Upper extremity

Question 1

Parts of axillary artery

Answer 1

1. from 1st rib to pectoralis minor
2. behind the pectoralis minor
3. below pectoralis minor to teres major

Question 2

branches of axillary artery

Answer 2

1. superior thoracic artery
2. thoracoacromial
3. lateral thoracic
4. subscapular
5. anterior humeral circumflex
6. posterior humeral circumflex

Question 3

Branches of subclavian artery

Answer 3

1. Vertebral
2. internal mammary
3. thyrocervical trunk
4. costocervical trunk
5. dorsal scapular

Question 4

origin of deep palmar arch

Answer 4

radial artery

Question 5

origin of superficial palmar arch

Answer 5

ulnar artery

Question 6

most common upper arm anatomy variant

Answer 6

earl division of brachial artery (high origin of the radial , or accessory / duplicate brachial artery)

Question 7

Parts of subclavian artery

Answer 7

1. origin of the vessel to the medial border of scalene anterior
2. behind the scalene anterior
3. lateral border of scalenus anterior to the outer border of the first rib

Question 8

Hypothenar hammer syndrome

Answer 8

repetitive trauma to the ulnar artery
artery gets injured at the hook of the hamate bone
ulnar artery aneurysm and digital arteries occlusive disease (embolization)

Question 9

aberrant left subclavian

Answer 9

artery most common with right sided aortic arch
6 fold increase in congenital heart disease
most are asymptomatic however greater proportion has symptoms than with aberrant right subclavian artery

Question 10

normal subclavian and axillary PSV

Answer 10

70-120cm/s

Question 11

brachial artery PSV

Answer 11

50-100cm/s

Question 12

radial / ulnar PSV

Answer 12

40-90cm/s

Question 13

How do you diagnose subclavian steal

Answer 13

check for effects of reactive hyperemia. Inflate BP cuff on arm, keep inflated for 3-4 min. Increased flow to the arm after deflation will make reverse flow in vertebral arteries more pronounced

Question 14

median nerve function

Answer 14

1) vascular branches to brachial artery –> sympathetic fibers
2) muscles: pronator teres
flexor carpi radialis
palmaris longus
flexor digitorum superficialis
flexor digitorum produnfus (lateral half)
pronator quadratus
oponens pollicis, abductor pollicis brevis, flexor policis brevis
3) motor to 1st and 2nd lumbrical muscle, thenar eminence
4) skin of palmar thumb, index, middle finger, 1/2 ring finger and neil beds of these fingers, lateral part of palm,

Question 15

Forearm fasciotomy

Answer 15

3 anatomic compartments: dorsal (superficial muscles), volar (deep muscles) and “mobile wad” (innervated by radial nerve)

• lazy S incision - releases the volar and dorsal compartment. May add incision on the dorsal aspect
• full decompression requires carpal tunel release

Question 16

Normal DBI

Answer 16

> 0.9

Question 17

DBI indicating hemodynamically significant lesion that produces symptoms

Answer 17

<0.7

Question 18

DBI for rest pain

Answer 18

<0.4

Question 19

Most frequent cause of UE

Ischemia

Answer 19

60% embolus from the heart

Question 20

Expose second part of axillary artery

Answer 20

Divide pectoralis minor muscle

Question 21

Expose distal 3rd of axillary artery

Answer 21

Oblique incision along lateral margin of pectoralis major muscle with arm abducted 90 degrees

Question 22

Mid to distal brachial artery exposure

Answer 22

Medial incision over bicipital groove
Avoid cutaneous branches of median nerve located within the subcutaneous tissue during dissection
In use brachial sheath longitudinally
Median nerve is located superficially
Divide crossing vein branches to minimize the risk of injury to ulnar nerve

Question 23

Radical artery course

Answer 23

In oblique line from brachial artery pulse medial to biceps tendon to style is process
In midforearm artery is medial to brachioradialis and lateral to flexor Capri radialis

Question 24

Distal radial artery approach

Answer 24

Vertical incision over anatomic snuff box on dorsum of hand

Deepen incision through subcutaneous tissue and expose radial artery on the floor of the snuffbox

