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Moores Blue Boxes > Upper Limb > Flashcards

Upper Limb Flashcards

1
Q

The clavicle is one of the most commonly fractured bones , especially in kids and adult athletes . What motion often causes clavicle break.

A

Indirect force transmitted from an outstretched hand through the bones of the forearm and arm to the shoulder during a fall
Or a fall directly on the shoulder

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2
Q

What is the weakest part of the clavicle

A

Junction of its middle and lateral thirds

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3
Q

After a clavicle fracture the ______ muscle elevated the medial fragment of the bone

A

Sternocleidomastoid

PALPABLE protruding

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4
Q

After fracture what happens to lateral clavicle

A

Trapezius cant hold up bc cnE nonselective venjjcxjbrfof Limbiczbxn weight?~|…!
PSHOULDER DROPS
Also may be pulled medially by the adductor muscles of tha arm such as l@-6@-.**#: Percentage pec major !

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5
Q

The strong ___ ligament usually prevents dislocation or the ac joint

A

Coracoclavicular

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6
Q

How treat

A

Sling to take weight of limb off clavicle and facilitate alignment
(Patient usually come in holding arm up with other arm )

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7
Q

Clavicle fracture during birth?

A

Green stick fracture
Heals fast
More incomplete

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8
Q

Green stick fracture

A

Usually kids
Bends and cracks rather then crack all the way
One side crack other side bent

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9
Q

The clavicle is the first bone to ___. When?

A

Ossify
Via intramembranous ossification
Beginning during 5th and 6th embryonic weeks
From medial and lateral primary ossification centers
The ends of clavicle later pass through a cartilaginous phase; three cartilages form growth zones similar to those of other long bones
A secondary ossification enter appears at the sternal end and forms a scale like epiphysis that begins to fuse with the shaft (siaphysis) between 18 and 25 years of age and is completely fused by 25-31.
This is the last of the epiphyses of long bones to fuse,
A very small epiphysis may be present at the acromegaly end of the clavicle; it must not be mistaken for a fracture

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10
Q

Sometimes failure of the two ossification centers of the clavicle fails to occur;

A

Bony defect forms between the lateral and medial thirds of the clavicle.
Prevent diagnosis of a fracture in a normal clavicle so know this!!!

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11
Q

What to do if not sure if fracture or defect

A

Radiograph…it is usually bilateral!

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12
Q

How do you fracture your scapula

A

Severe trauma, like pedestrian vehicle accidents

Also usually rib fractures

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13
Q

Treat fractured scapula

A

Nothing bc scapula covered on both sides by muscles

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14
Q

Most scapula fractures involve a protruding subcutaneous ___

A

Acromion

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15
Q

Most injuries of the humerus are fractures of the ___ ___. In what population

A

Surgical neck

Elderly people with osteoporosis whose demineralizeed bones are britttle

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16
Q

Numeral fractures often result in one fragment being driven into the spongy bone of the other fragment. What is this called

A

Impacted fracture

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17
Q

How normally inure the surgical head other humerus (impacted)

A

Minor fall on the hand with force being transmitted up the forearm bones of extended limb

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18
Q

Why can person move arm passively with little pain in impacted fracture

A

Impaction of the fragments

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19
Q

Who gets allusion fracture of the greater tubercle of the humerus

A

Middle aged and elderly people

Small part of tubercle is avulsed (torn away)

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20
Q

How get avulsion fracture of greater tubercle of the humerus

A

Dislocation of the humerus

In younger people-impaction with excessive abduction or flexion of the arm

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21
Q

Arm position if have avulsionf rapture of the greater tubercle

A

Muscles (especially subscapularis) that remain attached to the humerus pull the limb into medial rotation

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22
Q

How get fracture of the shaft of humerus

A

Direct blow or torsion of the arm

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23
Q

In kids, fracture of shafts of long bones are often ____ fractures

A

Green stick

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24
Q

Transverse fracture of the numeral shaft

A

Deltoid muscle carries the proximal fragment laterally

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25
Q

Spiral of oblique fracture of the numeral shaft

A

May get from indirect injury resulting from a fall on the outstretched hand
Overriding of the oblique ends of anobliquelt fractured bone may result in shortening of the limb

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26
Q

Bc the humerus is surrounded by muscles and has a wel developed ____, properly aligned bone fragments usually unite well

A

Periosteum

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27
Q

Intercondylar fracture of the humerus

A

Severe fall on the flexed elbow or with high impact injuries such as MVA
Olecranon of the ulna is driven like a wedge between the medial and lateral parts of the condyle of the humerus separating one or both parts front he numeral shaft

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28
Q

The surgical neck is in direct contact with the ___ nerve

A

Axillary

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29
Q

The radial groove is in direct contact with the ____ nerve

A

Radial

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30
Q

The distal end of the humerus is in direct contact with the ___ nerve

A

Median

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31
Q

The medial epicondyle is in direct contact with the __ nerve

A

Ulnar

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32
Q

Fractures or radius or ulna in young and old people?

A

Young-green stick

Old and athletic adults -severe injury

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33
Q

Direct injury fo radius or ulna

A

Transverse fractures at the same level, usually middle third of the bones

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34
Q

Bc the radius and ulna are firmly bound by the interosseous membrane, a fracture of one is often associated with a __ of the nearest joint

A

Dislocation

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35
Q

Direct injury of humerus causes __ fracture and indirect causes

A

Transverse

Oblique or spinal

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36
Q

Fracture of the distal end of the radius is a common fracture in adults over 50. It occurs more frequently in women secondary to ___

A

Osteoporosis

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37
Q

Colles fracture

A

Completetransverse fracture of the distal 2 cm of the radius
Most common fracture of forearm
The distal fragment is displaced dorsally and is often comminuted (broken into pieces)

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38
Q

How get colles fracture

A

Forced extension of the hand usually trying to ease a fall by outstretching the upper limb

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39
Q

What happens usually with fracture of radius ulna

A

Ulnar styloid process is avulsed

Radial styloid process projects further distally than ulnar

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40
Q

What happens with colles

A

Relationship reversed bc o shortening or the radius

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41
Q

Dinner fork deformity

A 
In colles fracture
Posterior angulation (bending) occurs in the forearm just proximal to the wrist and the normal anterior curvature of the relaxed hand. The posterior bending is produced by the posterior displacement and tilt of the distal fragment of the radius
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42
Q

History of person with colles fracture

A

Slipping or tripping and outstretch limb with forearm and hand protonated to break fall

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43
Q

Why is bony union usually good after colles

A

Blood supply to the distal end of radius

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44
Q

Distal end of radius fractures in kids

A

May extend through the distal epiphyseal plate

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45
Q

Epiphyseal plate injuries

A

Older children bc of frequent falls in which forces are transmitted from he hand to the radius and ulna

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46
Q

Healing of epiphyseal plate injury

A

May result in malalignment of the epiphyseal plate and disturbance of radial growth

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47
Q

What is the most frequently fractured carpal bone

A

Scaphoid

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48
Q

How fracture scaphoid

A

Fall on palm when hand is abducted, the fracture occurring across the narrow part of the scaphoid

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49
Q

Palpating of fracture scaphoid

A

Pain in anatomical snuff box not he lateral side of the wrist, especially during dorsiflexion and abduction of the hand.

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50
Q

Often radiographs of the wrist do not reveal fracture of scaphoid. What may it be misdiagnosed as

A

Severely sprained wrist

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51
Q

Why do radiographs reveal fracture 1-=14 days after scaphoid fracture

A

Resorption has occurred

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52
Q

Why may union of scaphoid take at least 2 months

A

Poor blood supply to proximal part of scaphoid

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53
Q

Avascular necrosis of the proximal fragment of the scaphoid may occur with scaphoid fracture and produce what

A

Degenerative joint disease of the wrist

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54
Q

In some cases of scaphoid fracture we will need to fuse the carpals surgically. What is this called

A

Arthrodesis

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55
Q

Why may fracture of the hamate result in nonunion of the fractured bony parts

A

The traction produced by the attached hypothecate muscles

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56
Q

With fracture of hamate, the ___ nerve and __ artery is close to the hook of the hamate and may be injured

A

Ulnar

Ulnar

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57
Q

What happens if damage ulnar nerve with hamate fracture

A

Decreased grip strength of the hand

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58
Q

The metacarpals(except which one) are bound together; hence isolated fractured tend to be stable and heal rapidly

A

1st

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59
Q

What may oblique (spiral) fractured of a metacarpal result in

A

Overriding of bone fragments and or rotation of the distal fragment, resulting in a shortened finger, or one that does not flex in harmony with the other fingers

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60
Q

How do metacarpals respond to severe crushing injuries of the hand

A

Multiple metacarpal fractures resulting in instability of the hand

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61
Q

Boxers fracture

A

Fracture of 5th metametacarpal
When unskilled person punches someone with a CLOSED and ABDUCTED fist
Head of bone rotates over the distal end of the shaft producing a flexion deformity

