Upper Limb Flashcards
The clavicle is one of the most commonly fractured bones , especially in kids and adult athletes . What motion often causes clavicle break.
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
What is the weakest part of the clavicle
Junction of its middle and lateral thirds
After a clavicle fracture the ______ muscle elevated the medial fragment of the bone
Sternocleidomastoid
PALPABLE protruding
After fracture what happens to lateral clavicle
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 !
The strong ___ ligament usually prevents dislocation or the ac joint
Coracoclavicular
How treat
Sling to take weight of limb off clavicle and facilitate alignment
(Patient usually come in holding arm up with other arm )
Clavicle fracture during birth?
Green stick fracture
Heals fast
More incomplete
Green stick fracture
Usually kids
Bends and cracks rather then crack all the way
One side crack other side bent
The clavicle is the first bone to ___. When?
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
Sometimes failure of the two ossification centers of the clavicle fails to occur;
Bony defect forms between the lateral and medial thirds of the clavicle.
Prevent diagnosis of a fracture in a normal clavicle so know this!!!
What to do if not sure if fracture or defect
Radiograph…it is usually bilateral!
How do you fracture your scapula
Severe trauma, like pedestrian vehicle accidents
Also usually rib fractures
Treat fractured scapula
Nothing bc scapula covered on both sides by muscles
Most scapula fractures involve a protruding subcutaneous ___
Acromion
Most injuries of the humerus are fractures of the ___ ___. In what population
Surgical neck
Elderly people with osteoporosis whose demineralizeed bones are britttle
Numeral fractures often result in one fragment being driven into the spongy bone of the other fragment. What is this called
Impacted fracture
How normally inure the surgical head other humerus (impacted)
Minor fall on the hand with force being transmitted up the forearm bones of extended limb
Why can person move arm passively with little pain in impacted fracture
Impaction of the fragments
Who gets allusion fracture of the greater tubercle of the humerus
Middle aged and elderly people
Small part of tubercle is avulsed (torn away)
How get avulsion fracture of greater tubercle of the humerus
Dislocation of the humerus
In younger people-impaction with excessive abduction or flexion of the arm
Arm position if have avulsionf rapture of the greater tubercle
Muscles (especially subscapularis) that remain attached to the humerus pull the limb into medial rotation
How get fracture of the shaft of humerus
Direct blow or torsion of the arm
In kids, fracture of shafts of long bones are often ____ fractures
Green stick
Transverse fracture of the numeral shaft
Deltoid muscle carries the proximal fragment laterally
Spiral of oblique fracture of the numeral shaft
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
Bc the humerus is surrounded by muscles and has a wel developed ____, properly aligned bone fragments usually unite well
Periosteum
Intercondylar fracture of the humerus
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
The surgical neck is in direct contact with the ___ nerve
Axillary
The radial groove is in direct contact with the ____ nerve
Radial
The distal end of the humerus is in direct contact with the ___ nerve
Median
The medial epicondyle is in direct contact with the __ nerve
Ulnar
Fractures or radius or ulna in young and old people?
Young-green stick
Old and athletic adults -severe injury
Direct injury fo radius or ulna
Transverse fractures at the same level, usually middle third of the bones
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
Dislocation
Direct injury of humerus causes __ fracture and indirect causes
Transverse
Oblique or spinal
Fracture of the distal end of the radius is a common fracture in adults over 50. It occurs more frequently in women secondary to ___
Osteoporosis
Colles fracture
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)
How get colles fracture
Forced extension of the hand usually trying to ease a fall by outstretching the upper limb
What happens usually with fracture of radius ulna
Ulnar styloid process is avulsed
Radial styloid process projects further distally than ulnar
What happens with colles
Relationship reversed bc o shortening or the radius
Dinner fork deformity
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
History of person with colles fracture
Slipping or tripping and outstretch limb with forearm and hand protonated to break fall
Why is bony union usually good after colles
Blood supply to the distal end of radius
Distal end of radius fractures in kids
May extend through the distal epiphyseal plate
Epiphyseal plate injuries
Older children bc of frequent falls in which forces are transmitted from he hand to the radius and ulna
Healing of epiphyseal plate injury
May result in malalignment of the epiphyseal plate and disturbance of radial growth
What is the most frequently fractured carpal bone
Scaphoid
How fracture scaphoid
Fall on palm when hand is abducted, the fracture occurring across the narrow part of the scaphoid
Palpating of fracture scaphoid
Pain in anatomical snuff box not he lateral side of the wrist, especially during dorsiflexion and abduction of the hand.
