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Pathophysiology - Connective Tissue / Musculoskeletal > Upper Extremity Injuries > Flashcards

Upper Extremity Injuries Flashcards

1
Q

What are the terminal branches of the brachial plexus (there are 5)? Where do they come from?

A 
MARMU
Lateral cord: Musculocutaneous
Posterior cord: Axillary, Radial
Lateral / medial cord: Median
Medial cord: Ulnar
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2
Q

What is the mnemonic for order of progression of brachial plexus? What things are contained (other than the branches which you just did)?

A 
Randy Travis Drinks Cold Beer
Roots: C5-T1
Trunks: Upper, Middle, Lower
Divisions: 3 posterior to posterior cord, 2 anterior to lateral cord, 1 anterior to medial cord
Cords: Lateral, posterior, medial
Branches: MARMU
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3
Q

What is the thoracodorsal nerve also called?

A

Middle subscapular. So you can just remember posterior cord as radial, axillary, and three subscapular nerves (Upper, middle, and lower)

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4
Q

Origin, insertion, innervation, and action of serratus anterior muscle?

A

Origin: Superolateral 8-9 ribs
Insertion: Medial border of scapula
Innervation: Long thoracic nerve (from roots of C5-C7)
Action: Protracts, rotates, and assists in abduction of scapula

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5
Q

Origin, insertion, innervation, and action of levator scapulae?

A

Origin: Transverse processes of CV1-4
Insertion: Medial superior border of scapula
Innervation: Dorsal scapular nerve (root of C5)
Action: Elevates and rotates scapula

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6
Q

Origin, insertion, innervation, and action of rhomboid minor?

A

Origin: Spinous processes of C7/T1
Insertion: Superior medial border of scapula
Innervation: Dorsal scapular nerve (root of C5)
Action: Retracts, elevates, and rotates scapula

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7
Q

Origin, insertion, innervation, and action of rhomboid major?

A

Origin: Spinous processes of T2-T5
Insertion: Medial border of scapula
Innervation: Dorsal scapular nerve (root of C5)
Action: Retracts, elevates, and rotates scapula

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8
Q

Origin, insertion, innervation, and action of subclavius?

A

Origin: First rib
Insertion: Inferior clavicle
Innervation: Nerve to subclavius (C5/C6, off same area as suprascapular nerve)
Action: Depress shoulder and stabilize sternoclavicular joint

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9
Q

Origin, insertion, innervation, and action of supraspinatus?

A

Origin: Supraspinous fossa
Insertion: Superior facet of greater tubercle of humerus
Innervation: Suprascapular nerve (C5/C6, off the upper trunk)
Action: Initiates arm abduction

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10
Q

Origin, insertion, innervation, and action of infraspinatus?

A

Origin: Infraspinous fossa
Insertion: Middle facet of greater tubercle of humerus
Innervation: Suprascapular nerve (C5/C6, off the upper trunk)
Action: External rotation in neutral position

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11
Q

Origin, insertion, innervation, and action of pectoralis major?

A

Origin: Medial 1/2 of clavicle, anterior sternum
Insertion: Lateral lip of intertubercular groove of humerus
Innervation: Medial (C8-T1) and lateral (C5-C7) pectoral nerves
Action: Flexion, adduction, and medial rotation of arm

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12
Q

Origin, insertion, innervation, and action of pectoralis minor?

A

Origin: Ribs 3-5
Insertion: Coracoid process
Innervation: Medial pectoral nerve (C8,T1)
Action: Pulls tip of shoulder down and protracts scapula, mainly stabilization function

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13
Q

Origin, insertion, innervation, and action of subscapularis?

A

Origin: Subscapular fossa
Insertion: Lesser tuberosity of humerus
Innervation: Upper and lower subscapular nerves (C5, C6)
Action: Internal rotation of arm

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14
Q

Origin, insertion, innervation, and action of teres major?

A

Origin: lateral scapular border, inferiorly
Insertion: Medial lip of intertubercular groove (pec major inserts on lateral lip)
Innervation: LOWER subscapular nerve (C5, C6)
Action: Internal rotation and adduction of arm. Extends a flexed arm.

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15
Q

Origin, insertion, innervation, and action of teres minor?

A

Origin: lateral scapular border superior to teres major
Insertion: Inferior facet of greater tubercle
Innervation: Axillary nerve (C5, C6) (along with deltoid)
Action: Chief external rotator of arm at 90 degrees abduction.