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62
Q

How get a crushing injury of the phalanges

A

Finger caught in a car door

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63
Q

Are phalange injuries painful

A

VERY bc of highly developed sensation int he fingers

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64
Q

A fracture of a distal phalanx

A

Usually comminuted and a painful hematoma soon develops

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65
Q

How fracture proximal or middle phalanx

A

Crushing or hyperextension

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66
Q

Why must phalangeal fractures be carefully realigned to restore normal function of the fingers

A

Close relationship of phalangeal fractures to the flexor tendons
Need to carefully realign to restore function of the fingers

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67
Q

Lateral rotation at glen oh unreal joint

A

C5

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68
Q

Medial rotation at glenohumeral joint

A

C6, 7, 8

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69
Q

Abduction at glenohumaral joint

A

C5

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70
Q

Addiction at glenohumeral joint

A

C6, 7, 8

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71
Q

Extension at glenohumeral joint

A

C6, 7, 8

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72
Q

Flexion at glenohumeral joint

A

C5

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73
Q

Flexion at elbow

A

C5, c6

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74
Q

Extension at elbow

A

C6, C7

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75
Q

Flexion of wrist

A

C6, c7

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76
Q

Extension of wrist

A

C6, c7

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77
Q

Arm supination

A

C6

By forearm muscles

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78
Q

Arm pronation

A

C7, c8

By forearm muscles

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79
Q

Digital flexion IP joint

A

C7 c8

By forearm muscles

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80
Q

Digital extension IP joints

A

C7 c8

By forearm muscles

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81
Q

Medial and lateral abduction of fingers MCP joint of 3rd digit

A

T1

By forearm muscles

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82
Q

Abduction and adduction of digits 2-5 MCP

A

T1

Intrinsic muscles of the hand

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83
Q

Supraclavicular nerves (cutaneous nerve)))

A

C3, C4
From cervical plexus
Pass anterior to clavicle, immediately deep to platysma, and supply skin over clavicle and superolateral aspect of pectoralis major

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84
Q

Superior lateral cutaneous nerve of arm (cutaneous nerve)

A

C5, C6
Terminal branch of axillary nerve
Emerges from beneath posterior margin of deltoid and supplies skin over lower part of this muscles and on lateral side of mid arm

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85
Q

Inferior lateral cutaneous nerve of arm

A

C5, c6
From radial nerve (or posterior cutaneous nerve of arm)
Perforated lateral hear of triceps , passing close to cephalic vein to supply skin over inferolateral aspect of arm

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86
Q

Posterior cutaneous nerve of arm

A 
C5-c8
Radial nerve (in axillla)
Crosses posterior to and communicates with interocstobrachial nerve and supplies skin on posterior arm. As far as olecronon
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87
Q

Posterior cutaneous nerve of forearm

A 
C5-c8
Radial nerve(with inferior lateral cutaneous nerve of arm)
Perforated lateral head of triceps, descends laterally in arm, then runs along and supplies posterior forearm to wrist
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88
Q

Lateral cutaneous nerve of forearm

A

C6-c7
From musculocutaneous nerve(terminal branch)
Emerges lateral to biceps tendon deep to cephalic vein, supplying skin of anterolateral forearm and wrist

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89
Q

Medial cutaneous nerve of forearm

A

C8, t1
Medial cord of brachial plexus (in axilla)
Descends medial to brachial artery, pierces deep fascia with Basilian vein in mid arm, dividing into anterior and posterior branches that enter forearm and supply kin of anteromedial aspect to wrist

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90
Q

Medial cutaneous nerve of arm

A

C8-t2
From medial cord of brachial plexus (in axilla)
Communicates with intercostobrachila nerve continuing to supply skin of medial aspect of distal arm

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91
Q

Intercostobrachial nerve

A

T2
From second intercostal nerve (as its lateral cutaneous branch)
Extends laterally, communicating with posterior and medial cutaneous nerves of arm, supplying skin of axilla and medial aspect of proximal arm

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92
Q

What is failure of a body part or organ to form usually due to (agenesis)

A

Lack of genetic signaling to produce primordial tissue and failure of subsequent development in the embryo

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93
Q

Agenesis of a vital structure

A

Not viable fetus

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94
Q

Poland syndrome

A

Uncommon
Unilateral congenital anomaly of upper limb development , lowest level of which is a genesis of the pectoralis major and pectoralis minor

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95
Q

Nipple in Poland syndrome

A

More inferior or absent in severe Poland by have breast hypoplasia

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96
Q

Functional concern of Poland syndrome

A

Similar to when woman gets radio all mastectomy
Weakened addiction and extension of arm and ability to draw the shoulder anteriorly , and lateral rotation of the limb at rest

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97
Q

Severe Poland

A

Breast hypoplasia, no nipple,

Missing 2-4 rib segments, and additional development define its of the free limb

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98
Q

The stratus anterior muscle is paralyzed with damage to what nerve

A

Long thoracic

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99
Q

Clinical presentation of paralysis of Serra thus anterior

A

Medical border of the scapula moves laterally and posterior lay away from the thoracic wall. Gives wing scapula appearance especially when person leans on hand or presses hand on wall

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100
Q

What happens when raise arm and have paralysis of serrated anterior

A

Medical border and inferior angle of scapula pull away from the posterior thoracic wall, a deformation known as winged scapula

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101
Q

Why wont the limb be able to elevate normally above the horizontal position if serratus anterior paralyzed

A

Serratus unable to upwardly rotate the scapula to position the glenoid cavity superiority to allow complete abduction or elevation of the limb

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102
Q

Does the trapezius also help raise the arm above the horizontal

A

Yup

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103
Q

The long thoracic nerve is protected when that areas are down. What about when they are up like in a knife fight

A

It courses on the superficial aspect of the serratus anterior, which is supplies so vulnerable

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104
Q

What surgery is the long thoracic nerve vulnerable in

A

Mastectomy

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105
Q

Near the inferior angle of the scapula is a small triangulargap in the musculature. What is it called

A

Triangle of auscultation

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106
Q

What are the borders of the triangle of auscultation

A

Superior border of the latissimus dorsi, medial border of scapula, and inferolateral border of trapezius

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107
Q

What can we use the triangle of auscultation for

A

Examine posterior segments of the lungs with a stethoscope in a heavily muscled individual

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108
Q

How can we enlarge the triangle of auscultation

A

Scapulae drawn anteriorly by folding the arms across the chest and the trunk is flexed the triangle enlarges

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109
Q

Clinical manifestation of spinal accessory nerve palsy

A

Dropped shoulder with a marked ipsilateral weakness when shoulders are elevated(shrugged) against resistance

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110
Q

How injure spinal accessory nerve

A

Traction injury such as whiplash, tumor, or cervical lymph node biopsy or surgical procedure at the posterior triangle

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111
Q

Surgery in the inferior part of the axilla puts the ___ nerve (c_-c_) sullying the latissimus dorsi at risk of injury

A

Thoracodorsal nerve (c6-c8)

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112
Q

Describe the path of the thoracodorsal nerve

A

Passes inferiorly along the posterior wall of the axilla and enters the medial surface of the latissimus dorsi close to where it becomes tendinitis

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113
Q

What other surgeries put thoracodorsal nerve at risk

A

Mastectomy

Scapular lymph node surgery by its terminal part lies anterior or them and the subscapular artery

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114
Q

What do the latissimus dorsi and the inferior part of the pectoralis major form

A

Anteroposterior muscular sling between the trunk and arm’ however the latissimus dorsi forms the more powerful part of the sling

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115
Q

Latissimus dorsi paralysis

A

Unable to raise the trunk with the upper limbs , like climbing
Can’t use an axillary crutch by the shoulder is pushed superiority by it
BC these activities require active depression of the scapula
Passive depression from gravity is sufficient for most other activities

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116
Q

Injury to the ___ __ nerve, the nerve to the rhomboid and elevator scapulae muscles, affects the actions of these muscles

A

Rhomboid and elevator scapulae

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117
Q

If the rhomboids on one side are paralyzed the scapula on the affected side is located farther from the midline than the __ side

A

Normal

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118
Q

The deltoid and there’s minor atrophy when the ___ nerve (c_-C-) is severely damaged

A

Axillary c5-c6

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119
Q

Where is the axillary nerve and how is it damaged

A

It passes inferior to the numeral head and winds around the surgical neck of the humerus ,
Sooo injured during fracture of this part of the humerus
Or anterior dislocation of the glenohumeral joint and by compression from the use of incorrect crutches

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120
Q

As the deltoid atrophied, the rounded contour ____ compared to the uninsured side

A

Flattens
Also has a slight hollow inferior to the acromion
Loss of sensation may occur over lateral side of proximal part of arm

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121
Q

Why when deltoid atrophied from axillary nerve injury do we get loss of sensation over lateral side of the proximal part of the arm

A

Supplies by superior lateral cutaneous nerve of arm , the cutaneous branch of the axillary nerve

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122
Q

Why must we need to know the location of axillary nerve

A

Runs transversely under cover of the deltoid at the level of the surgical neck of the humerus
COMMON SITE OF IM INJECTION OF DRUGS

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123
Q

Why may a direct blow or indirect injury of the shoulder of a child or adolescent produce a fracture-dislocation of the proximal numeral epiphysis

A

Bc the joint capsule of the glenohumeral joint, reinforced by the rotator cuff is stronger than the epiphysial plate

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124
Q

In severe fractures of the proximal numeral epiphysis, the shaft of the humerus is markedly displaced. Is the numeral head?