Often radiographs of the wrist do not reveal fracture of scaphoid. What may it be misdiagnosed as
Severely sprained wrist
Why do radiographs reveal fracture 1-=14 days after scaphoid fracture
Resorption has occurred
Why may union of scaphoid take at least 2 months
Poor blood supply to proximal part of scaphoid
Avascular necrosis of the proximal fragment of the scaphoid may occur with scaphoid fracture and produce what
Degenerative joint disease of the wrist
In some cases of scaphoid fracture we will need to fuse the carpals surgically. What is this called
Arthrodesis
Why may fracture of the hamate result in nonunion of the fractured bony parts
The traction produced by the attached hypothecate muscles
With fracture of hamate, the ___ nerve and __ artery is close to the hook of the hamate and may be injured
Ulnar
Ulnar
What happens if damage ulnar nerve with hamate fracture
Decreased grip strength of the hand
The metacarpals(except which one) are bound together; hence isolated fractured tend to be stable and heal rapidly
1st
What may oblique (spiral) fractured of a metacarpal result in
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
How do metacarpals respond to severe crushing injuries of the hand
Multiple metacarpal fractures resulting in instability of the hand
Boxers fracture
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
How get a crushing injury of the phalanges
Finger caught in a car door
Are phalange injuries painful
VERY bc of highly developed sensation int he fingers
A fracture of a distal phalanx
Usually comminuted and a painful hematoma soon develops
How fracture proximal or middle phalanx
Crushing or hyperextension
Why must phalangeal fractures be carefully realigned to restore normal function of the fingers
Close relationship of phalangeal fractures to the flexor tendons
Need to carefully realign to restore function of the fingers
Lateral rotation at glen oh unreal joint
C5
Medial rotation at glenohumeral joint
C6, 7, 8
Abduction at glenohumaral joint
C5
Addiction at glenohumeral joint
C6, 7, 8
Extension at glenohumeral joint
C6, 7, 8
Flexion at glenohumeral joint
C5
Flexion at elbow
C5, c6
Extension at elbow
C6, C7
Flexion of wrist
C6, c7
Extension of wrist
C6, c7
Arm supination
C6
By forearm muscles
Arm pronation
C7, c8
By forearm muscles
Digital flexion IP joint
C7 c8
By forearm muscles
Digital extension IP joints
C7 c8
By forearm muscles
Medial and lateral abduction of fingers MCP joint of 3rd digit
T1
By forearm muscles
Abduction and adduction of digits 2-5 MCP
T1
Intrinsic muscles of the hand
Supraclavicular nerves (cutaneous nerve)))
C3, C4
From cervical plexus
Pass anterior to clavicle, immediately deep to platysma, and supply skin over clavicle and superolateral aspect of pectoralis major
Superior lateral cutaneous nerve of arm (cutaneous nerve)
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
Inferior lateral cutaneous nerve of arm
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
Posterior cutaneous nerve of arm
C5-c8 Radial nerve (in axillla) Crosses posterior to and communicates with interocstobrachial nerve and supplies skin on posterior arm. As far as olecronon
Posterior cutaneous nerve of forearm
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
Lateral cutaneous nerve of forearm
C6-c7
From musculocutaneous nerve(terminal branch)
Emerges lateral to biceps tendon deep to cephalic vein, supplying skin of anterolateral forearm and wrist
Medial cutaneous nerve of forearm
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
Medial cutaneous nerve of arm
C8-t2
From medial cord of brachial plexus (in axilla)
Communicates with intercostobrachila nerve continuing to supply skin of medial aspect of distal arm
Intercostobrachial nerve
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
What is failure of a body part or organ to form usually due to (agenesis)
Lack of genetic signaling to produce primordial tissue and failure of subsequent development in the embryo
Agenesis of a vital structure
Not viable fetus
Poland syndrome
Uncommon
Unilateral congenital anomaly of upper limb development , lowest level of which is a genesis of the pectoralis major and pectoralis minor
Nipple in Poland syndrome
More inferior or absent in severe Poland by have breast hypoplasia
Functional concern of Poland syndrome
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
Severe Poland
Breast hypoplasia, no nipple,
Missing 2-4 rib segments, and additional development define its of the free limb
The stratus anterior muscle is paralyzed with damage to what nerve
Long thoracic
Clinical presentation of paralysis of Serra thus anterior
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
What happens when raise arm and have paralysis of serrated anterior
Medical border and inferior angle of scapula pull away from the posterior thoracic wall, a deformation known as winged scapula
Why wont the limb be able to elevate normally above the horizontal position if serratus anterior paralyzed
Serratus unable to upwardly rotate the scapula to position the glenoid cavity superiority to allow complete abduction or elevation of the limb
Does the trapezius also help raise the arm above the horizontal
Yup
The long thoracic nerve is protected when that areas are down. What about when they are up like in a knife fight
It courses on the superficial aspect of the serratus anterior, which is supplies so vulnerable
What surgery is the long thoracic nerve vulnerable in
Mastectomy
Near the inferior angle of the scapula is a small triangulargap in the musculature. What is it called
Triangle of auscultation
What are the borders of the triangle of auscultation
Superior border of the latissimus dorsi, medial border of scapula, and inferolateral border of trapezius
What can we use the triangle of auscultation for
Examine posterior segments of the lungs with a stethoscope in a heavily muscled individual
How can we enlarge the triangle of auscultation
Scapulae drawn anteriorly by folding the arms across the chest and the trunk is flexed the triangle enlarges
Clinical manifestation of spinal accessory nerve palsy
Dropped shoulder with a marked ipsilateral weakness when shoulders are elevated(shrugged) against resistance
How injure spinal accessory nerve
Traction injury such as whiplash, tumor, or cervical lymph node biopsy or surgical procedure at the posterior triangle
Surgery in the inferior part of the axilla puts the ___ nerve (c_-c_) sullying the latissimus dorsi at risk of injury
Thoracodorsal nerve (c6-c8)
Describe the path of the thoracodorsal nerve
Passes inferiorly along the posterior wall of the axilla and enters the medial surface of the latissimus dorsi close to where it becomes tendinitis
What other surgeries put thoracodorsal nerve at risk
Mastectomy
Scapular lymph node surgery by its terminal part lies anterior or them and the subscapular artery
What do the latissimus dorsi and the inferior part of the pectoralis major form
Anteroposterior muscular sling between the trunk and arm’ however the latissimus dorsi forms the more powerful part of the sling
Latissimus dorsi paralysis
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
Injury to the ___ __ nerve, the nerve to the rhomboid and elevator scapulae muscles, affects the actions of these muscles
Rhomboid and elevator scapulae
If the rhomboids on one side are paralyzed the scapula on the affected side is located farther from the midline than the __ side
Normal
The deltoid and there’s minor atrophy when the ___ nerve (c_-C-) is severely damaged
Axillary c5-c6
Where is the axillary nerve and how is it damaged
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
As the deltoid atrophied, the rounded contour ____ compared to the uninsured side
Flattens
Also has a slight hollow inferior to the acromion
Loss of sensation may occur over lateral side of proximal part of arm
Why when deltoid atrophied from axillary nerve injury do we get loss of sensation over lateral side of the proximal part of the arm
Supplies by superior lateral cutaneous nerve of arm , the cutaneous branch of the axillary nerve
Why must we need to know the location of axillary nerve
Runs transversely under cover of the deltoid at the level of the surgical neck of the humerus
COMMON SITE OF IM INJECTION OF DRUGS
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
Bc the joint capsule of the glenohumeral joint, reinforced by the rotator cuff is stronger than the epiphysial plate
In severe fractures of the proximal numeral epiphysis, the shaft of the humerus is markedly displaced. Is the numeral head?
