Upper Limb Flashcards
Which view other than AP, is required for shoulder dislocation?
Axillary view
which nerve is most commonly affected in shoulder dislocations?
axillary nerve
what does the axillary nerve supply? (motor)
Deltoid, teres minor
what does the axillary nerve supply? (sensory)
regimental badge area
from what cord of the brachial plexus does the axillary nerve arise?
Posterior cord
through which space does the axillary nerve pass?
quadrangular space
what forms the superior border of the quadrangular space?
Teres minor
what forms the inferior border of the quadrangular space?
Teres major
what forms the medial border of the quadrangular space?
long head of triceps
what forms the lateral border of the quadrangular space?
humeral shaft
what structures pass through the quadrangular space?
Axillary nerve, posterior circumflex humeral artery
what classification system is used for supracondylar fractures?
Gartland
which neurological injury is most common in displaced supracondylar fractures?
Neuropraxia of anterior interosseous nerve (close to fracture site with soft tissue tethering)
which muscles are supplied by the anterior interosseous nerve?
Flexor pollicis longus
Flexor digitorum profundus (radial 1/2)
in the boast guidelines is absence of a radial pulse an indication for urgent surgery in supracondylar fractures?
Yes
what size K wire should be used for supracondylar fracture fixation ?
2mm
what are kanavels cardinal signs for flexor sheath infection?
- Fusiform swelling of digit
- Finger held in flexion
- pain on passive extension
- tenderness along flexor sheath
which organisms commonly cause flexor sheath infections?
Staph aureus
Staph epidermidis (skin flora)
MRSA
what is the origin of the FDS muscle?
Common flexor origin, adjacent part of the ulnar with a second part originating from the radius.
where does FDS insert?
Middle phalanges
where does FDP originate?
Interroseous membrane and part of the ulna
where are the incisions made for a flexor sheath washout?
2 x transverse incisions over A1 & A5 pulley
which two ligaments make up the coracoclavicular ligament?
Conoid ligament
Trapzeoid ligament
which of the conoid or trapezoid ligament is most medial?
Conoid ligament
which 3 ligaments are at the medial end of the clavicle?
Interclavicular ligament
Costoclavicular ligament
sternoclavicular ligament
what are the muscular attachments of the clavicle?
Deltoid
Pec major
Trapezius
Subclavius
Sternocleidomastoid
Sternohyoid
which end of the clavicle is concave?
Acromial end
which end of the clavicle is convex?
Sternal end
what structures pass through the 2 heads of FDS in the forearm?
Median nerve
Ulnar artery
what nerve innervates FDP?
Anterior interosseous nerve (radial half)
Ulnar nerve (ulnar half)
in which compartment is FDS in the forearm?
intermediate
what are the 4 cardinal/Kanavels signs of flexor sheath infection?
Fusiform swelling
Held in flexion
pain on passive extension
tenderness along flexor sheath
where do you make the incisions for a flexor sheath washout?
Over A1 and A5 pulley
What radiographic sign is seen in posterior shoulder dislocation?
lightbulb sign
which structures are at risk in the FCR approach to the wrist?
Median nerve
Radial artery
which muscle lies underneath the FCR tendon?
FPL
which muscle must be lifted of the distal radius in FCR approach?
Pronator quadratus
which direction is the FCR commonly retracted?
Ulnarly (protect median nerve)
what position should a patient be placed for the deltopectoral approach to the shoulder?
Beachchair
what is the inter nervous plane for the deltopectoral approach to the shoulder?
Deltoid (axillary nerve)
Pec major (medial + lateral pectoral nerves)
which structures are at risk in the deltopectoral approach to the shoulder?
Musculocutaneous nerve
Axillary nerve
Cephalic vein
Anterior circumflex humeral artery
what steps are involved in superficial dissection of the deltopectoral approach?
Skin, fat, deltopectoral fascia, cephalic vein mobilised
what steps are involved in deep dissection of the deltopectoral approach?