A

Nah, the numeral head retains its normal relationship with the glenoid cavity of the scapula

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125
Q

Injury or disease may damage the muscular endings rotator cuff, producing what

A

Instability of the glenohumeral joint

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126
Q

With trauma, what is the most commonly ruptured tendon of the rotator cuff

A

Supraspinatus

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127
Q

Degenerative tendinitis of the rotator cuff

A

Common

Old people

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128
Q

Subacromial bursa

A

Look up

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129
Q

Brachial plexus

A

Draw it out

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130
Q

Dorsal scapular nerve

A

Posterior aspect of anterior Ramos of c5 with a frequent contribution from c4
Pierces middle scalene and descends deep to lavatory scapulae and rhomboids
Innervates rhomboids and occasionally elevator scapulae

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131
Q

Long thoracic nerve

A

Posterior aspect of anterior rami of C5, 6, 7,
Passes through cervico-axillary canal , descending posterior to c8 and t1 roots of plexus. Runs inferiorly on superficial surface of serratus anterior
Innervates serratus anterior

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132
Q

Suprascapular nerve

A

Superior trunk , receiving fibers from c5, c6, and often c4
Passes laterally across lateral cervical region (posterior triangle of neck) superior to brachial plexus then through scapular notch inferior to superior transverse scapular ligament
Innervates supraspinatus and infraspinatus muscles and glenohumeral joint

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133
Q

Subclavian nerve

A

Superior trunk, receiving fibers from c5, c6, and often c4
Descends posterior to clavicle and anterior to brachial plexus and subclavian artery; often giving an accessory root to the phrenic nerve
Innervates subclavius and sternoclavicular joint (accessory phrenic rooot innervates diaphragm)

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134
Q

Lateral pectoral nerve

A

Side branch of lateral cord, receiving fibers from c5, 6, 7 ,
Pierces costocoracoid membrane to reach deep surface of pectoral muscles; a communicating branch to the medial pectoral nerve passes anterior to axillary artery and vein
Innervates pectoralis major, but some lateral. Pectoral nerve fibers pass to pectoralis minor via branch to medial pectoral nerve

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135
Q

Musculocutaneous nerve

A

Terminal branch of lateral cord, receiving fibers from c5-c7
Exits axilla by piercing coracobrachialis; descends between biceps brachial and brachialis and supplying both; continues as lateral cutaneous nerve of forearm
Innervates muscles of anterior compartment of arm (coracobrachialis, biceps brachial and brachialis) and skin of lateral aspect of forearm

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136
Q

Median nerve

A

Lateral root of median nerve is a terminal branch of lateral cord (c6, 7) medial root of. Medial nerve is a terminal branch of medial cord (c8, t1)
Lateral and medial roots merge to form median nerve lateral to axillary artery; descends through arm adjacent to brachial artery with nerve gradually crossing anterior to artery to lie medial to artery in cubical fossa
Innervates muscles anterior forearm compartment (except for flexor Capri ulnar is and ulnar half of flexor digitorum profundus) five intrinsic muscles in the near half of palmar skin

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137
Q

Medial pectoral

A

Side branches of medial cord receiving fibers from c8-t1
Passes between axillary artery and vein then pierces pectoralis minor and enters deep surfaces of pectoralis major IT LIES LATERAL TO LATERAL PECTORAL NERVE
Innervates pectoralis minor and sternocostsal part of pec major

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138
Q

Medial cutaneous nerve of arm

A

Side branches of medial cord, receiving fibers from c8 and t1
Smallest nerve of plexus; rubs along medial side of axillary and brachial begins; communicates with intercostobrachial nerve
Innervates skin of medial side of arm as far distal as medial epicondyle of humerus and ole Ramon of ulna

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139
Q

Medial cutaneous nerve of forearm

A

Side branches of medial cord receiving fibers from c8-t1
Initially runs with ulnar nerve (with which it may be confused) but pierces deep fascia with basilic vein and enters subcutaneous tissue, dividing into anterior and posterior branches
Skin of medial side of forearm as far distal as wrist

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140
Q

Ulnar nerve

A

Larger terminal branch of medial cord receiving fibers from c8, t1, and often c7
Descends medial arm;passes posterior to medial epicondyle of humerus. Then descends ulnar aspect of forearm to hand
Innervates flexor carps ulnaris and ulnar half of flexor digitorum profundus, most intrinsic muscles of the hand, and skin of hand medial to axial line of digit 4

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141
Q

Upper subscapular nerve

A

Side branch of posterior cord receiving fibers from c5
Passes posteriorly entering subscapular is directly
Innervates superior portion of subscapular is

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142
Q

Lower subscapular nerve

A

Side branch of posterior cord, receiving fibers from c6
Passes inferolaterally, deep to subscapular artery and vein
Innervates inferior portion of subscapular is and there’s major

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143
Q

Thoracodorsal nerve

A

Side branch of posterior cord, receiving fibers from c6, 7, 8,
Arises between upper and lower subscapular nerves and runs inferolaterally along posterior axillary wall to apical part of latissimus dorsi
Innervates latissimus dorsi

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144
Q

Axillary nerve

A

Terminal branch of posterior cord, receiving fibers from c5 and c6
Exits axillary fossa posteriorly, passing through quadrangular space with posterior circumflex numeral artery; gives rise to superior lateral brachial cutaneous nerve; then winds around surgical neck of humerus deep to deltoid
Innervates glenohumeral joint, there’s minor and deltoid muscles, and skin or superolateral arm (over inferior deltoid)

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145
Q

Radial nerve

A

Larger terminal branch of posterior cord (largest branch of plexus) receiving fibers from c5-t1
Exits axillary fossa posterior to axillary artery;passes posterior to humerus in radial groove with deep brachial artery, between lateral and medial heads of triceps;perforated lateral intermuscular septum , enters cubical fossa, dividing into superficial (cutaneous) and deep (motor) radial nerves
Innervates all muscles of posterior compartments of arm and forearm, skin of posterior and inferolateral arm, posterior forearm, and dorsi of hand lateral to axial line of digit 4

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146
Q

Many arterial anastomoses occur around the ____. What vessels join here

A

Scapula

Dorsal scapular, suprascapular(via circumflex scapular), and subscapular

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147
Q

The importance of the ___ ___ made possible by these anastomoses becomes apparent when ligation of a lacerated subclavian or axillary artery is necessary

A

Collateral circulation

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148
Q

Why may the axillary artery need be ligated

A

Between the 1st rib and subscapular artery

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149
Q

Can the axillary artery be affected by atherosclerosis

A

Yaaaa vascular stenosis

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150
Q

What happens with compromise of blood flow through axillary artery

A

Reversal of flow in subscapular artery enables blood to reach the third part of the axillary artery

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151
Q

The subscapular artery receives blood through several anastomoses with what arteries

A

Suprascapular artery
Dorsal scapular artery
Intercostal arteries

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152
Q

Slow occlusion of axillary artery

A

Enables sufficient collateral circulation to develop, preventing ischemia

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153
Q

Sudden axillary artery occlusion

A

Does not allow sufficient time for adequate collateral circulation to develop…inadequate supply of blood to the arm, forearm, and hand

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154
Q

White potential collateral pathways (periarticular anastomses) exist around the shoulder joint proximally and the elbow joint distally, surgical ligation of axillary artery between the origins of the subscapular artery and profunda brachii

A

Cut off blood supply to the arm bc collateral circulation is inadequate

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155
Q

Where can you palpate the axillary artery

A

Inferior part of the lateral wall of the axilla

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156
Q

What can you do if there is profuse bleeding from stab or bullet wound around axilla

A

Compress the third part of the axillary artery against the humerus or its origin (as subclavian artery crosses first rib)
By exerting downward pressure on the angle between the clavicle and the inferior attachment of the sternocleidomastoid muscle

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157
Q

Aneurysm of the axillary artery

A

Enlargement of the first part of the axillary artery

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158
Q

What happens if there is aneurysm of axillary

A

Compress the trunks of the brachial plexus causing pain and anesthesia in the areas of skin supplied by effected nerves

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159
Q

What populations get axillary aneurysms

A

Baseball pitchers, football quarterbacks

Bc of rap is and forceful arm movements

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160
Q

Why do wounds of the axilla often involve the axillary vein

A

Large size and exposed position

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161
Q

When the arm is full ____ the axillary vein overlaps the axillary artery anterior

