Upper Limb Flashcards
Median Nerve: where would sensory be distributed to?
- lateral aspect of palm and radial 3.5 fingers anteriorly (trigger fingers)
- radial side
- runs down middle of the arm
Median Nerve: Motor
- muscles of anterior forearm
- except for ulna 1/2 of flexor digitorum profundus and flexor capri ulnaris
- LOAF
- Lumbricals (radial 2)
- O- opponens pollics
- A: abductor pollicis brevis
- F: flexor pollicis brevis
Median Nerve: common points of entrapment
- thoracic outlet
- pronator teres
- carpal tunnel
Ulnar Nerve: Sensory
- anterior and posterior surfaces of medial 1.5 of fingers and associated pal area (pinky and half of ring finger)
- doctor evil muscles
Ulnar Nerve: Motor
- intrinsic muscles of the hand
- except for the thenar muscles (LOAF)
- flexor carpi ulnaris and 1/2 of flexor digitorum profundus
Ulnar Nerve Common Points of Entrapment
- thoracic outlet
- cubital tunnel
- guyon’s canal
Ulnar; thoracic outlet
- more often affected in this area
Ulnar; cubital tunnel
- hit our funny bone- this area.
- it hurts because it is just hiding under the skin, there isn’t much covering or protection over it, ligament is over ulnar nerve and if ligament is damaged then it can allow ulnar nerve to stick out of cubital tunnel
Ulnar: guyon’s canal
right by our wrist (pesiform)
ulnar nerve entrapment deficits
- lots of deficits in hand, thumb won’t be very affected, grip strength deficits, and pins and needles
Radial Nerve: sensory
- posterior forearm and most of posterior hand (radial 1/2)
Radial Nerve: Motor
- elbow, wrist, finger, extensors, supinators
- all extensors
Common points of entrapment for radial nerve:
- thoracic outlet- less common
- mid-humerus; radial nerve spirals around humerus and wedges between spinal groove of humerus. fracture here we can injure the radial nerve
- radial tunnel: goes through a couple muscles and we can get posterior interosseous nerve injury
Humerus Fractures: proximal MOI- younger people
MOI: high energy trauma (young patients) , example falling off a bike after landing a big jump
Humerus Fractures: proximal MOI: older people
FOOSH- fall on outstretched arm
- common for old people to slip and fall
- may have neruovascular compromise, especially in the axillary nerve- sharp pieces can tear through the nerve
Axillary Nerve Injury Deficits : motor
- deltoid (anterior, middle and posterior deltoid)–> GH flexion, extension, abduction, - teres minor (GH external rotation)
Axillary Nerve Injury Deficits: sensory
- anterior, lateral, posterior upper arm (where deltoid is)
- anterior dislocation can be better, your axillary nerve injury can shut down muscles and person cannot move, therefore they can’t hurt themselves again
- secondly, greater tuberosity fracture, predictive of having decreased risk of injury reoccurring due to immobilizing longer.
- in event of instability, immobilization is good to help stiffen out
Humeral Shaft Fracture-MOI
- MOI: high-energy trauma (younger patients), FOOSH in older patients.
- may have neurovascular compromise- especially in the radial nerve
- radial nerve wraps around spiral
Radial Nerve Deficits: Motor
- wrist/finger extension, supination
Radial Nerve Deficits: sensory
- posterior forearm and posterior hand (radial 1/2)
Elbow Anatomy: head of radius
- articulates with humerus making up the radial humeral joint.
- we have a ligament running over the radial joint called annular ligament and we can sprain this ligament
Elbow Anatomy: radius fracture
- we can fracture radial and the fracture is common and tricky part is that when people break radial head, the fracture usually becomes intra-articular meaning the fracture line ends up going through the surface
- It is now prone to malalignment and improper healing and can get chronic elbow stiffness
Elbow Anatomy: medial and lateral epicondyle
- serve as common flexor origin or common extensor origin- flexor attach on medial and extensor origin is where wrist and fingers attach
Elbow Anatomy: coronoid process
- part of what articulates with ulnar humeral joint, can chip off a piece of this process and then the coronoid process can go within the joint and then you have a loose body feel where there is a piece of bone floating which causes a bony end feel and affects the joint
Ulnar Neuropathy: sensation
- ulnar half of D4 and all D5 and associated palm area
Ulnar Neuropathy: motor
- innervates the intrinsic muscles of hand except for thenar muscles (LOAF) and it does 2 muscles of forearm- flexor carpi ulnaris and ulnar 1/2 flexor digitorum profundus
Olecranon Dislocation and Nerve
- with dislocation we can influence ulnar nerve
- with every time we bend elbow, we wrap the ulnar nerve around. if we hit funny bone it causes issues up and down ulnar nerve.
