has a little labrum (cartilage) that buckles up but is very easy to tear
-only thing securing humeral head from going off balance is rotator cuff muscles
-MC- supraspinatus -> trouble with abduction
-2 causes- MC extrinsic compression (wear and tear) OR intrinsic degeneration (years of rotator cuff tendon wear -> blood supply decrease -> tear)
rotator cuff action and innervation
-supraspinatus- only one that doesnt rotate shoulder -> major abductor
-after 15 degrees abduction -> deltoid takes over
-subscapularis- medial rotation
-infraspinatus and teres minor- lateral/external rotation
-teres minor - axillary nerve
-supraspinatus, infraspinatus- suprascapular nerve
-subscapular- subscapular nerve
muscles that flex and extend the shoulder
-pectoralis major- flexion
-latissimus dorsi- extension
-deltoid- 3 heads
-teres major- extends
-tendons running in the bicipital groove- lady and 2 majors -> pec major (anterior), lat, teres major (posterior)
-bicep tendon runs over top
deltoid actions
-3 functions bc 3 heads
-clavicular- flexion
-acromial- abduction
-scapular- extension
-axillary nerve
ligaments of shoulder
-help hold humerus in glenoid fossa
-labrum- cartilage ring- hold loosely in ring -> stabilized by muscles and ligaments
-slap tear- superior labrum tear from anterior to posterior- MC -> bicep tendon inserts
-quickly lift, fall on hand -> bicep popping off and curling up
shoulder dislocation
-less muscle in this area- MC area -> anterior
-anterior dislocation - humerus move forward anteriorly -> falling on extended arm
-posterior- head of humerus behind the socket, uncommon -> serve shock, seizures
-inferior- arm pushed down and out of socket towards armpit
complications post shoulder dislocation
-recurrence- age, damage done
-high recurrence with younger -> first time in younger children should be surgically repaired
-fracture-humeral head- hillsachs fracture secondary to dislocation
-nerve injury- axillary nerve
-between the humerus and triceps long head -> 2 spaces -> quadrangular space and triceps hiatus
-axillary nerve and posterior circumflex in quadrangular
-triceps hiatus- radial nerve, profunda brachia artery
quadrangular space syndrome
-compression of axially nerve
-pain over posterior lateral shoulder
-numbness
-vascular compromise of circumflex
-young adults, no trauma
-MRI- atrophy of teres muscle -> axillary nerve problem
subclavian artery
-subclavian artery over the first rib -> gives off superior thoracic artery in 1st segment -> once it hits pec minor -> becomes axillary artery -> gives off 2 branches in 2nd segment -> thoracoacromial and lateral thoracic arteries
-3rd segment- posterior and anterior humeral circumflex artery and subscapular - at the level of surgical neck
-past teres major -> axial becomes brachial artery
-ex. elderly falls on hand -> breaks surgical neck -> posterior and anterior humeral circumflex arteries, subscapular, and axillary nerve are in danger
brachial artery
-brachial artery comes down and crosses over elbow joints
-becomes radial and ulnar artery
-ulnar artery -> interosseous branches- feed the deeper layers
-injury to brachial artery -> compartment syndrome -> ischemia and paralysis to muscle
-volkmans contracture
volkmans contracture
-occurs after injury to elbow or upper arm
-usually crush injury
-brachial artery damage
-pt goes into acute compartment syndrome
-if untreated- contracture of muscles -> permanent deformity -> flexion of fingers and wrists
-ischemia and paralysis of muscles
-can also happen with brachial plexus injury (less common)
flexors of arm
-anterior compartment
-biceps brachii- shoulder and elbow supination (crosses over several joints)
-brachialis- elbow
-coracobrachialis- shoulder
-musculocutaneous nerve
biceps tendon
-attaches below elbow
-testing reflex
-C6 spinal nerves being tested
arm extensors
-posterior compartment
-innervated by radial nerve
-triceps branchii- long, medial, lateral head -> all combine to attach to olecranon of ulna
-anconeus- humerus to ulna
-long head- adduction and extension of shoulder***
elbow
-7 major muscles- biceps tendon, triceps, brachialis, brachoradialis, aconeus, pronator teres, pronator quadratus
-3 flexors
-2 extensors
-2 rotate forearms- pronator teres and supinator
-9 muscles cross elbow to work on hand and metacarpals
ligaments of elbow
-radial collateral
-ulnar collateral
-annular- over radial head
-tennis elbow- lateral epicondylitis pain -> occurs with extension of wrist or fingers -> pain over lateral epicondyle
-ulnar collateral tear- repeated pitching and twisting -> constant pain from overuse
-tommy john surgery- UCL tear repair
-annular ligament disruption- over radial head ->fracture or subluxation of radial head
-subluxation of radial head- nurse maids elbow
supination of arm
-supinator
-biceps brachii (assist)
pronator of arm
-pronators teres
-pronator quadratus
-brachioradialis (assist)
elbow joint: composite hinge joint
-humeroulnar joint- composite hinge joint -> flex and extend -> wrench (olecranon of ulna) and nut (trochlea of humerus)
-humeroradial joint- ball and socket- pronation and supination
-radioulnar joint- pivot joint- prevents spinning out of control (excessive pronation/supination) -> prevents nurse maid elbow dislocation
-3 joints
-humeroulnar joint:
-olecranon and humerus- olecranon wraps 180 degrees around humerus
-olecranon and ulna -> wrench around nut -> stable -> flex and extend
subluxation vs dislocation of elbow
-dislocation- force that pushes radial and ulnar out of joint and dislocate posteriorly
-humeral head out of olecranon- extreme force
-subluxation- bones are in tract with each other but out of communication with each other -> abrupt pulling, swinging child, pulling by arm -> radial head splits out from under the annular ligament -> decrease stability of pivot joint NURSE MAIDS!!