A

Abducted

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162
Q

Why is a surgical or traumatic wound in the proximal part of the axillary vein particularly dangerous

A

Profuse bleeding and risk of air entering it and producing an air emboli

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163
Q

What is subclavian vein puncture

A

Catheter is placed into the subclavian vein

Common clinical procedure

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164
Q

When does the axillary vein become the subclavian vein

A

When the first rib is crossed

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165
Q

How does the needle go in subclavian vein puncture

A

Advanced medially to enter the subclavian vein as it crosses the 1st rib —-th terminal axillary vein is actually what’s punctured—-but the needle tip proceeds into subclavian immediately

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166
Q

The axillary artery lies __ and ___ to the axillary artery and parts of the brachial plexus that begin to surround the artery at this point

A

Anterior inferior

WATCH WHEN DOING A SUBCLAVIAN VEIN PUNCTURE

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167
Q

An infection in the upper limb can cause the axillary nodes to enlarge and become tender and inflamed, a condition called _____

A

Lymphangitis

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168
Q

The ___ group of nodes is usually the first to be involved

A

Humeral

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169
Q

Clinical characterization of lymphangitis

A

Warm red tender streaks in skin of the limb

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170
Q

What else produces enlargement of axillary nodes besides infection of upper limb

A

Infections of pectoral region and breast including superior part of the abdomen

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171
Q

What may happen to axillary nodes in metastatic cancer (apical nodes)

A

Adhere to the axillary vein requiring excision of vessel

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172
Q

Also enlargement of the apical nodes may obstruct the ___ vein superior to the pectoralis minor

A

Cephalic

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173
Q

What nodes are important for staying of breast cancer

A

Axillary

174
Q

Removing or radiation of axillary lymph nodes

A

Lymphatic drainage of upper limb impeded get lymphededma, swelling as a result of accumulated lymph , especially in the subcutaneous tissue

175
Q

What two nerves are at risk during axillary node resection

A

Long thoracic nerve to serrated anterior (identified and maintained against thoracic wall—cut get winged scapula)

Thoracodorsal nerve to altissimo Dorsi(medial rotation and adduction of arm are weakened, but no deformity) sometimes this nerve is sacrificed to remove malignant cells

176
Q

Are variations in formation of the brachial plexus common

A

Yes

177
Q

In addition to the 5 anterior rami (c5-c8 and t1) that form the roots of the brachial plexus, small contributions may be made by the anterior rami of _ or _

A

C4

T2

178
Q

When the superiormost root (anterior ramus) of the plexus if c4 and the inferoirmost root is C8, it is a ___ brachial plexus

A

Prefixed

179
Q

When the superior root is C6 and inferior root is t2, it is a ___ brachial plexus

A

Post fixed

180
Q

Problem with post fixed plexus

A

Inferior trunk of the plexus may be compressed by the 1st rib, producing neuromuscular symptoms of the upper limb

181
Q

Another common variation of brachial plexus

A

Lateral or medial cords may receive fibers from anterior rami inferior or superior to the usual levels respectively

182
Q

The median nerve may have _ roots, but the components of the nerve are the same, arise from he same place, and reach the same destination

A

2

183
Q

What does injury to the brachial plexus cause

A

Affect movements and cutaneous sensation in upper limb
Paralysis and anesthesia
Depends on what part is injured

184
Q

What may cause brachial plexus injury

A

Disease, stretching, and wounds in the lateral cervical region (posterior triangle) of neck or in the axilla

185
Q

What causes Injuries to superior part of brachial plexus c5 and C6

A

From excessive increase in angle between neck and shoulder (throuwn from motorcycle, or a horse and lands on shoulder in way that separates the neck and shoulder)
Shoulder often hits something while head continues to move
Stretches of ruptures superior parts of the brachial plexus or avulsed the roots of the plexus from the spinal cord

186
Q

Symptoms of injury to superior brachial plexus c5 C6

A

Waiters tip position
Limb hangs to side in medial rotation.

Addicted shoulder, medially rotated arm and extended elbow
Lateral aspect of forearm also loses sensation

187
Q

How may a neonate get an upper brachial plexus injury

A

Excessive stretching of neck during delivery

188
Q

What’s another name for injuries to superior parts of brachial plexus

A

Erb-Duchenne palsy , paralysis of muscles of shoulder and arm supplied by c5 C6 , deltoids, biceps, and brachialis

189
Q

Chronic micro trauma to the superior trunk of the brachial plexus from carrying a heavy backpack can produce motor and sensory deficits int he distribution of the ___ and ___ nerves

A

Musculocutaneous and radial

Hikers can get muscle spasms and severe disability if carry heavy backpack long time

190
Q

Acute brachial plexus neuritis (neuropathy)

A

Neurological disorder of unknown cause that is characterized by the sudden onset of severe pain, usually around the shoulder. Typically pain begins at night and is followed by muscle weakness and sometimes muscular atrophy (neurological amytrophy)

191
Q

Inflammation of the brachial plexus (brachial neuritis) is often preceded by some event, like what

A

URI, vaccination, nonspecific trauma

192
Q

The nerve fibers involved are usually derived from the superior trunk of the brachial plexus in what

A

Brachial neuritis

193
Q

Why get compression of cords of the brachial plexus

A

Prolonged hyperabduction of the arm during performance of manual tasks over the head, such as painting a ceiling

194
Q

In compression of cords, what are the cords compressed between

A

Coracoid process of scapula and pectoralis minor tendon

195
Q

Symptoms of compression of cord of brachial plexus

A

Pain radiating down the arm, numbness, paresthesia(tingling), erythema (redness), and weakness of hands.

196
Q

What does compression of the axillary artery and vein cause

A

Ischemia of the upper limb and distension os the superficial veins

197
Q

Hyperabduction syndrome

A

Compression axillary vessels and nerves

Ischemia of upper limb and distension of the superficial veins

198
Q

Injuries to inferior parts of brachial plexus are called what

A

Klumpke paralysis

Less common

199
Q

How get inferior brachial plexus injuries

A

Upper limb is suddenly pulled superiorly-for examplewhen a person grabs something superiorly like grabbing tree branch

200
Q

How may baby get klumpke paralysis

A

Pull arms during birth

201
Q

What does inferior brachial plexus injury cause

A

C8-T1 injury and may avulsed the roots of the spinal nerves front he spinal cord. The short muscles of the hand are affected and a CLAW HAND results

202
Q

Brachial plexus block

A

Injection of anesthetic solution into or immediately surrounding the axillary sheath interrupts conduction of impulses of peripheral nerves and produces anesthesia of the structures supplied by the branches of the cords of the plexus

203
Q

What is blocked with a brachial plexus block

A

Sensation in all deep structures of the upper limb and the skin distal to the middle of the arm

204
Q

What does tourniquette and brachial plexus block allow surgeons to do

A

Operate on on upper limb without general anesthesia

205
Q

Needle approach for brachial plexus block

A

Supraclavicular and infraclavicular

206
Q

Biceps reflex

A

DTR that is tested for C5 C6
Relaxed limb is passively probated and hammer tapped at base of nail bed
Norma-involuntary contraction of biceps felt as momentarily tensed tendon

207
Q

Diminished biceps reflex

A

C5 C6

Central or peripheral nervous system disease or metabolic disorder (thyroid disease)

208
Q

Biceps tendinitis

A

Microtears of the tendon of the long head of the biceps when the musculotendinous unit is acutely loaded and is associated with degeneration of the tendon, vascular disruption and an inflammatory repair response

209
Q

Describe the tendon of the long head of the biceps

A

Enclosed by a synovial sheath and moves back and forth in the intertubercular sulcus (bicipital groove) of the humerus

210
Q

Wear and tear of the tendon of the long head of the biceps causes what

A

Shoulder pain

211
Q

Tendinosis

A

Degeneration in tendon collagen causing disorganization of the collagen in response to poor vascularization , chronic overuse, or aging; there is no inflammatory response in this case

212
Q

Degeneration, tendinosis, and tendinitis can occur bc of repetitive microtrauma, which is common in throwing sports and use of racquet . A tight, narrow and/or rough intertubercular sulcus may irritate and inflame the tendon, producing tenderness and ________ (__ __)

A

Crepitus (cracking sound)

213
Q

The tendon of the long head of the biceps can be partially or completely dislocated from the ___ ___ in the humerus

A

Intertubercular sulcus

214
Q

What may cause dislocation of the long head of the biceps brachii

A

PAINFUL traumatic separation of the proximal epiphysis of the humerus . Also occurs in older people with history of biceps tendinitis
Usually a sensation of popping or catching is felt during arm rotation

215
Q

Why get rupture of the tendon of the long head of the biceps brachii

A

Wear and tear of an inflamed tendon as it moved back and forth int he intertubercular sulcus of the humerus
>35 yo

216
Q

How does the tendon of the long head of the biceps brachii ruptures

A

Torn from its attachment to the supraglenoid tubercle of the scapula

217
Q

What is rupture of tendon or long head of biceps brachii associated with

A

Snap or pop
Forceful flexion of arm against excessive resistance (weight lifters)
Or more commonly, prolonged tendinitis that weakens it (repetitive overhead movements such as in swimmers and baseball pitchers that tear the weakened tendon in the inttubular sulcus)

218
Q

What is the basis for measuring blood pressure

A

Occlusion, compression and resumption of blood flow in the brachial artery

219
Q

How is blood pressure measured

A 
Wrap cuff(sphygomanometer) around arm, centered over brachial artery 
Cuff inflated to occlude blood flow through brachial artery 
Cuff gradually deflated while ausculatating for sounds of turbulent flow using a stethoscope with its bell placed over the cubical fossa
220
Q

When measuring bp the first instance of sound is what

What is it when sound stops

A

Systolic

Diastolic

221
Q

What do we call stopping bleeding through manual or surgical control of blood

A

Hemostasis

222
Q

Where is the best place to compress brachial artery to control hemorrhage

A

Medial to the humerus near the middle of the arm

223
Q

Why may the brachial artery be clamped distal to the origin of the deep artery of the arm without producing tissue damage . What is the anatomical basis for this procedure.