- we can get students elbow where we have a bursa and if we rub elbows over a desk all day, friction can occur and cause it to swell up.
- can also get it from bending elbows in front of us on a table or desk
Olecranon Dislocation
- second most common large joint dislocation following shoulder dislocation
- most common paediatric dislocation
- posterior dislocation accounts for 90% of cases
- this is a medical emergency, can cause lasting and permanent neurovascular issues and this can cause irreversible damage
Olecranon Dislocation MOI
- usually a combination of
- axial loading
- supination/external rotation of the forearm
- valgus posterolateral force
Olecranon Dislocation: terrible triad
Can have elbow dislocation PLUS:
- LCL sprain,
- Radial head fracture
- Coronoid trip fracture
Olecranon Dislocation Clinical Presentation
- pain +++
- swelling
- swelling can lead to compartment syndrome–> bleeding or swelling in a compartment can increase pressure which can occlude perfusion pressure if compartment pressure raises above it,
- other words; we bleed into joint and pressure raises so high that there is no room for swelling and bleeding to disperse so it can cut off blood flow and cause tissue death
Olecranon Dislocation; deformity and neurovascular compromise
- deformity of elbow with limited ability to flex and extend the joint
- may be abnormally prominent posteriorly
- possible neurovascular compromise especially of ulnar nerve– decreased pulse
Epicondylalgias - Medial
- golfer’s elbow
- tendonopathy of the common flexor origin (CFO)
Epicondylalgias- Lateral
- tennis elbow
- tendonopathy of the common extensor origin (CEO)
Medial Epicondylalgias- Golfer’s Elbow
- repetitive overuse injury involving the anterior forearm tendons originating at the medial epicondyle of the humerus (CFO)
- PFPF
- one layer under that
- deep layer has 3 muscles; primary function is wrist and finger flexion and pronation
- pronator teres + wrist/finger flexors
- commonly tendinosis–> chronic issues, don’t come on overnight
- lacks inflammation
Medial Epicondylagias- Risk Factors
- sports or work related repetitive forearm pronation, excessive valgus stress at the elbow and wrist flexion
- dramatic valgus of elbow- traction at medial epicondyle (pitcher)
Medial Epicondylagias- Clinical Presentation
- pain with resisted wrist flexion, forearm pronation
- painful and weakened grip strength
- tenderness just distal (~0.5-1cm) and at medial epicondyle
Lateral Epicondylagia- Tennis Elbow
- repetitive overuse injury involving the posterior forearm tendons originating at the lateral epicondyle of humerus (CEO)
- supinator + wrist/finger extensors
- extensor carpi radialis brevis is most commonly effected
- most commonly is tendinosis
- lacks inflammation
- ECRL- attaches on first finger making an L
Lateral Epicondylagia- Tennis Elbow test:
- resit finger extension of the middle finger, ECRB originates on lateral epicondyle and inserts on base of middle fingers metacarpal
Lateral Epicondylagia- Tennis Elbow Risk Factors
- sports or work requiring repetitive wrist extension and supination, especially if loads increase and/or rest periods decrease
- tennis backhand, muscles in posterior forearm are very activated, pulling happening at lateral epicondyle
- may not hurt with front hand swing but hurts more with back hand - posterior muscles affected- extensors are here
Lateral Epicondylagia- Tennis Elbow Presentation
- pain with resisted wrist extension, forearm supination
- painful and weakened grip strength
- tenderness just distal (0.5-1cm) and at lateral epicondyle
Epicondylagia Management: Education
- activity modification (avoidance of excessive gripping)
- equipment modification (decrease circumference, weight of handle)
Epicondylagia Management: exercise
- isometric> concentric> eccentric strengthening
- stretching/flexibility of wrist flexors and extensors
- if one is tight, the other has to fight against it
Epicondylagia Management: other
- golfers elbow strap
Carpal Tunnel: median nerve review