-cant bend wrist
-relocating subluxed radial head- palm up and bending at elbow
forearm
-4 compartments
-anterior (flexor and pronators) and posterior (extensor) compartment
-superficial and deep compartment
-posterior- has dorsal and henrys mobile wad compartment
anterior compartment of forearm
-3 wrist flexors- flexor carpi radialis, palmaris longus, flexor carpi ulnaris
-3 finger flexor- flexor digitorum superifcialis, flexor digitorum profundus, flexor pollicis longus
-pronator quadratus- anterior deep compartment -> pronate forearm
-ALL ARE MEDIAN NERVE EXCEPT flexor carpi ulnaris (ulnar nerve)
posterior compartment of forearm
-3 muscles in the lateral compartment for mobile wad of henry- extensor carpi radialis longus, extensor carpi radialis brevis brachioradialis -> most mobile movement of muscles -> easy to retract these for surgery
-all innervated by radial nerve
-all originate on lateral epicondyle
acromioclavicular joint
-joins the clavicle and acromion process
-AC ligament- usually doesnt require surgical repair unless severe
-coracoclavicular ligament
-tears are based on the damage at these ligaments
-nerves- lateral pectoral and axillary
sternoclavicular joint
-ball and socket
-posterior rotation- external rotation of shoulder
-protraction and retraction
-elevation and depression
frozen shoulder
glenohumeral
clavicle injury
-carrying his arm for comfort -> signals immobilization helps -> signals bigger problem
-hand dominance is important to note
-nondisplaced fracture- no angle of fracture
-posterior displacement of clavicle- numbness, diminished pulses, ischemia of limb
forces on the clavicle
-sternocleidomastoid pulling up
-pectoralis pulling medially
-trapezius is pulling up
-weight of arm pulling down
-coracoclavicular ligaments pulling
clavicle repair
-plate and screw on both ends of clavicle
-causes so much discomfort sometimes even
-union is more common (or uncommon?) in younger (they move a lot)
-depending on angle
-need to be immobile for union
elbow dimpling
-epicondyles misplaced
-forearm appears looks longer
-radial head displaced
-especially worried about ulnar nerve
dermatomes
-ulnar nerve injury- pinky decreased sensation
-median nerve- middle hand and tops of middle fingers
-radial- dorsum parts of hand and thumb
ulnar nerve
-motor to intrinsic and extrinsic muscles
-loss of extension -> flexion takes over
-weakened intrinsic ->
-cant extend the pinkys -> exaggerated flexion
-flexor digitorum profundus and flexor digitorum superficialis -> not innervated by ulnar -> take over -> excessive flexion of PIP and DIP joints
-ulnar claw hand
forearm fracture
-distal radial fracture
-ulna dislocation
-interosseous muscle sheared
-severe pain with movement of fingers
-fingers are cool to touch, decreased sensation of 2nd and 3rd digits -> median nerve injury
-progression of these symptoms shows -> compartment syndrome
-must relieve or else permanent damage
compartment syndrome
-5 Ps
-Pain with passive movement (someone else is moving it and there is pain)
-Paresthesia
-Pallor
-Paralysis
-Pulselessness
-3 As (for peds)
-increase analgesic
-Anxiety
-Agitation
stryker pressure monitor
-assess compartment pressure