Nah, the numeral head retains its normal relationship with the glenoid cavity of the scapula
Injury or disease may damage the muscular endings rotator cuff, producing what
Instability of the glenohumeral joint
With trauma, what is the most commonly ruptured tendon of the rotator cuff
Supraspinatus
Degenerative tendinitis of the rotator cuff
Common
Old people
Subacromial bursa
Look up
Brachial plexus
Draw it out
Dorsal scapular nerve
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
Long thoracic nerve
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
Suprascapular nerve
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
Subclavian nerve
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)
Lateral pectoral nerve
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
Musculocutaneous nerve
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
Median nerve
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
Medial pectoral
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
Medial cutaneous nerve of arm
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
Medial cutaneous nerve of forearm
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
Ulnar nerve
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
Upper subscapular nerve
Side branch of posterior cord receiving fibers from c5
Passes posteriorly entering subscapular is directly
Innervates superior portion of subscapular is
Lower subscapular nerve
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
Thoracodorsal nerve
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
Axillary nerve
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)
Radial nerve
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
Many arterial anastomoses occur around the ____. What vessels join here
Scapula
Dorsal scapular, suprascapular(via circumflex scapular), and subscapular
The importance of the ___ ___ made possible by these anastomoses becomes apparent when ligation of a lacerated subclavian or axillary artery is necessary
Collateral circulation
Why may the axillary artery need be ligated
Between the 1st rib and subscapular artery
Can the axillary artery be affected by atherosclerosis
Yaaaa vascular stenosis
What happens with compromise of blood flow through axillary artery
Reversal of flow in subscapular artery enables blood to reach the third part of the axillary artery
The subscapular artery receives blood through several anastomoses with what arteries
Suprascapular artery
Dorsal scapular artery
Intercostal arteries
Slow occlusion of axillary artery
Enables sufficient collateral circulation to develop, preventing ischemia
Sudden axillary artery occlusion
Does not allow sufficient time for adequate collateral circulation to develop…inadequate supply of blood to the arm, forearm, and hand
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
Cut off blood supply to the arm bc collateral circulation is inadequate
Where can you palpate the axillary artery
Inferior part of the lateral wall of the axilla
What can you do if there is profuse bleeding from stab or bullet wound around axilla
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
Aneurysm of the axillary artery
Enlargement of the first part of the axillary artery
What happens if there is aneurysm of axillary
Compress the trunks of the brachial plexus causing pain and anesthesia in the areas of skin supplied by effected nerves
What populations get axillary aneurysms
Baseball pitchers, football quarterbacks
Bc of rap is and forceful arm movements
Why do wounds of the axilla often involve the axillary vein
Large size and exposed position
When the arm is full ____ the axillary vein overlaps the axillary artery anterior
Abducted
Why is a surgical or traumatic wound in the proximal part of the axillary vein particularly dangerous
Profuse bleeding and risk of air entering it and producing an air emboli
What is subclavian vein puncture
Catheter is placed into the subclavian vein
Common clinical procedure
When does the axillary vein become the subclavian vein
When the first rib is crossed
How does the needle go in subclavian vein puncture
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
The axillary artery lies __ and ___ to the axillary artery and parts of the brachial plexus that begin to surround the artery at this point
Anterior inferior
WATCH WHEN DOING A SUBCLAVIAN VEIN PUNCTURE
An infection in the upper limb can cause the axillary nodes to enlarge and become tender and inflamed, a condition called _____
Lymphangitis
The ___ group of nodes is usually the first to be involved
Humeral
Clinical characterization of lymphangitis
Warm red tender streaks in skin of the limb
What else produces enlargement of axillary nodes besides infection of upper limb
Infections of pectoral region and breast including superior part of the abdomen
What may happen to axillary nodes in metastatic cancer (apical nodes)
Adhere to the axillary vein requiring excision of vessel
Also enlargement of the apical nodes may obstruct the ___ vein superior to the pectoralis minor
Cephalic
What nodes are important for staying of breast cancer
Axillary
Removing or radiation of axillary lymph nodes
Lymphatic drainage of upper limb impeded get lymphededma, swelling as a result of accumulated lymph , especially in the subcutaneous tissue
What two nerves are at risk during axillary node resection
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
Are variations in formation of the brachial plexus common
Yes
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 _
C4
T2
When the superiormost root (anterior ramus) of the plexus if c4 and the inferoirmost root is C8, it is a ___ brachial plexus
Prefixed
When the superior root is C6 and inferior root is t2, it is a ___ brachial plexus
Post fixed
Problem with post fixed plexus
Inferior trunk of the plexus may be compressed by the 1st rib, producing neuromuscular symptoms of the upper limb
Another common variation of brachial plexus
Lateral or medial cords may receive fibers from anterior rami inferior or superior to the usual levels respectively