- median nerve ruin down middle of forearm
- dry needling, know exactly where median nerve is so you can avoid it
- assessing- tip of fingers so you know it’s more consistent
Carpal Tunnel Syndrome
- common peripheral entrapment neuropathy caused by compression of medial nerve at wrist
- due to elevated pressure in carpal tunnel, a narrow fibrosis-osseous pathway at the base of the palm
- 9+ tendons and medial nerve run through the carpal tunnel, any small increase in pressure can impinge these structures
- normal pressure within is 3-5mmHg, pressure exceeding 40-55mmHG can interfere with intramural circulation and impair blood flow within nerve
- nerve can become aggravated and starved of oxygen causing weakness
Carpal Tunnel Syndrome Etiology (locoregional)
- inflammatory
- tenosynovitis- inflammation of sheaving of tendon
anatomic:
- - bony abnormalities in carpal bones or radius (distal radish fracture, sublimed lunate - can manipulate and push it back to where it is supposed to be)
- more traumatic- distal radish fracture
Carpal Tunnel Syndrome Etiology- Systemic
- obesity
- inflammatory arthritis (rheumatoid)- already have inflammation, it can cause increase in pressure
- pregnancy (3rd trimester)
Carpal Tunnel Syndrome Symptoms
- paraesthesias- pins and needles, tingling, numbness through medial nerve distribution distal to wrist (first 3 fingers)
- grip strength weakness- LOAF muscles and majority of anterior forearm supplied by medial nerve
- atrophy of thenar eminence
Carpal Tunnel Special Tests
- +ve Tinel’s
- +ve Phalens / Reverse Phalens
Carpal Tunnel Management: education
- activity modification/ergonomics: fix set up of keyboards
Carpal Tunnel Management: other
- spinting: maintains wrist neutral to reduce amount of mechanical load on the medial nerve; particularly at night
- therapeutic ultrasounds
- acupuncture ?? maybe
- adding a padding under wrist or avoid vibrations
Exercise Contraindications for Carpal Tunnel
- forced or repetitive end-ranges wrist flexion or extension
- wrist curls, push ups
- forced repetitive gripping
- upper limb vibration (power tools or lawn mower)
Distal Radius Fracture;
- most common orthopaedic injury~ 18% of all fractures
- MOI: FOOSH
- susceptibel to fracture because it is ~80% of surface area and bears ~80% of the axial load
- treatment is based on fracture pattern and stability
Types of Distal Radius Fracture
COLLES
- most common
- broken fragment tilts upward (dorsally displaced)
- FOOSH; wrist extension
- Dinner fork deformity
Types of Distal Radius Fracture
SMITH
- broken fragment tilts downward (ventrally displaced)
- FOOSH; wrist flexion
- “garden spade deformity”
Distal Radius Fracture Management (extra-articular)
- closed reduction and split/cast immobilization
Distal Radius Fracture Management (intra-articular)
- 50% are intra-articular
- surgery; open reduction, internal fixation (ORIF) - plate and screws
Scaphoid Fractures
- most common carpal bone to fracture
- most often fractured at the proximal pole or waist of scaphoid
- MOI: FOOSH
- often misdiagnosed as wrist sprain
- some x rays can come back negative because fracture is so small its easy to miss
Scaphoid Fracture Clinical Presentation:
- tenderness of anatomic snuffbox- underneath is where we have scaphoid
- tenderness of scaphoid tubercle
- pain with longitudinal loading of thumb
- negative ^^ can rule it out because they have high sensitivity
- pain at base of thumb
- pain with wrist and thumb movements
Vulnerable to Avascular Necrosis
- nutrition of proximal pole is dependent on vascular flow from distal portions
- following a scaphoid fracture, the vascular supply can be interrupted resulting in non-union and/or osteonecrosis of proximal pole
Prognosis: distal pole
- immobilization for 6-8 weeks
- blood supply supplies distal first- good blood flow= good prognosis
Prognosis: proximal pole
- immobilization for 16-20 weeks
- may take longer to reach union, low union rate they may put screw in it to prevent non-union
- may require internal fixation surgery to address non -union