A

The arterial anastomoses around the elbow provide a functionally and surgically important collateral circulation
Ulnar and radial arteries wills till receive sufficient blood through the anastomoses around the elbow

224
Q

Although collateral pathways confer some protection against gradual temporary and partial occlusion, sudden complete occlusion or laceration of the brachial artery creates a surgical emergency because paralysis of muscles results from what

A

Ischemia of the elbow and forearm within a few hours

225
Q

Muscles and nerves can tolerate up to _ hours if ischemia

A

6

226
Q

What happens after 6 hours

A

Fibrous scar tissue replaces necrotic tissue and causes te involved muscles to shorten permanently producing a flexion deformity called the ischemic compartment syndrome

227
Q

Ischemic compartment syndrome

A

Or volkmann or ischemic contracture
Flexion of fingers and sometimes the wrist results in loss of hand power as a result of irreversible necrosis of the forearm flexor muscles

228
Q

A midhumeral fracture may injure the ___ nerve in the groove in the humeral shaft

A

Radial

229
Q

What happens when injure radial nerve ——-triceps

A

Fracture not likely to paralyze triceps bc of the high origin of the nerves of 2/3 heads

230
Q

What is a Supra-epicondylar fracture

A

Fracture of the distal part of the humerus near the supraepicondylar ridges
Distal bone fragment may be displaced anteriorly or posteriorly

231
Q

Why in a supraepicondylar fracture does the distal bone fragment displace anteriorly or posteriorly

A

Brachialis and triceps tend to pull the distal fragment over the proximal fragment shortening the limb
NOTE any of the nerves or branches of brachial vessels related to the humerus may be injured by a displaced bone fragment

232
Q

Injury to the musculocutaneous nerve in the axilla is uncommon. Why? How would you get it?

A

Protected here

May get from a knife

233
Q

What does a musculocutaneous nerve injury result in

A

Paralysis of coracobrachialis, biceps, and brachialis

234
Q

Why get slightly weak flexion at glenohumeral joint when have musculocutaneous nerve injury

A

Affecting long head of biceps brachial and the coracobrachialis

235
Q

get incredibly weakened flexion of elbow and supination of forearm with musculocutaneous nerve injury , but it is still possible. Why

A

Can still use the brachioradialis and supinator which are supplied by radial nerve

236
Q

Where get loss of sensation with damage to musculocutaneous nerve

A

Lateral surface of forearm supplied by lateral cutaneous nerve of forearm

237
Q

What is the lateral cutaneous nerve of forearm

A

Continuation of musculocutaneous

238
Q

What does injury of the radial nerve superior to the origin of its branches to the triceps brachial result in

A

Paralysis of triceps, brachioradialis, supinator, and extensor muscles of the wrist and fingers
Also loss of skin sensation in areas supplied

239
Q

When the radial nerve is injured in the radial groove the triceps is usually not completely paralyzed. Why

A

Only the medial head is affected

240
Q

What is paralyzed when the radial nerve is damaged in the radial groove

A

Muscles in the posterior compartment of the forearm that are supplied by more distal branches of the nerve

241
Q

Characteristic sign of radial nerve injury

A

Wrist drop
Can’t extend and fingers at MCP joint
Unopposed tonus of flexor muscles and gravity get a flexed wrist

242
Q

When sampling blood from the cubical fossa and there is a common pattern of superficial veins. Which is chosen ?

A

Median cubical vein

243
Q

Describe median cubical vein

A

Directly on the deep fascia, running diagnosable from the cephalon vein of the forearm to the basilic vain of the arm. It crosses the bicipital aponeurosis, which separates it from the underlying brachial artery and median nerve and provides some protection to the latter.

244
Q

The pattern of veins in the cubical fossa vary greatly. In 20% what is the situation

A

A median antebrachial vein (median vein of forearm) divides into a median basilic vein, which joins the basilic vein of the arm, and a median cephalon vein, which joins the cephalon vein of the arm

245
Q

What else may the median cubical vein be used for besides drawing blood

A

Introduction of cardiac catheters to secure blood samples from the great vessels and chambers of the heart. Also coronary angiography

246
Q

Elbow tendinitis

A

Painful musculoskeletal condition that may follow repetitive use of the superficial extensor muscles of the forearm
Pain is felt over the lateral epicondyle and radiates down the posterior surface of the forearm

247
Q

Why do people with elbow tendinitis feel pain when they open a door or lift a glass

A

Repeated forced flexion and extension of the wrist strain the attachment of the common extensor tendon, producing inflammation or the periosteum of the lateral epicondyle (lateral epicondylitis)

248
Q

Which epicondyle do flexors attach to

A

Medial

Golfers

249
Q

Which epicondyle do extensor attach to

A

Lateral

Tennis elbow

250
Q

Mallet or baseball finger

A

Sudden severe tension on a long extensor tendon may values part of its attachment to the phalanx
Get distal interphalangeal joint suddenly being forced into extreme flexion (hyperflexion) when, for example, a baseball is miscaught or a finger is jammed into the base pad

251
Q

What. Does hyperflexion at IP joint cause

A

Aculse the attachment of the tendon to the base of the distal phalanx

252
Q

If you have mallet or baseball finger, what can you NOT do

A

Extend the distal interphalangeal joint

Deformity bears resemblance to a mallet

253
Q

How does one fracture their olecranon

A

Fall on the elbow combined with sudden powerful contraction of the triceps brachii

254
Q

A fractured olecranon is pulled away by the tonic contracture of ___ and the injury is considered an ___ fracture

A

Triceps

Avulson

255
Q

Treatment of olecranon fracture

A

Pinning bc of the pull from triceps

Takes a while and cast worn for long time

256
Q

Synovial cyst of wrist

A

Nontender cystic swelling appears on the hand, most commonly on the dorsi of the wrist
Size of grape

257
Q

What is in a synovial wrist cyst

A

Clear mutinous fluid

258
Q

___ of the wrist makes a synovial cyst on the wrist enlarge

A

Flexion

259
Q

Common site of cyst

A
  • close to or communicate with synovial sheaths on the dorsi of the wrist
  • distal attachment of the ECRB tendon to the base of the 3rd metacarpal
260
Q

A cystic swelling of the common flexor synovial sheath on the anterior aspect of the wrist can enlarge enough to produce compression of the ___ nerve by narrowing the carpal tunnel

A

Median

Carpal tunnel syndrome

261
Q

Carpal tunnel syndrome

A

Pain and parenthesia

In the sensory distribution of the median nerve and clumsiness of finger movements

262
Q

High division of brachial artery

A

Sometimes the brachial artery divides at a more proximal level than usual
The ulnar and radial arteries begin in the superior or middle part of the arm and the median nerve passes between them .
Note the musculocutaneous and median nerves commonly communicate

263
Q

In 3% of people the ulnar artery descends superficial to the flexor muscles. Clinically of concern?