Short head of biceps + coracobrachialis (conjoint tendon) retracted medially
Subscapularis partially cut
Capsule incision
where does the musculocutaneous nerve enter the biceps muscle?
5-8cm distal to the coracoid process
what is the superior border of the triangular interval?
teres major
what is the medial border of the triangular interval?
long head of triceps
what is the lateral border of the triangular interval?
humerus
what are the contents of the triangular interva?
radial nerve, profunda brachii artery
what is the superior border of the triangular space?
teres minor
what is the inferior border of the triangular space?
teres major
what is the lateral border of the triangular space?
long head of triceps
what are the contents of the triangular space?
circumflex scapular artery
what are the contents of the antecubital fossa?
Tendon of biceps
Brachial artery
Median Nerve
which structure is most medial in the antecubital fossa?
Median nerve
which structure if the most lateral in the antecubital fossa?
Tendon of biceps
which muscles make up the floor of the antecubital fossa?
Brachialis + Supinator
what is the lateral border of the antecubital fossa?
Medial border of brachioradialis
what is the medial border of the antecubital fossa?
Lateral border of pronator teres
what makes up the roof of the antecubital fossa?
Fascia and skin
which muscles originate from the medial epicondyle of the humerus?
Superficial Flexors
(Pronator teres, FCR, PL, FCU)
which muscle is considered to be in the intermediate compartment of the anterior forearm?
FDS
what muscles does the median nerve supply in the hand?
LOAF muscles:
- 1st + 2nd lumbricals
- Opponens pollicis
- Abductor pollicis brevis
- Flexor pollicis brevis
how do you test the function of Abductor pollicis brevis?
Place hand facing up on table, ask pt to point thumb to ceiling
what movements test all nerves in the hand?
- OK sign
- Cross 2 fingers
- Thumbs up
what areas does the median nerve supply sensation in the hand?
Skin of palm
Nail beds of radial 3.5 digits
what are the borders of the carpal tunnel?
roof - flexor retinaculum
floor - carpal bones
ulnar - pisiform + hook of hamate
radial - scaphoid tubercle + trapezium
what are the contents of the carpal tunnel?
median nerve
FPL
4 x FDS
4 x FDP
where is the palmar cutaneous branch of the median nerve given off?
5cm proximal to wrist
travels superficial to carpal tunnel
this definition describes what:
angle formed by a line drawn perpendicular to the axis of the radial shaft and a line that crosses along the radial intraarticular surface
volar tilt
what is a normal volar tilt?
11 degrees
what is a normal radial height?
11 degrees
the below describes what:
between 2 perpendicular lines - one at the level of the ulnar border of the radius and one at the level of the radial styloid
Radial height
the below describes what:
angle between a line drawn between the radial styloid and ulnar border of radius and a line drawn perpendicular to shaft/long axis of radius
radial inclination
what is a normal radial incliniation?
21 degrees
what alignment is considered acceptable in a distal radius fracture?
<3mm loss in radial height
<10 degree loss in volar tilt
<5 degree change in radial inclination
what is the internervous plane used in the FCR approach to the distal radius?
FCR - median nerve
FPL - AIN
what is the radial border of the anatomical snuffbox?
EPB + APL
What is the ulnar border of the anatomical snuffbox?
EPL
what forms the floor of the anatomical snuffbox?
Radial styloid, scaphoid, trapezium, base of metacarpal
what forms the roof of the anatomical snuffbox?
Deep fascia
what is the blood supply to the scaphoid?
Dorsal carpal branch of radial artery
what does the mnemonic CRITOL stand for with regards to ossification at the elbow?
C - capitellum 2y
R - radial head 4y
I - internal epicondyle 6y
T - trcohlea 8y
O - olecranon 10y
L - lateral epicondyle 12y
what does the mnemonic CRITOL stand for with regards to ossification at the elbow?
C - capitellum 2y
R - radial head 4y
I - internal epicondyle 6y
T - trcohlea 8y
O - olecranon 10y
L - lateral epicondyle 12y
what characteristics will a gartland I supracondylar fracture have?