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
2
What does injury to the brachial plexus cause
Affect movements and cutaneous sensation in upper limb
Paralysis and anesthesia
Depends on what part is injured
What may cause brachial plexus injury
Disease, stretching, and wounds in the lateral cervical region (posterior triangle) of neck or in the axilla
What causes Injuries to superior part of brachial plexus c5 and C6
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
Symptoms of injury to superior brachial plexus c5 C6
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
How may a neonate get an upper brachial plexus injury
Excessive stretching of neck during delivery
What’s another name for injuries to superior parts of brachial plexus
Erb-Duchenne palsy , paralysis of muscles of shoulder and arm supplied by c5 C6 , deltoids, biceps, and brachialis
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
Musculocutaneous and radial
Hikers can get muscle spasms and severe disability if carry heavy backpack long time
Acute brachial plexus neuritis (neuropathy)
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)
Inflammation of the brachial plexus (brachial neuritis) is often preceded by some event, like what
URI, vaccination, nonspecific trauma
The nerve fibers involved are usually derived from the superior trunk of the brachial plexus in what
Brachial neuritis
Why get compression of cords of the brachial plexus
Prolonged hyperabduction of the arm during performance of manual tasks over the head, such as painting a ceiling
In compression of cords, what are the cords compressed between
Coracoid process of scapula and pectoralis minor tendon
Symptoms of compression of cord of brachial plexus
Pain radiating down the arm, numbness, paresthesia(tingling), erythema (redness), and weakness of hands.
What does compression of the axillary artery and vein cause
Ischemia of the upper limb and distension os the superficial veins
Hyperabduction syndrome
Compression axillary vessels and nerves
Ischemia of upper limb and distension of the superficial veins
Injuries to inferior parts of brachial plexus are called what
Klumpke paralysis
Less common
How get inferior brachial plexus injuries
Upper limb is suddenly pulled superiorly-for examplewhen a person grabs something superiorly like grabbing tree branch
How may baby get klumpke paralysis
Pull arms during birth
What does inferior brachial plexus injury cause
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
Brachial plexus block
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
What is blocked with a brachial plexus block
Sensation in all deep structures of the upper limb and the skin distal to the middle of the arm
What does tourniquette and brachial plexus block allow surgeons to do
Operate on on upper limb without general anesthesia
Needle approach for brachial plexus block
Supraclavicular and infraclavicular
Biceps reflex
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
Diminished biceps reflex
C5 C6
Central or peripheral nervous system disease or metabolic disorder (thyroid disease)
Biceps tendinitis
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
Describe the tendon of the long head of the biceps
Enclosed by a synovial sheath and moves back and forth in the intertubercular sulcus (bicipital groove) of the humerus
Wear and tear of the tendon of the long head of the biceps causes what
Shoulder pain
Tendinosis
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
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 ________ (__ __)
Crepitus (cracking sound)
The tendon of the long head of the biceps can be partially or completely dislocated from the ___ ___ in the humerus
Intertubercular sulcus
What may cause dislocation of the long head of the biceps brachii
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
Why get rupture of the tendon of the long head of the biceps brachii
Wear and tear of an inflamed tendon as it moved back and forth int he intertubercular sulcus of the humerus
>35 yo
How does the tendon of the long head of the biceps brachii ruptures
Torn from its attachment to the supraglenoid tubercle of the scapula
What is rupture of tendon or long head of biceps brachii associated with
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)
What is the basis for measuring blood pressure
Occlusion, compression and resumption of blood flow in the brachial artery
How is blood pressure measured
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
When measuring bp the first instance of sound is what
What is it when sound stops
Systolic
Diastolic
What do we call stopping bleeding through manual or surgical control of blood
Hemostasis
Where is the best place to compress brachial artery to control hemorrhage
Medial to the humerus near the middle of the arm
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.
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
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
Ischemia of the elbow and forearm within a few hours
Muscles and nerves can tolerate up to _ hours if ischemia
6
What happens after 6 hours
Fibrous scar tissue replaces necrotic tissue and causes te involved muscles to shorten permanently producing a flexion deformity called the ischemic compartment syndrome
Ischemic compartment syndrome
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
A midhumeral fracture may injure the ___ nerve in the groove in the humeral shaft
Radial
What happens when injure radial nerve ——-triceps
Fracture not likely to paralyze triceps bc of the high origin of the nerves of 2/3 heads
What is a Supra-epicondylar fracture
Fracture of the distal part of the humerus near the supraepicondylar ridges
Distal bone fragment may be displaced anteriorly or posteriorly
Why in a supraepicondylar fracture does the distal bone fragment displace anteriorly or posteriorly
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
Injury to the musculocutaneous nerve in the axilla is uncommon. Why? How would you get it?