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16
Q

Origin, insertion, innervation, and action of latissimus dorsi?

A

Origin: Spinous processes of T6-LV5, sacrum, iliac crest
Insertion: Intertubercular groove
Innervation: Thoracodorsal (C6-C8), also called middle subscapular
Action: Extends, adducts, and medially rotates humerus

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17
Q

What are the origin, insertion, innervation, and action of the biceps brachii?

A

Origin: Long head from superglenoid tubercule, short head from coracoid process
Insertion: Radial tuberosity of radius
Innervation: Musculocutaneous nerve (C5-C7)
Action: Flexor of forearm, major supinator of forearm, minor flexor of arm through short head

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18
Q

What are the origin, insertion, innervation, and action of the coracobrachialis?

A

Origin: coracoid process
Insertion: medial mid-shaft humerus
Innervation: Musculocutaneous nerve (C5-C7)
Action: flexor of arm

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19
Q

What are the origin, insertion, innervation, and action of the brachialis?

A

Origin: Anterior humeral shaft
Insertion: tuberosity of ulna
Innervation: Musculocutaneous nerve (C5-C7)
Action: flexor of arm

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20
Q

What are the origin, insertion, innervation, and action of the deltoid?

A

Origin: Spine of scapula, acromion, lateral 1/3 of clavicle
Insertion: Deltoid tuberosity
Innervation: Axillary nerve (C5,C6), same as teres minor
Action: Abduction, flexion, and extension of arm. Can also rotate internally / externally.

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21
Q

What muscles does the median nerve innervate proximal to the wrist?

A

Palmaris longus
FCR, FDS, FDP (lateral 1/2), FPL
Pronator quadratus
Pronator teres

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22
Q

What muscles does the median nerve innervate distal to the wrist?

A

LOAF
L - lumbricals (1st/2nd)
OAF = thenar muscles
O = opponens pollicis
A = ABductor pollicus brevis (adductor by ulnar nerve)
F = Flexor pollicis brevis (superficial head)

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23
Q

What nerve innervates brachioradialis?

A

RADIAL nerve

-> the only flexor of the forearm innervated by non-musculocutaneous.

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24
Q

What muscles does radial nerve innervate other than brachioradialis?

A

Anconeus
ECRL / ECRB
Supinator
All other useless extensors of the wrist

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25
Q

What muscles does the ulnar nerve innervate proximal to the wrist?

A

Flexor carpi ulnarus

Flexor digitorum profundus (medial 1/2)

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26
Q

What muscles does the ulnar nerve innervate distal to the wrist?

A 
Adductor pollicius
DEEP head of flexor pollicis brevis
Dorsal / palmar interossei
Medial two lumbricals
Hypothenar muscles (adductor, opponens, flexor)
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27
Q

What are the borders of the quadrangular space?

A

Medial: Long head of triceps
Lateral: Humeral shaft
Inferior: Teres major
Superior: Teres minor

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28
Q

What are the contents of the quadrangular space?

A

Axillary nerve

Posterior circumflex humeral artery

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29
Q

What are the borders of the triangular space and what is the content?

A

Lateral: Long head of triceps
Superior: Teres minor
Inferior: Teres major

Contents: Circumflex scapular artery

30
Q

What are the borders and contents of the triangular interval?

A

Superior: Teres major
Medial: Long head of triceps
Lateral: Shaft of humerus

Contents: Radial nerve and profunda brachii artery (deep brachii)

31
Q

What is injured in Erb’s palsy and how will the arm look?

A

Think Erb-dUchenne palsy -> Upper trunk traction / tear = C5/C6

Loss of suprascapular nerve, musculocutaneous nerve, axillary nerve

Unable to flex, supinate, abduct, or externally rotate arm:

Extended arm, held at side, internally rotated, in pronation = Waiter’s tip

32
Q

What is the mechanism of action of Erb’s palsy in infants and adults?

A

Infants - Pulling laterally on neck during delivery injuries the opposite side (upper trunk separates). Most common

Adults - trauma which separates head from shoulder during fall

33
Q

What nerves are affected in Klumpke’s Palsy?