Question 25

Ulnar artery exposure

Answer 25

Course: from medial Eli condyle of humerus to pusiform bone. In midforearm: beneath deep fascia between bellies of flexor digitorun laterally abd flexor carpin ulnaris medially At wrist: artery is latera to flexor carpi ulnaris (most medial tendon palpable at the wrist)

Question 26

What nerves to look out for when exposing ulnar artery

Answer 26

Ulnar nerve on the latera aspect of artery in the distal ⅔ | Palmar cutaneous branches of the ulnar nerve are superficial to the artery and should be preserved

Question 27

Interosseus artey course

Answer 27

Initial few milimitera of the common interosseus can be accessed by following ulnar artery down from brachial artery and then dividing some of the fibers of the superficial flexor digitorum - look for the large branch going latera and deep from ulnar artery Common interosseus bifurcated into anterior and posterior interosseous proximal to forearm interosseus is membrane

Question 28

Exposure of the interpsseous artery

Answer 28

Same incision used to expose midportion ulnar arterseparate flexor carpi ulnaris from superficial flexor digitorum Elevate superficial flexor digitorum along the median nerve and dissect along the antrior surface of flexor digitorum profundus Elevate flexor pollicis longus towards radius to expose anterior interosseous neurovascular bundle Posterior interosseous artery is beat approached through dorsal forearm incision along medial aspect of radius

Question 29

Duplex feature that favors subclsvian artery stenosis over occlusion

Answer 29

Early systolic deceleration in vertebral artery

Question 30

What’s quadrilateral space

Answer 30

Bordered by teres minor superiority, numeral shaft laterally, teres major inferiorly and long head of the triceps muscle medially. 20% of arterial TOS, mainly in young athletes with overhead arm motions. Posterior humeral circumflex artery is affected

Question 31

Radical nerve

Answer 31

Originated from the posterior cord of the brachial plexus C5-8 and T1 1. Cutaneous innervation: dorsum of the hand and 1,2,3 and lateral 4th finger; back of the arm 2. Motor: triceps, brachioradialis, extensor carpi radialis longus and brevis, supinator, extensor digitorum, extensor carpi ulnaris, abductor policis longus, extensor pollicis longus and brevis

Question 32

Injury to radial nerve at the axillary

Answer 32

Saturday night palsy Loss of extension of forearm, weakness of supination, loss of extension of hand and finger Wrist drop Loss of sensation in latera arm, posterior forear , dorsal hand

Question 33

Mid arm radial nerve injury

Answer 33

Mid shaft humerus fracture Weakness of supination. And loss of extension of hand and fingers Wrist drop Loss of sensation in posterior arm, dosas hand

Question 34

Radial nerve injury at the elbow

Answer 34

Radius neck fracture, elbow dislocation Weakness in extension of hand and loss of extension of fingers Finger droop and partial wrist drop No sensory deficit

Question 35

Median nerve injury above the elbow

Answer 35

Supracondylar humerus fracture Loss of pronation of forearm, weakness in flex ion of the hand at the wrist Loss of abduction and opposition of thumb Ape hand deformity, benediction sign Loss of sensation in 1,2,3 and half of 4 digits and thenar region

Question 36

Ulnar nerve

Answer 36

Sensation to 5th digit and medial half of the 4th digit Motor: flexor carpi ulnaris, flexor digitorum profundus, hypothenar muscles (opponens, abductor, flexor digiti minimis), 3,4 lumbeical muscles, adductor policis,

Question 37

Musculocutaneous nerve

Answer 37

Coracobrachialis, biceps, brachialis, Sensation to the latera side of the forearm from elbow to wrist

Question 38

Brachial plexus

Answer 38

Upper - C5-6 Middle - C7 Lower - C8-T1 Each trunk then splits into two (anterior and posterior) division . Then regroup to become three cords: Posterior (c5-8, t1) Lateral (c5-c7) Medial (c8-t1)

Question 39

What nerves come from the lateral cord of brachial plexus

Answer 39

Lateral pectoral Musculocutaneous Lateral root of median nerve

Question 40

What nerves come from posterior cord

Answer 40

``` Upper scapular Thoracodorsal Lower subscapular Axillary nerve Radial nerve ```

Question 41

What nerves come from medial does od brachial plexus

Answer 41

Medial pectoral nerve Medial root of the medial nerve Medial cutaneous nerve of the arm and forearm Ulnar nerve