A

Can see pulsation of a superficial ulnar artery
If mistake for a vein and pierce, may cause bleeding
IF CERTAIN DRUGS ARE INJECTED INTO THE ABBERANT ARTERY IT COULD BE FATAL

264
Q

Describe the location of the radial artery where we take pulse

A

Where radial artery lies on the anterior surface of the distal end of the radius , lateral to the tendon of the FCR

265
Q

Why dont use thumb to take pulse

A

Has its own pulse

266
Q

Where else can feel radial pulse

A

Pushing into anatomical snuff box

267
Q

Variations in radial artery

A

May be more proximal
May be a branch of axillary or brachial arteries
Sometimes superficial to the deep fascia instead of deep to it

268
Q

When a superficial vessel is pulsating near the wrist what is is probably

A

Superficial radial artery

269
Q

Concern of superficial radial artery

A

Vulnerable to laceration

270
Q

Median nerve severed in elbow region

A

Lose flexion of the proximal IP joints of the 1st-3rd digits and weakened in the 4th and 5th digits
Flexion of the distal IP joints of the 2nd and 3rd digits is lose
Flexion of distal IP joints of 4th and 5th not affected

271
Q

When median nerve severed below elbow why is the flexion of the distal IP joint of 4th and 5th digits not lost

A

Bc medial part of FDO, which produces these movements is supplied by the ulnar nerve

272
Q

When median nerve is severed below the elbow why is flexion of MCP of digits 2 and 3 affected

A

Bc digital branches of the median nerve supply the 1st and 2nd lumbricals

273
Q

What happens when a person with median nerve injury tries to make a fist

A

2 and 3rd finders remain partially extended (HAND OF BENEDICTION)

274
Q

With median nerve damage below elbow what happens to the air muscle function

A

Lost as in carpal tunnel syndrome

275
Q

What happens when anterior interosseous nerve is injured

A

The air muscles unaffected

Paresis of the flexor digitorum profundus and flexor polices longus

276
Q

Anterior interosseous nerve injury and person tried to make the okay sign (anterior interosseous syndrome )

A

Pinch posture due to absence of flexion of the IP joint of the thumb and distal IP joint of the index finger

277
Q

Pronator syndrome

A

Nerve entrapment syndrome caused by compression of the median nerve near the elbow between the heads of the pronator trees as a result of trauma, muscular hypertrophy, or fibrous bands

278
Q

Clinical presentation of pronator syndrome

A

Pain and tenderness in proximal aspect of the anterior forearm and hypesthesia(decreased sensation) of palmar aspects of the radial three and a half digits and adjacent palm

279
Q

When get symptoms of pronator syndrome

A

Following activities that involve repeated pronation

280
Q

Communications between median and ulnar nerves in forearm

A

Occasionally
Slender nerves
Even with complete lesion of median nerve, some muscles may not be paralyzed
Erroneous conclusion that the median nerve has not been damaged!!!

281
Q

Where does ulnar nerve injury most commonly happen

A

Where nerve passes posterior to the medial epicondyle of the humerus

282
Q

What causes ulnar nerve injury where passes posterior to medial epicondylis

A

Medial part of the elbow hits a hard surface, fracturing the medial epicondyle (funny bone)

283
Q

Lesion of ulnar nerve superior to the medial epicondyle will produce parenthesis where

A

Median part of the dorsi mood of the hand

284
Q

Compression of the ulnar nerve at the elbow (cubical tunnel syndrome)

A

Common

285
Q

Where does ulnar nerve injury usually cause numbness (paresthesia)

A

Medial part of the palm and the medial one and a half fingers

286
Q

Ulnar nerve injury distal part of forearm

A

Enervates most intrinsic hand muscles.
Wrist addiction impaired
When try to flex wrist it is drawn laterally by FCR(median nerve)

287
Q

Why cant make a fist after ulnar nerve injury

A

In absence of opposition, metacaphalangeal joints become hyperextended and can’t flex 4th or 5th digits at the distal IP joints

288
Q

Can a person with ulnar nerve injury extend IP joints when trying to straighten fingers

A

No

289
Q

What do you call a hand with ulnar nerve injury

A

Claw hand

290
Q

Why get claw hand with ulnar nerve injury

A

Atrophy of interosseous muscles of the hand supplied by the ulnar nerve
Unopposed action of the extensor and FDP

291
Q

Cubical tunnel syndrome

A

Ulnar nerve compressed in cubical tunnel(rare) by the tendinitis arch joining the numeral and ulnar heads of attachment of the FCU

292
Q

Signs and symptoms of cubical tunnel syndrome

A

Same as ulnar nerve lesion in ulnar groove on the posterior aspect of medial epicondyle of humerus

293
Q

How is radial nerve most commonly injured

A

In the arm by a fracture of the numeral shaft

294
Q

Primary clinical manifestation of radial nerve injury

A

Wrist drop

295
Q

Injury to the deep branch of the radial nerve happens when

A

Wounds of posterior forearm are deep (penetrating

296
Q

What happens if injure deep branch of the radial nerve

A

Inability to extend thumb and the MP joints of other digits

297
Q

How test integrity of deep branch

A

Ask patient to extend MP joints while examiner provides resistance
Intact-long extensor tendons should appear prominently on dorsi of hand
Not intact-occurs at IP joints supplied by other nerves dont see extensor tendons

298
Q

Loss of sensation with deep radial nerve injury

A

Nope

Entirely muscular and articulate

299
Q

Loss of sensation with superficial branch of radial nerve

A

Minimal
Coin shaped area of anesthesia distal to the bases of the 1st and 2nd metacarpals
Not a lot bc overlap of cutaneous nerves!

300
Q

Dupuytren contracture

A

Disease of the palmar fascia resulting in progressive shortening , thickening, and fibrosis of the palmar fascia and aponeurosis

301
Q

What does fibrous degeneration of the longitudinal bands of the palmar aponeurosis on the medial side of the hand do

A

Pulls the 4th and 5th fingers into partial flexion at the MCP and proximal IP joints

302
Q

Population that gets dupuytren contracture

A

Men over 50

Bilateral

303
Q

Presentation of dupuytren contracture

A

Painless modular thickening of the palmar aponeurosis that adhere to skin
Progressive contracture of the longitudinal bands produce raised ridges in the palmar skin that extend from the proximal part of the hand to the base the the 4th and 5th fingers

304
Q

Treat dupuytren contracture

A

Surgical excision of all fibrotic parts of the palmar fascia to free the fingers

305
Q

In hand infections, where do swellings not he hand appear and why

A

Dorsum

Palmar surface is thick

306
Q

Why are potential fascia spaces on the palm of the hand clinically important for hand infections

A

Determine extent and direction of the spread of pus formed by these infections

307
Q

Depending on site of infection where will pus accumulate in hand infection

A

The air, hypothecate, midpalmar, or adductor compartments

308
Q

Where can an untreated hand infection spread

A

Proximal from midpalmar space through the carpal tunnel into the forearm, anterior to the pronator quadratics and its fascia

309
Q

Tenosynovitis

A

Infection of the digital synovial sheaths

310
Q

What may cause tenosynovitis

A

Puncture of finger with a rusty nail

311
Q

Clinical presentation of tenosynovitis

A

Digit swells and movement painful

312
Q

Why is infection in tenosynovitis usually confined to the infected finger

A

Tendons of 2, 3, 4, nearly always have separate synovial sheaths

313
Q

Untreated tenosynovitis

A

Proximal ends of sheaths may rupture allowing infection. To spread to midpalmar space

314
Q

How could tenosynovitis in little finger spread to space between the pronator quadratics and overlying flexor tendon (parona space)

A

Synovial sheath of little finger is continuous with the common flexor sheath, tenosynovitis may spread to the common flexor sheath and through the palm and carpal tunnel to anterior forearm

315
Q

Tenosynovitis of thumb may spread where and how

A

Via continuous synovial sheath to the FPL (radial bursa)

316
Q

What does spread of finger infection depend on

A

Variations in their connections with the common flexor sheath

317
Q

Where are the APL and EPB

A

Same tendinitis sheath on the dorsum of the wrist

318
Q

What does excessive friction of the APL and EPB on their common sheath result in

A

QUERVAIN TENOVAGINITIS STENOSANS

Fibrous thickening of the sheath and stenosis of the osseofibrous tunnel

319
Q

What causes QUERVAIN tenovaginiitis stenosans -excessive friction of APL and EPB on their common sheath

A

Repetitive forceful use of hands during gripping and wringing (squeezing of clothes)

320
Q

Symptoms of QUERVAIN tenovaginitis stenosans

A

Pain in the wrist that radiates proximal to the forearm and dismally toward the thumb
Local tenderness if felt over the common flexor sheath on the lateral side of the wrist

321
Q

What do you get from repetitive forceful use of fingers

A

Thickening of a fibrous digital sheath on the palmar aspect of the digit produces stenosis of the osseofibrous tunnel

322
Q

What happens FDS and FDP enlarge proximal to the tunnel ———digital tenovaginitis stenosis (trigger finger or snapping finger)

A

Unable to extend finger
When finger extend passively a snap is audible
Flexion produces another snap as the thickened tendon moves

323
Q

What is a big concern when palmar arches are lacerated

A

BLEEDING

324
Q

When palmar arches are lacerated why may it be insufficient to only legate one forearm artery

A

Bc they have numerous communications in the forearm and hand and thus bleed from both ends

325
Q

How could we create a bloodless surgical operating field for treating complicated hand injuries

A

Compress the brachial artery and its branches proximal to elbow with a tourniquet
This prevents blood from reaching the ulnar and radial arteries through the anastomoses around the elbow