A

kLumpke’s = Lower trunk tear or traction = C8-T1

Affects especially the ulnar nerve, as well as the distal median nerve (proximal flexors affected less than distal hand muscles)

34
Q

What is the cause of Klumpke’s palsy mechanically and what defect is typically seen?

A

Traction / forced abduction of arm -> i.e. catching a treebranch in adulthood or forcing arm upward during delivery of an infant

Total claw hand is seen: loss of medial and lateral lumbricals

  • > extension and MCP joints and flexion and PIP and DIP joints
  • > wrist is also extended (loss of FCU)
35
Q

What is thoracic outlet syndrome and what causes it?

A

Compression of lower trunk of the brachial plexus (like Klumpke’s palsy) also with involvement of subclavian vessels

Causes: Pancoast tumor, cervical rib (rib growing from C7)

36
Q

What are the symptoms of thoracic outlet syndrome?

A

Due to lower trunk involvement -> Klumpke’s palsy

Ischemia, pain, and edema of upper extremities due to compression of subclavian vessels in arms

37
Q

What causes medial vs lateral scapular winging?

A

Medial - absent pull of serratus anterior towards chest wall -> medial border protrudes. Due to long thoracic nerve dysfunction.

Lateral - absent retraction and elevation by trapezius - shoulder droops down. Due to CN11 dysfunction

38
Q

Which way will fragments be pulled in clavicle fracture?

A

Medial fragment is pulled posterosuperiorly by SCM

Lateral fragment is pulled inferolaterally by pec major and weight of arm.

39
Q

What are the muscles of the rotator cuff?

A 
SITS:
Supraspinatus
Infraspinatus
Teres Minor
Subscapularis
40
Q

What tests are used to assess supraspinatus and infraspinatus?

A

Supraspinatus - positive empty can test

Infraspinatus - Weakness to external rotation at neutral position

41
Q

Where is teres minor commonly injured, and how is the muscle tested?

A

Tested by external rotating during 90 degrees of abduction

Commonly injured by compression of axillary nerve as it runs through quadrangular space

42
Q

Which way does the shoulder typically dislocate and how does it happen?

A

Usually an anterior dislocation

Secondary to trauma, seizures, or electrocution

43
Q

Which nerve is typically injured in shoulder dislocation and what are the symptoms?

A

Typically the axillary nerve

-> deltoid / teres minor wasting with paresthesias

44
Q

What are the clinical features of pectoralis major tear?

A

Ecchymosis, pain, and weakness with adduction, flexion, and internal rotation of humerus

45
Q

What are the primary nerves affected in proximal, medial, and distal humerus fractures?

A

ARM: From proximal to distal
A - axillary
R - radial
M - median

46
Q

What are the symptoms / complications of proximal humerus fractures?

A

Pain, decreased range of motion, axillary nerve damage: deltoid atrophy

Complications: avascular necrosis of humeral head

47
Q

What will be the symptoms of a mid-shaft fracture of the humerus?

A

Radial nerve -> wrist drop, loss of elbow, wrist, and finger extension

Decreased grip strength -> extension of wrist needed to maximally activate finger flexors

Loss of sensation over posterior arm / forearm and dorsal hand (lateral 3 and 1/2 fingers except tips)

48
Q

What type of fracture do kids often get when playing on monkeybars / trampolines?

A

Supracondylar fractures

49
Q

What are the two types of supracondylar fractures, and which is most common? How do you tell them apart?

A

Extension - most common - line of humerus will be anterior to capitulum on X-ray

Flexion - line of humerus will be posterior to capitulum (end of humerus) on X-ray -> indicates arm was flexed during injury

50
Q

What nerves are injured in extension type supracondylar fractures? What direction will injure each?

A

Extension type: Humerus is displaced anteriorly -> damage nerves anterior to elbow.

Anteromedial -> median nerve is injured
Anterolateral -> radial nerve is injured

51
Q

What nerve is injured in flexion type supracondylar fractures? How do you check the integrity of this after surgery?

A

Rarer -> ulnar nerve

-> make the patient fan their fingers out then make a fist -> responsible for interosseous muscles as well as medial FDP

52
Q

How do you check the integrity of the median nerve post supracondylar fracture repair?

A

Make them make an A-ok sign -> flexion of 1st and 2nd digits

53
Q

What is the cause of nursemaid’s elbow? How will the patient present?