Displacement <2mm
intact humeral line
what characteristics will a gartland II supracondylar fracture have?
Displacement >2mm
anterior humeral line disrupted
posterior cortex intact
what characteristics will a gartland III supracondylar fracture have?
displaced with periosteum torn and no cortical contact
what characteristics will a gartland VI supracondylar fracture have?
as with III but unstable in flexion and extension
what are flexor tendon sheaths?
Synovial sheaths surrounded by a fibrous later
what are the function of flexor tendon sheaths?
Synovial fluid provides nutrition and lubrication to tendons
Fibrous layer prevents bow stringing of tendons
what are the displacing forces in a clavicle fracture?
Medial - sternoclediomastoid
Lateral infero - pec major
Lateral - weight of arm
what is the allmann classification of clavicle fractures?
Grade I - middle 1/3
Grade II - Lateral 1/3
Grade III - Medial 1/3
what are the absolute indications for fixation in clavicle fractures?
Open Fracture
Subclavian artery/vein injury
displaced fracture with skin tenting
floating shoulder
symptomatic non union
what is a ‘floating shoulder’?
ipsilateral clavicle and scapula neck fractures
what are the relative indications for fixation in clavicle fractures?
Brachial plexus injury
polytrauma
seizure disorder
closed head injury
unstable fracture pattern (neer IIA/IIB/V)
displaced >2cm shortening
how do you manage a clavicular non union?
asymptomatic - nothing
symptomatic - ORIF + bone graft
which muscles attach onto the olecranon?
Triceps - posterior aspect
Anconeus - Lateral aspect
what are the clinical features of a displaced olecranon fracture?
Bruising
Swelling
Palpable gap
inability to extend elbow
what is the usual mechanism for dislocating the elbow joint?
Hyperextension (axial load)
ie. fall on outstretched hand
rotational/valgus force in posterolateral direction
in what direction does the elbow usually dislocate?
Posterior
(posterolateral)
what steps take place to reduce a posteriorly dislocated elbow?
Traction
Supination
Flexion
Posterior pressure on olecranon
what is the post reduction management of a stable elbow dislocation?
Above elbow backslab - immobilise for 7-10 days
Early ROM
which soft tissue structures may need repair after a posteriorly dislocated elbow ?
LCL or MCL
which ligament is the first to go in a posteriorly dislocated elbow?
LCL
(MCL is last)
what is the terrible triad associated with elbow injurues?
Elbow dislocation (posterolateral)
Radial head fracture
Coronoid fracture
what are the static stabilizers of the elbow joint?
Ulnohumeral joint
Radiocapitellar joint
MCL
LCL
capsule
Flexor + extensor origins
what are the dynamic stabilizers of the elbow joint?
Triceps
Brachialis
Anconeus
what should be done prior to immobilisation after reduction of elbow dislocation?
elbow should be taken through ROM in flexion - extension plane to assess the stable range
what are gilulas carpal arcs?
used in assessment of normal alignment of carpys on PA wrist radiographs
what may disruption of gilulas arcs indicate?
Ligamentous injury or fracture at side of the broken arc
what neurovascular injury are patients with perilunate dislocations susceptible to?
Acute carpal tunnel syndrome
what do the boast guidelines state re dislocations with neurological symptoms?
need urgent relocation
what must you do after every reduction?
- repeat radiographs
- examine neurovascular status
- document findings
what is a bankart lesion?
Avulsion of anterior labrum
what is a bony bankart lesion?
fracture of anterior inferior glenoid
what is a hill sachs defect?
chondral impaction injury in the posteroseuprior humeral head secondary to contact with the glenoid rim
greater tuberosity fractures are associated with what type of shoulder dislocation?
anterior - >50y
lesser tuberosity fractures are associated with what type of shoulder dislocation?
posterior
a reverse hill sachs defect is what?
chondral impactio injury to anterior humeral head in posterior shoulder dislocations