326
Q

Intermittent bilateral attacks of ischemia of the digitis

A

RAYNAUD-Cyanosis and paresthesia and pain brought on by cold or emotional stimuli

327
Q

What causes raynaud

A

Anatomical abnormality or disease

328
Q

How treat ischemia from raynaud syndrome

A

Cervicodorsal presympatheic sympathectomy (excision of a segment of a sympathetic nerve) to dilate the digital arteries
Arteries of upper limb are supplied by sympathetic nerves
Postsynaptic fibers from the sympathetic ganglia enter nerves that form the brachial plexus and are distributed to the digital arteries through branches arising from he plexus

329
Q

What are the two common places of median nerve lesion

A

Forearm and wrist

Most common is where nerve passes through carpal tunnel

330
Q

What causes carpal tunnel

A

Any lesion that reduces the size of the carpal tunnel or increases size of none structures or their covering that pass through it

331
Q

What may cause swelling of tendons or their synovial sheaths in the carpal tunnel

A

Fluid retention, infection, excessive exercise of fingers

332
Q

The median nerve has 2 terminal sensory branches tat supply skin of the hand. What symptoms of median nerve lesions does this relate to

A

Paresthesia(tingling), hypoesthesia(diminished sensation), or anesthesia(no sensation) in the lateral three and a half digits

333
Q

Tell me about the palmar cutaneous branch of the median nerve and how does this effect carpal tunnel

A

Arises proximal to and does not pass through the carpal tunnel
Sensation in the central palm remains unaffected

334
Q

Tell me about the terminal motor branches of the median nerve

A

Through the carpal tunnel
Recurrent branch-three thenar muscles
Branches of lumbricals 1 and 2

335
Q

If pressure of carpal tunnel isn’t alleviated, there will be what

A

Progressive loss of coordination and strength of the thumb (weakness of APB and opponens policis)

336
Q

People with carpal tunnel are unable to __ their thumb

A

Oppose

337
Q

What do people with carpal tunnel have trouble doing

A

Buttoning shirt, gripping things like a brush

338
Q

As carpal tunnel progresses…

A

Sensory changes radiate into forearm and axilla

339
Q

Treat carpal tunnel with carpal tunnel release

A

Surgical division of the flexor retinaculum
Incision made toward the medial side of the wrist and flexor retinaculum to avoid possible injury to the recurrent branch of the median nerve

340
Q

What nerve is often damaged by laceration of the wrist

A

Median nerve bc pretty close to the surface

341
Q

Symptoms of median nerve trauma(slash wrist)

A

Paralysis of the muscles of the thenar eminence (except the adductor policies and deep head of the flexor policies brevis) and the first to lumbricals

342
Q

With median nerve injury __ of the thumb is not possible

A

Opposition

343
Q

With trauma to the median nerve fine control movement of the _ and _ digits are impaired

A

2 3

344
Q

With median nerve injury sensation is lost where

A

Over the thumb and adjacent two and a half fingers

345
Q

If the median nerve is severed in the forearm or wrist, the thumb cannot be opposed. However, what might mimic opposition although ineffective

A

APL and adductor polices (supplied by the posterior interosseous and ulnar nerves, respectively)

346
Q

Symptoms of median nerve injury resulting from perforating wounds in the elbow region

A

Loss of flexion of the proximal and distal interphalangeal joints and 2 and 3 digits
Also ability to flex the MCP joints is affected bc digital branches of the median nerve supply the 1st and 2nd lumbricals

347
Q

Simian hand

A

Thumb movements are limited to flexion and extension of the thumb in the plane of the palm

348
Q

What causes simian hand

A

Inability to oppose and limited abduction of the thumb

349
Q

The __- ___ of the median nerve to the thenar muscles les subcutaneously and may be severed by relatively minor lacerations.

A

Recurrent branch

350
Q

Symptoms of severance of recurrent branch of median nerve

A

Paralyzed the thenar muscles, and the thumb loses much of its usefulness

351
Q

Ulnar canal syndrome

A

Compression of the ulnar nerve may occur at the wrist where it passes between the pisiform and the hook of hamate

352
Q

The depression between the hook of hamate and pisiform turn into what

A

Pisohamate ligament into an osseofibrous tunnel, the ulnar canal (guyon tunnel)

353
Q

Ulnar canal symptoms (guyon tunnel syndrome )

A

Hypoesthesia (reduced sense of touch or sensation) in the medial one and a half fingers and weakness of the intrinsic muscles of the hand

354
Q

Contradiction to proximal ulnar nerve injury, In ulnar canal syndrome their ability to ___ is unaffected, and there is no radial deviation of the hand

A

Flex

355
Q

In ulnar canal syndrome there is clawing of the _ and _ fingers (hyperextension at MCP and flexion at PIP)

A

4 5

356
Q

Handle bar neuropathy

A

People ride long on bike with hands extended puts pressure on their hamate which compresses the ulnar nerve

357
Q

Symptoms of handle bar neuropathy

A

Sensory loss on the medial side of the hand and weakness of the intrinsic hand muscles

358
Q

Although radial nerve supplied no muscles int he hand, radial nerve injury in the arm can produce serious hand disability

A

Inability to extend the wrist resulting from paralysis of extensor muscles of the forearm, all of which are innervates by radial nerve

359
Q

Clinical picture of radial nerve injury in arm and hand disability

A

Hand flexed at the wrist and lies flaccid, (wrist drop)
Fingers of the relaxed hand also remain in the flexed position at the MCP joints
Loss of ability to attend wrist affects the length tension relationship ….reduce grip strength and functional lifting

360
Q

IP joints in radial nerve injury in arm and hand disability

A

Can be extended weakly through the action of the intact lumbricals and interossei which are supplied by the median and ulnar nerves.

361
Q

Even in serious radial nerve injuries anesthesia cutaneously is minimal due to overlap. What area may lose sensation

A

Small area on the lateral part of the dorsum of hand

362
Q

Dermatoglyphics

A

Study ridge patterns on palm of hand

363
Q

Dermatoglyohics trisomy 21

A

Highly characteristic also have simian crease

364
Q

Can people have simian crease without downs

A

Yea 1% do

365
Q

For examining wounds and doing surgery KNOW where superficial and deep palmar arches are…. where is the superficial palmar arches

A

Same level as the distal end of the common flexor sheath

366
Q

Incisions or wounds along the medial surface of the thenar eminence may injure what

A

Recurrent branch of median nerve to the thenar muscles

367
Q

Skiers thumb

A

Rupture or chronic laxity of the collateral ligament if the 1st MP joint

368
Q

How get skiers thumb

A

Hyperabduction of the MP joint of the thumb which occurs when the thumb is held by the ski pole while the rest of the hand hits the ground or enters the snow

369
Q

Severe skier thumb

A

Head of metacarpal has an avulsion fracture

370
Q

Bull riders thumb

A

Sprain of the radial collateral ligament and an avulsion fracture of the lateral part of the proximal phalanx of the thumb,,,,common if ride mechanical bull

371
Q

How get anterior dislocation of the lunate (uncommon )

A

Fall on the dorsiflexed wrist

Lunate pushed out of its place in the floor of the carpal tunnel toward the palmar surface of the wrist

372
Q

A displaced lunate may compress the median nerve and lead to ___ __ __

A

Carpal tunnel syndrome

373
Q

The lunate has a poor blood supple. What may happen in dislocate

A

A vascular necrosis

374
Q

How treat avascular necrosis of lunate

A

May have to remove

375
Q

Degenerative joint disease of the wrist, surgical fusion of carpals (arthrodesis) may be necessary to televise the severe pain

A

Yup

376
Q

Fracture-separation of the distal radial epiphysis

A

Kids

Bc frequent falls in which forces are transmitted from the hand to the radius

377
Q

Radiograph of fracture-separation of the distal radial epiphysis

A

Dorsal displacement of the distal radial epiphysis is obvious

378
Q

Prognosis of fracture-separation of the distal radial epiphysis

A

Good if epiphysis is placed in its normal position during reduction

379
Q

Bursitis of elbow

A

Subcutaneous olecranon bursa is exposed to injury during falls on the elbow and infection from abrasions of skin covering the olecranon

380
Q

How may you get bursitis of the elbow

A

Repeated excessive pressure and friction as occurs in wrestling causes bursa to be inflamed , producing a friction subcutaneous olecranon bursitis

381
Q

What is subcutaneous olecranon bursitis also known as

A

Miners elbow

Dart throwers elbow

382
Q

Subtendininous olecranon bursitis

A

Less common
From excessive friction between the triceps tendon and olecranon, resulting from repeated flexion extension of the forearm, as occurs during certain assembly line jobs

383
Q

With subtendinous olecranon bursitis why is pain most severe with flexion

A

Pressure exerted on the inflamed subtendinous olecranon bursa by the triceps tendon

384
Q

Bicipiitoradial bursitis

A

Pain when forearm is probated bc this compresses the bicipitoradial bursa against the anterior half of the tuberosity of the radiusss