Protected here
May get from a knife
What does a musculocutaneous nerve injury result in
Paralysis of coracobrachialis, biceps, and brachialis
Why get slightly weak flexion at glenohumeral joint when have musculocutaneous nerve injury
Affecting long head of biceps brachial and the coracobrachialis
get incredibly weakened flexion of elbow and supination of forearm with musculocutaneous nerve injury , but it is still possible. Why
Can still use the brachioradialis and supinator which are supplied by radial nerve
Where get loss of sensation with damage to musculocutaneous nerve
Lateral surface of forearm supplied by lateral cutaneous nerve of forearm
What is the lateral cutaneous nerve of forearm
Continuation of musculocutaneous
What does injury of the radial nerve superior to the origin of its branches to the triceps brachial result in
Paralysis of triceps, brachioradialis, supinator, and extensor muscles of the wrist and fingers
Also loss of skin sensation in areas supplied
When the radial nerve is injured in the radial groove the triceps is usually not completely paralyzed. Why
Only the medial head is affected
What is paralyzed when the radial nerve is damaged in the radial groove
Muscles in the posterior compartment of the forearm that are supplied by more distal branches of the nerve
Characteristic sign of radial nerve injury
Wrist drop
Can’t extend and fingers at MCP joint
Unopposed tonus of flexor muscles and gravity get a flexed wrist
When sampling blood from the cubical fossa and there is a common pattern of superficial veins. Which is chosen ?
Median cubical vein
Describe median cubical vein
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.
The pattern of veins in the cubical fossa vary greatly. In 20% what is the situation
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
What else may the median cubical vein be used for besides drawing blood
Introduction of cardiac catheters to secure blood samples from the great vessels and chambers of the heart. Also coronary angiography
Elbow tendinitis
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
Why do people with elbow tendinitis feel pain when they open a door or lift a glass
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)
Which epicondyle do flexors attach to
Medial
Golfers
Which epicondyle do extensor attach to
Lateral
Tennis elbow
Mallet or baseball finger
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
What. Does hyperflexion at IP joint cause
Aculse the attachment of the tendon to the base of the distal phalanx
If you have mallet or baseball finger, what can you NOT do
Extend the distal interphalangeal joint
Deformity bears resemblance to a mallet
How does one fracture their olecranon
Fall on the elbow combined with sudden powerful contraction of the triceps brachii
A fractured olecranon is pulled away by the tonic contracture of ___ and the injury is considered an ___ fracture
Triceps
Avulson
Treatment of olecranon fracture
Pinning bc of the pull from triceps
Takes a while and cast worn for long time
Synovial cyst of wrist
Nontender cystic swelling appears on the hand, most commonly on the dorsi of the wrist
Size of grape
What is in a synovial wrist cyst
Clear mutinous fluid
___ of the wrist makes a synovial cyst on the wrist enlarge
Flexion
Common site of cyst
- 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
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
Median
Carpal tunnel syndrome
Carpal tunnel syndrome
Pain and parenthesia
In the sensory distribution of the median nerve and clumsiness of finger movements
High division of brachial artery
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
In 3% of people the ulnar artery descends superficial to the flexor muscles. Clinically of concern?
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
Describe the location of the radial artery where we take pulse
Where radial artery lies on the anterior surface of the distal end of the radius , lateral to the tendon of the FCR
Why dont use thumb to take pulse
Has its own pulse
Where else can feel radial pulse
Pushing into anatomical snuff box
Variations in radial artery
May be more proximal
May be a branch of axillary or brachial arteries
Sometimes superficial to the deep fascia instead of deep to it
When a superficial vessel is pulsating near the wrist what is is probably
Superficial radial artery
Concern of superficial radial artery
Vulnerable to laceration
Median nerve severed in elbow region
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
When median nerve severed below elbow why is the flexion of the distal IP joint of 4th and 5th digits not lost
Bc medial part of FDO, which produces these movements is supplied by the ulnar nerve
When median nerve is severed below the elbow why is flexion of MCP of digits 2 and 3 affected
Bc digital branches of the median nerve supply the 1st and 2nd lumbricals
What happens when a person with median nerve injury tries to make a fist
2 and 3rd finders remain partially extended (HAND OF BENEDICTION)
With median nerve damage below elbow what happens to the air muscle function
Lost as in carpal tunnel syndrome
What happens when anterior interosseous nerve is injured
The air muscles unaffected
Paresis of the flexor digitorum profundus and flexor polices longus
Anterior interosseous nerve injury and person tried to make the okay sign (anterior interosseous syndrome )
Pinch posture due to absence of flexion of the IP joint of the thumb and distal IP joint of the index finger
Pronator syndrome
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
Clinical presentation of pronator syndrome
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
When get symptoms of pronator syndrome
Following activities that involve repeated pronation
Communications between median and ulnar nerves in forearm
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!!!
Where does ulnar nerve injury most commonly happen
Where nerve passes posterior to the medial epicondyle of the humerus
What causes ulnar nerve injury where passes posterior to medial epicondylis
Medial part of the elbow hits a hard surface, fracturing the medial epicondyle (funny bone)
Lesion of ulnar nerve superior to the medial epicondyle will produce parenthesis where
Median part of the dorsi mood of the hand
Compression of the ulnar nerve at the elbow (cubical tunnel syndrome)
Common
Where does ulnar nerve injury usually cause numbness (paresthesia)
Medial part of the palm and the medial one and a half fingers
Ulnar nerve injury distal part of forearm
Enervates most intrinsic hand muscles.
