Upper Limb Clinical cases

Question 1

22 year old man had a Foosh and present in A+E on the same day with tenderness in the anatomical snuff box.

a) what bone is likely fractured?
b) when do you xRay
c) what is the risk and why?

Answer 1

a) scaphoid
b) same day and 10 days -2 weeks later (fracture sometimes only visible when active healing starts)
c) Avascular necorsis of proximal part, radial artery supply is distal to proximal.

Question 2

Fractures at which site of the humerus will risk what nerve damage?

Answer 2

Intratuburcular- axilarry
midshaft- radial in the radial groove
supracondylar- median
Medial epicondyle- ulnar

Question 3

In a …. neck fracture we worry about the ant and post circumflex arteries being damaged?

Answer 3

surgical

Question 4

Where is the commonest place to fracture your clavicle?

Answer 4

Auction between medial 2/3 and lateral 1/3

Question 5

Which muscles are responsible for the position of the classic fragments and humorous after a typical clavicle fracture?

Answer 5

Sternocleidomastoid pulls the medial fragment up
The wight of the lower limb pulls the lateral 1/3 down
Pectorals major internally rates the upper limb

Question 6

What is a Klumke palsy?

Answer 6

Bottom of brachial plexus injurry through hyper-abduction of the shoulder- C8 and T1 injured- claw hand lost all intrinsics hand muscles

Question 7

What is a waiters tip posture?

Answer 7

Damage to the superior parts of the brachial plexus- hyper extension of the neck
Arm medially rotated, whist flexed and arm adducted

Question 8

Which nerves do we worry about at which positions in humerus damage?

Answer 8

Surgical neck- axillary
Midshaft- radial
Supracondylar- median
Medial epicondyle- ulnar

Question 9

Which direction do distal fragments move in a smiths fracture?

Answer 9

palmar movement

Question 10

If the radius fractures and the distal fragment moves dorsally its called a ? fracture

Answer 10

Colle’s

Question 11

Damage to the long thoracic nerve results in what?

Answer 11

Serratus anterior palsy- winging of the scapula

Question 12

What are the signs of an axillary nerve injury?

Answer 12

deltoid atrophy and loss of arm abduction
Hollow inferior to acromian
regimental badge sensation lost

Question 13

What is axillary clearance?

Answer 13

Removal of the apical lymph nodes in metastatic breast cancer to reduce chance of spread.

Question 14

Ruptured long head of biceps requires what action?

Answer 14

The tendon detaches from the supraglenoid tubercle of scapula and is often cosmetic so no surgical treatments available

Question 15

Why is triceps brachii often spared in a mid shaft humeral fracture affecting the radial nerve?

Answer 15

Often already supplied so only muscles distal to the injury affected

Question 16

A patient presents with weakened elbow flexion and opinion, what nerve injury do you suspect?

Answer 16

Musculocutaneous nerve - lateral forearm senation will also be reduced

Question 17

What are the borders of the cubital fossa and how do you remember the contents?

Answer 17

Sup- imaginary line between humeral epicondyles.
med- pronator teres
lat- brachiradialis
The median cubital vein is superficial to it and is used in venipuncture
TAN- biceps tendon, branchial artery, median nerve

Question 18

Name the borders of the anatomical snuff box

Answer 18

Extensor pollisuc longus- medial

abductor pollicus longus and extensor pollicus brevis - lateral

Question 19

What is lateral epicondylitis?

Answer 19

Inflammation of the common extensor tendon - tennis elbow

Question 20

Why do olecranon factors often need surgery?

Answer 20

Triceps brachii pulls fragment up and seaplanes the fracture.

Question 21

The okay sign is used to check fucntion of which nerve?

Answer 21

Median

Question 22

Where is the median nerve prone to harm?

Answer 22

Elbow

Question 23

What 4 places may the ulnar nerve be damaged?

Answer 23

Post to med epicondyle
Cubital tunnel
Wrist
Hand

Question 24

What is the ulnar paradox?

Answer 24

Ulnar claw exist when you ask a patient to make a high five hand.
If ulnar N is damaged at the elbow you damage innervation to FDP- which makes the claw look less bad.
If the nerve is damaged at the first FDP has already been supplied and thus looks worse

Question 25

Cubital tunnel syndrome gives paralysis where?

Answer 25

Medial half of palm and medial 1.5 digits

Question 26

What is duputrens contracture?

Answer 26

Palmer fascia thickens, fibrosis and contracts, pulling the 4th and 5th metacarpals toward the palm.

Question 27

What is tendosynovitis?

Answer 27

Infection of synovial sheaths on the digits.

Question 28

What happens in carpel tunnel?

Answer 28

Median nerve compresed as it enters the hand.

This can be through the tunnel getting smaller or the tendons with in swelling up and taking up more space.

Question 29

What wrist injury may injure the median nerve at the wrist and what muscles will be paralysed?

Answer 29

Self harm
Lumbrical (lateral 2)
Oponins pollicus
Abductor pollicus brevis
Flexor pollisus brevis

Question 30

What is ulnar canal syndrome?

Answer 30

Compression of the ulnar nerve in Guyons tunnel at the wrist

Question 31

What is nurse maids elbow?

Answer 31

subluxation of the radial head through the annular ligament

Question 32

What gives a painful arc?

Answer 32

degenerative tendonitis

humeral head pinches of coracoacromial arch.

Question 33

Which way would the humerus dislocate in a seizure?

Answer 33

posterior

Question 34

Shoulder dislocation risks which nerve?

Answer 34

Axilary

Question 35

Elbow dislocations tend to be?

Answer 35

posterior