385
Q

Adhesive capsular is of the glenohumeral joint

A

Adhesive fibrosis and scarring between the inflamed joint capsule of the glenohumeral joint, rotator cuff, subacromial bursa and deltoid usually cause adhesive capsulitis

386
Q

What does someone with adhesive capsulitis of the glenohumeral joint have trouble doing

A

Abducting the arm and can obtain apparent abduction of up to 45 degrees by elevating and rotating the scapula

387
Q

Bc of lack of movement in adhesive capsulitis of the thumb joint stain is placed not he _ joint which may be painful during other movements

A

Ac

388
Q

What injuries may initiate adhesive capsulitis of glenohumeral joint

A

GH dislocation
Calcification supraspinatus tendinitis
Partial tearing of the rotator cuff
Bicipital tendinitis

389
Q

Avulsion of medial epicondyle

A

Forced separation in kids that fall with severe abduction of extended elbow
Traction on ulnar collateral ligament pulls medial epicondyle distally

390
Q

Why does avulsion of medial epicondyle happen in kids

A

Epiphysis for medial epicondyle may not fuse with distal end of humerus until 20

391
Q

Traction injury of the ulnar nerve is a frequent complication of abduction avulsion of medial epicondyle. Why

A

Stretching of ulnar nerve is that is passes posterior to the medial epicondyle before entering the forearm

392
Q

Ulnar collateral ligament reconstruction when there is rupture, tearing and stretching with athletic throwing

A

Tommy john procedure
Autologous transplant of a long tendon from the contralateral forearm or leg and is passed through holes drilled in medial epicondyle of humerus and lateral aspect of the coronoid process of the ulna

393
Q

Dislocation of elbow joint is usually ____

A

Posterior

394
Q

What causes posterior dislocation of the elbow joint

A

Children fall on hands with elbows flexed

Or hyperextension or blow that drives the ulna posterior or posterolateral

395
Q

In posterior dislocation of the elbow the distal end of the humerus is driven trough the weak ___ part of the fibrous layer of the joint capsule as the radius and ulna dislocate ___

A

Anterior

Posterior

396
Q

What is associated with dislocation of the elbow joint

A

Ulnar collateral ligament is torn
Fracture of head of radius, coronoid, process, or olecronon process of ulna
Injury to ulnar nerve -numb little finger and weak flexion and adduction of wrist

397
Q

Subluxation and dislocation of the radial head /nursemaids elbow

A

In preschool kids(girls)
Suddenly jerked up when swung
Tears the distal attachment of the anular ligament where it is loosely attached to the neck of the radius
Radial head moves distally, partially out of the socket formed by the anular ligament
Proximal part of the torn ligament may become trapped between the head of the radius and the capitulum of the humerus

398
Q

How does kid present with nurse aids elbow/subluxation and dislocation of the radial head

A

May refuse to use the limb

Hold the limb with elbow flexed and probated

399
Q

Source of pain in nursemaids elbow

A

Pinched anular ligament

400
Q

Treatment of nursemaids elbow

A

Supination do the forearm while elbow is flexed

The tear heals when limb is placed in sling for 2 weeks

401
Q

Tearing of the fibrocartilaginous glenoid labrum

A

Throw baseball or football of have shoulder instability and subluxation
Sudden contraction of the biceps or forceful subluxation of the humeral head over the glenoid labrum

402
Q

Symptom of glenoid labrum tear(usually the anterosuperior part)

A

Pain while throwing

Sense of popping or snap ping during abduction and lateral rotation of the arm

403
Q

Why is the glenohumeral joint frequently dislocated

A

Freedom of movement in instability

404
Q

Most glenohumeral joint disclocationg are in the ___ direction. Why

A

Downward (but are described as anterior or posterior dislocations indicating whether humeral head is descended anterior or posterior to the infraglenoid tubercle and long head of triceps). Bc coraco-acromial arch and support of rotator cuff are effective at preventing upward dislocation

405
Q

What causes anterior dislocation of the glenohumeral joint

A

Young adults or athletes by excessive extension and lateral rotation of the humerus
Head of humerus driven anterior inferiorly and fibrous layer of the joint capsule and glenoid labrum may be stripped front he anterior aspect of the glenoid cavity in the process

406
Q

What does hard blow to humerus when the gh joint is fully abducted

A

Tilts head of the humerus inferiorly onto the inferior weak part of joint capsule. This may tear the capsule and dislocate the shoulder so that the humeral head comes to lie inferior to the glenoid cavity and anterior to the infraglenoid tubercle. The strong flexor and adductor muscles of the glenohumeral joint usually subsequently pull the humeral head anterosuperiorly into a subcoracoid position.

407
Q

How does patient look with dislocation of glenoid humeral joint

A

Supports arm and cant use it

408
Q

Inferior dislocation of the gh joint often occurs after avulsion fracture of the what

A

Greater tubercle of the humerus , owing to absence of the upward and medial pull produced by muscles attaching to the tubercle

409
Q

The _ nerve may be injured when the gh joint dislocates because of its close relation to the inferior part of the joint capsule

A

Axillary

410
Q

Why is dislocation of the SC joint rare

A

Strength, which depends on its ligaments, its disc, and the way forces are generally transmitted along the clavicle

411
Q

Most dislocations of SC joint

A

Less then 25 from fractures through epiphyseal plate because the epiphysis at the sternal end of the clavicle does not close until 23-25

412
Q

Ankylosis of SC joint

A

Stiffening or fixation
Sometimes necessary surgicallysection of the center of the clavicle is removed , creating a pseudojoint or flail joint to permit scapular movement

413
Q

How dislocate the AC joint

A

Extrinsic coracoclavicular ligament is strong, the AC joint is weak and easily injured by a direct blow in contact sports and hard fall on shoulder or on the outstretched upper limb
Hockey player driven into boards or severe blow to the superolateral part of the back

414
Q

What is an ac joint dislocation often called

A

Shoulder separation

415
Q

When is shoulder separation severe

A

When both AC and coracoclavicular ligaments are torn

416
Q

Why does the shoulder separate and clavicle fall when coracoclavicular ligament tears

A

Weight of upper limb

417
Q

Rupture of the coracoclavicular ligament

A

Allows fibrous layer of the joint capsule to be torn so that the acromion can pass inferior to the acromion end of the clavicle. Dislocation of the AC joint makes the acromion more prominent and the clavicle may move superior to this process

418
Q

Calcific tendinitis of shoulder / calcific scapulohumeral bursitis

A

Inflammation and calcification of the subacromial bursa result in pain, tenderness, and limitation of movement of the GH joint

419
Q

Deposition of calcium in the supraspinatus tendon is common. What does this cause?

A

Increased local pressure that often causes excruciating pain during abduction of the arm; the pain may radiate as far as the hand
The calcium deposit may irritate the overlying subacromial bursa producing an inflammatory reaction known as subacromial bursitis

420
Q

With calcified tendinitis of shoulder why no pain as long as the gh joint is addicted

A

In this position the painful lesion is away from he inferior surface of the acromion

421
Q

With calcified tendinitis of the shoulder what angle causes pain

A

50-130 degrees of abduction (painful arc syndrome ) bc during this arc the supraspinatus tendon is in intimate contact with the inferior surface of the acromion

422
Q

What kind of peron gets pain with calcified tendinitis of the shoulder

A

Males over 50 after unusual or excessive use of the gh joint

423
Q

How is rotator cuff usually injured

A

Repetitive use of upper limb above the horizontal

424
Q

The supraspinatus area is relatively ___

A

Avascular

425
Q

Repetitive use of the rotator cuff muscles may allow the humeral head and rotator cuff to impinge on the ____ arch , producing irritation of the arch and inflammation or the rotator cuff

A

Coracoacromial

426
Q

Then what happens

A

Degenerative tendinitis of the rotator cuff and attrition of the supraspinatus tendon also occurs

427
Q

How test for degenerative tendinitis/tendinosis of rotator cuff

A

Person is asked to lower the sully abducted limb slowly and smoothly from 90 degrees will drop in uncontrolled manor

428
Q

How else may rotator cuff injuries occur

A

Sudden strain of the muscles such as a window that is. Stuck
This strain may rupture a previously degenerated musculotenfinous rotator cuss
A fall on the shoulder

429
Q

Often the intracapsular part of the tendon of the long head of the biceps brachii becomes frayed leaving it adherent to the intertubercular sulcus.

A

Shoulder stiffness occurs

430
Q

Why is the gh joint usually compromised when the rotator cuff is injured

A

They fuse, the integrity of the fibrous layer of the joint capsule

As a result the articular cavity communicated with the subacromial bursa.

431
Q

Because the supraspinatus muscle is no longer functional with a complete tear of the rotator cuff, the person cant initiate ___ of the upper limb. If the arm is passively abducted 15 degrees or more, the person can usually maintain of continue abduction using the ___

A

Abduction

Deltoid

Moores Blue Boxes (15 decks)

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