Wrist addiction impaired
When try to flex wrist it is drawn laterally by FCR(median nerve)
Why cant make a fist after ulnar nerve injury
In absence of opposition, metacaphalangeal joints become hyperextended and can’t flex 4th or 5th digits at the distal IP joints
Can a person with ulnar nerve injury extend IP joints when trying to straighten fingers
No
What do you call a hand with ulnar nerve injury
Claw hand
Why get claw hand with ulnar nerve injury
Atrophy of interosseous muscles of the hand supplied by the ulnar nerve
Unopposed action of the extensor and FDP
Cubical tunnel syndrome
Ulnar nerve compressed in cubical tunnel(rare) by the tendinitis arch joining the numeral and ulnar heads of attachment of the FCU
Signs and symptoms of cubical tunnel syndrome
Same as ulnar nerve lesion in ulnar groove on the posterior aspect of medial epicondyle of humerus
How is radial nerve most commonly injured
In the arm by a fracture of the numeral shaft
Primary clinical manifestation of radial nerve injury
Wrist drop
Injury to the deep branch of the radial nerve happens when
Wounds of posterior forearm are deep (penetrating
What happens if injure deep branch of the radial nerve
Inability to extend thumb and the MP joints of other digits
How test integrity of deep branch
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
Loss of sensation with deep radial nerve injury
Nope
Entirely muscular and articulate
Loss of sensation with superficial branch of radial nerve
Minimal
Coin shaped area of anesthesia distal to the bases of the 1st and 2nd metacarpals
Not a lot bc overlap of cutaneous nerves!
Dupuytren contracture
Disease of the palmar fascia resulting in progressive shortening , thickening, and fibrosis of the palmar fascia and aponeurosis
What does fibrous degeneration of the longitudinal bands of the palmar aponeurosis on the medial side of the hand do
Pulls the 4th and 5th fingers into partial flexion at the MCP and proximal IP joints
Population that gets dupuytren contracture
Men over 50
Bilateral
Presentation of dupuytren contracture
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
Treat dupuytren contracture
Surgical excision of all fibrotic parts of the palmar fascia to free the fingers
In hand infections, where do swellings not he hand appear and why
Dorsum
Palmar surface is thick
Why are potential fascia spaces on the palm of the hand clinically important for hand infections
Determine extent and direction of the spread of pus formed by these infections
Depending on site of infection where will pus accumulate in hand infection
The air, hypothecate, midpalmar, or adductor compartments
Where can an untreated hand infection spread
Proximal from midpalmar space through the carpal tunnel into the forearm, anterior to the pronator quadratics and its fascia
Tenosynovitis
Infection of the digital synovial sheaths
What may cause tenosynovitis
Puncture of finger with a rusty nail
Clinical presentation of tenosynovitis
Digit swells and movement painful
Why is infection in tenosynovitis usually confined to the infected finger
Tendons of 2, 3, 4, nearly always have separate synovial sheaths
Untreated tenosynovitis
Proximal ends of sheaths may rupture allowing infection. To spread to midpalmar space
How could tenosynovitis in little finger spread to space between the pronator quadratics and overlying flexor tendon (parona space)
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
Tenosynovitis of thumb may spread where and how
Via continuous synovial sheath to the FPL (radial bursa)
What does spread of finger infection depend on
Variations in their connections with the common flexor sheath
Where are the APL and EPB
Same tendinitis sheath on the dorsum of the wrist
What does excessive friction of the APL and EPB on their common sheath result in
QUERVAIN TENOVAGINITIS STENOSANS
Fibrous thickening of the sheath and stenosis of the osseofibrous tunnel
What causes QUERVAIN tenovaginiitis stenosans -excessive friction of APL and EPB on their common sheath
Repetitive forceful use of hands during gripping and wringing (squeezing of clothes)
Symptoms of QUERVAIN tenovaginitis stenosans
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
What do you get from repetitive forceful use of fingers
Thickening of a fibrous digital sheath on the palmar aspect of the digit produces stenosis of the osseofibrous tunnel
What happens FDS and FDP enlarge proximal to the tunnel ———digital tenovaginitis stenosis (trigger finger or snapping finger)
Unable to extend finger
When finger extend passively a snap is audible
Flexion produces another snap as the thickened tendon moves
What is a big concern when palmar arches are lacerated
BLEEDING
When palmar arches are lacerated why may it be insufficient to only legate one forearm artery
Bc they have numerous communications in the forearm and hand and thus bleed from both ends
How could we create a bloodless surgical operating field for treating complicated hand injuries
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
Intermittent bilateral attacks of ischemia of the digitis
RAYNAUD-Cyanosis and paresthesia and pain brought on by cold or emotional stimuli
What causes raynaud
Anatomical abnormality or disease
How treat ischemia from raynaud syndrome
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
What are the two common places of median nerve lesion
Forearm and wrist
Most common is where nerve passes through carpal tunnel
What causes carpal tunnel
Any lesion that reduces the size of the carpal tunnel or increases size of none structures or their covering that pass through it
What may cause swelling of tendons or their synovial sheaths in the carpal tunnel
Fluid retention, infection, excessive exercise of fingers
The median nerve has 2 terminal sensory branches tat supply skin of the hand. What symptoms of median nerve lesions does this relate to
Paresthesia(tingling), hypoesthesia(diminished sensation), or anesthesia(no sensation) in the lateral three and a half digits
Tell me about the palmar cutaneous branch of the median nerve and how does this effect carpal tunnel
Arises proximal to and does not pass through the carpal tunnel