A

Annular ligament around radial head gets caught in the radiohumeral joint when the extended, pronated arm is tugged

Patient will present in pain with arm pronated and slightly flex

54
Q

How can you fix nursemaid’s elbow?

A
  1. Supinate elbow
  2. Hyperflex the forearm
    - > will slip back into position
55
Q

What are the symptoms of medial vs lateral epicondylitis?

A

Medial - Golfer’s elbow -> pain with resisted wrist flexion / pronation

Lateral - Tennis elbow -> pain with resisted wrist extension

56
Q

What is messed up which requires Tommy John surgery and how is it diagnosed?

A

Ulnar collateral ligament

Valgus force onto lateral elbow causes gapping of medial elbow. Medial elbow will be constantly in pain.

57
Q

What typically causes a biceps tear and what signs and symptoms will be present?

A

Excessive eccentric biceps contraction (i.e. lifting furniture) which causes biceps tendon to detach from radial tuberosity

Tests: Hook test (positive if you can’t feel biceps tendon on palpation), reverse popeye deformity (biceps contracts higher up in arm since it isn’t attached distally)

58
Q

What typically causes a triceps tear and what sign is seen on X-ray?

A

Excessive eccentric tension on triceps i.e. lifting weight -> triceps detach from olecranon

Flake sign seen on X-ray
-> calcifications at end of triceps (olecranon)

59
Q

What is the name for the proximal and distal ulnar nerve entrapments?

A

Proximal - Cubital Tunnel Syndrome -> compression posteriorly around medial epicondyle

Distal - Ulnar Tunnel Syndrome (in Guyon’s canal) -> compression of ulnar nerve as it travels through distal wrist and hand

60
Q

What is the cause of Guyon canal syndrome?

A

Classically seen in cyclists due to pressure from handlebars. Also can happen if you break your hamate

(This is ulnar tunnel syndrome)

61
Q

What are the symptoms of the ulnar nerve intrapments?

A

Sensory deficits over medial 1.5 fingers, loss of interossei, and clawing of fingers 4/5 (FCU is preserved but lumbricals are not)

Positive Tinel’s sign at elbow for cubital tunnel syndrome, or wrist for Guyon canal.

62
Q

What is a Greenstick fracture and who gets it?

A

Common pediatric fracture
-> fracture extends partway through the width of the bone
-> half broken, half bent
(bent like a green twig)

63
Q

What is a torus fracture?

A

A compression fracture seen in pediatrics, typically in the radius or ulna
-> immature skeleton is SOFT and compresses (buckles) on itself. Will heal with immobilization.

Also called a buckle fracture

64
Q

What makes up the roof, floor, ulnar wall, and radial wall of the carpal tunnel?

A

Roof - transverse carpal ligament
Floor - proximal carpal row (scaphoid, lunate, triquetrum, pisiform)
Ulnar wall: pisiform and hook of hamate
Radial wall: scaphoid and trapezium

Ulnar and radial walls are the most lateral bones from each row

65
Q

What are the contents of the carpal tunnel?

A

Median nerve and 9 flexor tendors:

4 FDP
4 FDS
1 Flexor pollicis longus

66
Q

What is the mnemonic for remembering the carpal bones of the hand?

A

Some Lovers Try Positions That They Cannot Handle

Scaphoid Lunate Triquetrum Pisiform

Trapezium Trapezoid Capitate Hamate

67
Q

What are common causes of carpal tunnel syndrome? What is one test for CTS which you haven’t heard before?

A
  1. Pregnancy - progesterone swells the synovium (edema)
  2. Repetitive activity
  3. Endocrine causes: i.e. acromegaly, myxedema

Remember: Durkan’s test -> press on median nerve for 30 sec

68
Q

What typically causes a scaphoid fracture and how can you tell when it has happened?

A

Falling on outstretched hands

Anatomical snuffbox will be palpable

69
Q

Why is it important to recognize scaphoid fracture early?

A

80% of blood flow to scaphoid is retrograde = poor blood supply

Can cause non-union of scaphoid (fracture never heals) or avascular necrosis -> predisposes to arthritis very early in life

70
Q

What bone may be dislocated to cause carpal tunnel syndrome? When should this be fixed?

A

Lunate -> drops right in the carpal tunnel.

Bone looks like a moon. Needs to be relocated quickly or will cause permanent damage

Pathophysiology - Connective Tissue / Musculoskeletal (17 decks)

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