Sensation in the central palm remains unaffected
Tell me about the terminal motor branches of the median nerve
Through the carpal tunnel
Recurrent branch-three thenar muscles
Branches of lumbricals 1 and 2
If pressure of carpal tunnel isn’t alleviated, there will be what
Progressive loss of coordination and strength of the thumb (weakness of APB and opponens policis)
People with carpal tunnel are unable to __ their thumb
Oppose
What do people with carpal tunnel have trouble doing
Buttoning shirt, gripping things like a brush
As carpal tunnel progresses…
Sensory changes radiate into forearm and axilla
Treat carpal tunnel with carpal tunnel release
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
What nerve is often damaged by laceration of the wrist
Median nerve bc pretty close to the surface
Symptoms of median nerve trauma(slash wrist)
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
With median nerve injury __ of the thumb is not possible
Opposition
With trauma to the median nerve fine control movement of the _ and _ digits are impaired
2 3
With median nerve injury sensation is lost where
Over the thumb and adjacent two and a half fingers
If the median nerve is severed in the forearm or wrist, the thumb cannot be opposed. However, what might mimic opposition although ineffective
APL and adductor polices (supplied by the posterior interosseous and ulnar nerves, respectively)
Symptoms of median nerve injury resulting from perforating wounds in the elbow region
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
Simian hand
Thumb movements are limited to flexion and extension of the thumb in the plane of the palm
What causes simian hand
Inability to oppose and limited abduction of the thumb
The __- ___ of the median nerve to the thenar muscles les subcutaneously and may be severed by relatively minor lacerations.
Recurrent branch
Symptoms of severance of recurrent branch of median nerve
Paralyzed the thenar muscles, and the thumb loses much of its usefulness
Ulnar canal syndrome
Compression of the ulnar nerve may occur at the wrist where it passes between the pisiform and the hook of hamate
The depression between the hook of hamate and pisiform turn into what
Pisohamate ligament into an osseofibrous tunnel, the ulnar canal (guyon tunnel)
Ulnar canal symptoms (guyon tunnel syndrome )
Hypoesthesia (reduced sense of touch or sensation) in the medial one and a half fingers and weakness of the intrinsic muscles of the hand
Contradiction to proximal ulnar nerve injury, In ulnar canal syndrome their ability to ___ is unaffected, and there is no radial deviation of the hand
Flex
In ulnar canal syndrome there is clawing of the _ and _ fingers (hyperextension at MCP and flexion at PIP)
4 5
Handle bar neuropathy
People ride long on bike with hands extended puts pressure on their hamate which compresses the ulnar nerve
Symptoms of handle bar neuropathy
Sensory loss on the medial side of the hand and weakness of the intrinsic hand muscles
Although radial nerve supplied no muscles int he hand, radial nerve injury in the arm can produce serious hand disability
Inability to extend the wrist resulting from paralysis of extensor muscles of the forearm, all of which are innervates by radial nerve
Clinical picture of radial nerve injury in arm and hand disability
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
IP joints in radial nerve injury in arm and hand disability
Can be extended weakly through the action of the intact lumbricals and interossei which are supplied by the median and ulnar nerves.
Even in serious radial nerve injuries anesthesia cutaneously is minimal due to overlap. What area may lose sensation
Small area on the lateral part of the dorsum of hand
Dermatoglyphics
Study ridge patterns on palm of hand
Dermatoglyohics trisomy 21
Highly characteristic also have simian crease
Can people have simian crease without downs
Yea 1% do
For examining wounds and doing surgery KNOW where superficial and deep palmar arches are…. where is the superficial palmar arches
Same level as the distal end of the common flexor sheath
Incisions or wounds along the medial surface of the thenar eminence may injure what
Recurrent branch of median nerve to the thenar muscles
Skiers thumb
Rupture or chronic laxity of the collateral ligament if the 1st MP joint
How get skiers thumb
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
Severe skier thumb
Head of metacarpal has an avulsion fracture
Bull riders thumb
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
How get anterior dislocation of the lunate (uncommon )
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
A displaced lunate may compress the median nerve and lead to ___ __ __
Carpal tunnel syndrome
The lunate has a poor blood supple. What may happen in dislocate
A vascular necrosis
How treat avascular necrosis of lunate
May have to remove
Degenerative joint disease of the wrist, surgical fusion of carpals (arthrodesis) may be necessary to televise the severe pain
Yup
Fracture-separation of the distal radial epiphysis
Kids
Bc frequent falls in which forces are transmitted from the hand to the radius
Radiograph of fracture-separation of the distal radial epiphysis
Dorsal displacement of the distal radial epiphysis is obvious
Prognosis of fracture-separation of the distal radial epiphysis
Good if epiphysis is placed in its normal position during reduction
Bursitis of elbow
Subcutaneous olecranon bursa is exposed to injury during falls on the elbow and infection from abrasions of skin covering the olecranon
How may you get bursitis of the elbow
Repeated excessive pressure and friction as occurs in wrestling causes bursa to be inflamed , producing a friction subcutaneous olecranon bursitis
What is subcutaneous olecranon bursitis also known as
Miners elbow
Dart throwers elbow
Subtendininous olecranon bursitis
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
With subtendinous olecranon bursitis why is pain most severe with flexion
Pressure exerted on the inflamed subtendinous olecranon bursa by the triceps tendon
Bicipiitoradial bursitis
Pain when forearm is probated bc this compresses the bicipitoradial bursa against the anterior half of the tuberosity of the radiusss
Adhesive capsular is of the glenohumeral joint
Adhesive fibrosis and scarring between the inflamed joint capsule of the glenohumeral joint, rotator cuff, subacromial bursa and deltoid usually cause adhesive capsulitis
What does someone with adhesive capsulitis of the glenohumeral joint have trouble doing
Abducting the arm and can obtain apparent abduction of up to 45 degrees by elevating and rotating the scapula
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
Ac
What injuries may initiate adhesive capsulitis of glenohumeral joint
GH dislocation
Calcification supraspinatus tendinitis
Partial tearing of the rotator cuff
Bicipital tendinitis
Avulsion of medial epicondyle
Forced separation in kids that fall with severe abduction of extended elbow
Traction on ulnar collateral ligament pulls medial epicondyle distally
Why does avulsion of medial epicondyle happen in kids
Epiphysis for medial epicondyle may not fuse with distal end of humerus until 20
Traction injury of the ulnar nerve is a frequent complication of abduction avulsion of medial epicondyle. Why
Stretching of ulnar nerve is that is passes posterior to the medial epicondyle before entering the forearm
Ulnar collateral ligament reconstruction when there is rupture, tearing and stretching with athletic throwing
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
Dislocation of elbow joint is usually ____
Posterior
What causes posterior dislocation of the elbow joint
Children fall on hands with elbows flexed
Or hyperextension or blow that drives the ulna posterior or posterolateral
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 ___
Anterior
Posterior
What is associated with dislocation of the elbow joint
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
Subluxation and dislocation of the radial head /nursemaids elbow
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
How does kid present with nurse aids elbow/subluxation and dislocation of the radial head
May refuse to use the limb
Hold the limb with elbow flexed and probated
Source of pain in nursemaids elbow
Pinched anular ligament
Treatment of nursemaids elbow
Supination do the forearm while elbow is flexed
The tear heals when limb is placed in sling for 2 weeks
Tearing of the fibrocartilaginous glenoid labrum
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
Symptom of glenoid labrum tear(usually the anterosuperior part)
Pain while throwing
Sense of popping or snap ping during abduction and lateral rotation of the arm
Why is the glenohumeral joint frequently dislocated
Freedom of movement in instability
Most glenohumeral joint disclocationg are in the ___ direction. Why
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
What causes anterior dislocation of the glenohumeral joint
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
What does hard blow to humerus when the gh joint is fully abducted
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.
How does patient look with dislocation of glenoid humeral joint
Supports arm and cant use it
Inferior dislocation of the gh joint often occurs after avulsion fracture of the what
Greater tubercle of the humerus , owing to absence of the upward and medial pull produced by muscles attaching to the tubercle
The _ nerve may be injured when the gh joint dislocates because of its close relation to the inferior part of the joint capsule
Axillary
Why is dislocation of the SC joint rare
Strength, which depends on its ligaments, its disc, and the way forces are generally transmitted along the clavicle
Most dislocations of SC joint
Less then 25 from fractures through epiphyseal plate because the epiphysis at the sternal end of the clavicle does not close until 23-25
Ankylosis of SC joint
Stiffening or fixation
Sometimes necessary surgicallysection of the center of the clavicle is removed , creating a pseudojoint or flail joint to permit scapular movement
How dislocate the AC joint
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
What is an ac joint dislocation often called
Shoulder separation
When is shoulder separation severe
When both AC and coracoclavicular ligaments are torn
Why does the shoulder separate and clavicle fall when coracoclavicular ligament tears
Weight of upper limb
Rupture of the coracoclavicular ligament
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
Calcific tendinitis of shoulder / calcific scapulohumeral bursitis
Inflammation and calcification of the subacromial bursa result in pain, tenderness, and limitation of movement of the GH joint
Deposition of calcium in the supraspinatus tendon is common. What does this cause?
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
With calcified tendinitis of shoulder why no pain as long as the gh joint is addicted
In this position the painful lesion is away from he inferior surface of the acromion
With calcified tendinitis of the shoulder what angle causes pain
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
What kind of peron gets pain with calcified tendinitis of the shoulder
Males over 50 after unusual or excessive use of the gh joint
How is rotator cuff usually injured
Repetitive use of upper limb above the horizontal
The supraspinatus area is relatively ___
Avascular
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
Coracoacromial
Then what happens
Degenerative tendinitis of the rotator cuff and attrition of the supraspinatus tendon also occurs
How test for degenerative tendinitis/tendinosis of rotator cuff
Person is asked to lower the sully abducted limb slowly and smoothly from 90 degrees will drop in uncontrolled manor
How else may rotator cuff injuries occur
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
Often the intracapsular part of the tendon of the long head of the biceps brachii becomes frayed leaving it adherent to the intertubercular sulcus.
Shoulder stiffness occurs
Why is the gh joint usually compromised when the rotator cuff is injured
They fuse, the integrity of the fibrous layer of the joint capsule
As a result the articular cavity communicated with the subacromial bursa.
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 ___
Abduction
Deltoid
