Upper Limb - Clinical Cases Flashcards by Patrick Nelson

Klumpke palsy has unopposed action of extensors, leading to what clinical finding?

claw hand

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What functions are affected if the musculocutaneous n. is injured?

shoulder flexion weakened, flexion of the elbow joint weakened, supination of forearm weakened

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Popeye deformity is due to what type of injury?

rupture of the tendon of the long head of biceps brachii

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What nerve supplies skin on medial side of palm?

palmar cutaneous branch of ulnar n.

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Impingement of AIN - attempt to make ‘ok’ sign results in pinch posture, what mm are involved?

FDP (lateral 1/2), FPL

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What nerve innervates the skin of medial arm to medial epicondyle?

medial brachial cutaneous n.

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What is crepitus?

crackling sound from biceps tendinitis

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Simian hand is part of what nerve injury?

median n. at wrist

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What does the posterior antebrachial cutaneous n. supply?

skin of posterior forearm

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What does the superior lateral brachial cutaneous n. innervate?

skin over lower deltoid

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What is ‘students elbow’ otherwise known as?

subcutaneous olecranon bursitis

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What innervates the lateral aspect of the forearm (anterior and posterior)?

lateral antebrachial cutaneous n.

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What muscles are affected when the radial n. is injured?

triceps brachii, brachioradialis, supinator mm, extensors of wrist and fingers

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What is the major clinical finding in clavicle fractures?

shoulder drop because trapezius m. is unable to hold up the lateral fragment of the clavicle

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What does the intercostobrachial n. innervate?

skin of upper medial arm (with medial brachial cutaneous n)

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Klumpke palsy invovles loss of sensation of the medial part of dorsum of hand and medial 1.5 digits and palmar surface of hand, what nerves are damaged?

dorsal branch of ulnar n., palmar branch and palmar digital branches of ulnar n.

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Pronator syndrome is nerve entrapment/impingement where?

between 2 heads of pronator teres m. - median n

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Erb-Duchenne can also cause sensory loss in what nerves?

superior lateral brachial cutaneous n., lateral antebrachial cutaneous n.

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What nerve is damaged that may cause a winged scapula?

long thoracic n. (C567); injured in knife fight or mastectomy

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What supplies the inferlateral arm?

inferior lateral brachial cutaneous n.

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What is tennis elbow otherwise known as?

lateral epicondylitis

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How can the musculocutaneous n. be injured?

knife fight

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Claw hand is a characteristic of three nerve injuries.

lower brachial plexus, klumpke palsy, ulnar n damage

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The superficial branch of the ulnar n. gives rise to the common palmar digital nn. which then give rise to proper palmar digital nn. - what do they innervate?

skin of palmar and dorsal aspects of medial 1.5 digits

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What is dupuytren contracture?

progressive shortening, thickening and fibrosis of palmar fascia and aponeurosis; pulls fingers into partial flexion at MP and PIP joints

What aa. are involved in the scapular anastomosis?

dorsal scapular a., suprascapular a., circumflex scapular a.

Transverse fractures of the shaft are from direct blows to the humerus. What nerve is at risk for damage? What muscle carries the proximal fragment laterally?

radial n., deltoid m.

What muscle may atrophy when the axillary n. is damaged?

deltoid m.

Injury to the axillary n. may also cause a loss of sensation over the lateral part of proximal arm, what is also damaged?

superior lateral brachial cutaneous n.

What nerve supplies skin of palmar and dorsal aspects of thumb and lateral 3.5 digits?

proper palmar digital nn. of median n.

What innervates the skin of the dorsum of the hand lateral to axis of 4th digit?

superficial branch of radial n.

What nerve supplies skin on medial aspect of dorsum of hand and the proximal portions of little and medial 1/2 of ring finger?

dorsal cutaneous branch of ulnar n.

What sensory nerves are affected when the radial n. is injured? Leads to loss of sensation to inferior lateral arm, posterior arm, forearm, dorsum of hand and lateral fingers

lower brachial cutaneous, posterior brachial and antebrachial cutaneous and superficial radial nn.

Injury to the radial n. in the forearm results in extensor mm inabilities but no loss of sensation, why?

superficial branch of radial n. is cut but only a small area near base of 1st and 2nd metacarpals, the rest of the hand and arm is innervated by median and ulnar nn

Where do injuries to the ulnar n. typically occur? (4 places)

posterior to ME, cubital tunnel, at wrist, in hand

What nerve is at risk for damage in surgical neck fractures of the humerus? How does this fracture typically occur?

axillary n.; fall on outstretched hand

Ulnar canal/guyon canal syndrome may produce clawing at 4th and 5th digits but ability to flex is unaffected and there's no radial deviation, why?

innervation already branched off for flexors, intrinsic hand muscles are weakened

What is the characteristic disability from radial n. injury?

wrist drop- inability to extend wrist and fingers at MP joint, flexed position due to gravity and unopposed flexors

What ligaments are torn in a separated shoulder?

acromioclavicular and coracoclavicular ll.

If the radial n. is only injured in the radial groove, there is just loss of sensation to dorsum of hand and lateral fingers, what sensory nerve is affected?

superficial radial n.

Describe Erb-Duchenne palsy (upper brachial plexus injury) in terms of muscle damage

paralysis in supraspinatus, infraspinatus, teres minor, deltoid, biceps brachii, brachialis

Which type of fracture of the humerus may result in foreshortening? What nerve is at risk for damage?

spiral fractures of the shaft, radial n. at risk

Describe the hand of benediction.

inability to flex MPs of 2nd and 3rd digits because lumbricals 1-2 supplied by median n

What is golfers elbow otherwise known as?

medial epicondylitis

How does the long head of the biceps brachii rupture?

repetitive overhead movement, may result from forceful flexion of forearm against excessive resistance

What are 3 ways the radial n. can be injured?

improper use of crutches, falling asleep with arm over chair (aka saturday night palsy), posterior dislocation of glenohumeral joint

What fracture can occur from falling on a flexed elbow? What nerve(s) are at risk?

intercondylar fracture, median or ulnar nn.

What do upper brachial plexus injuries damage?

C56 nerve roots and/or superior trunk

Dislocation of the elbow joint may injury the ulnar n., causing what symptoms?

numbness of little finger, weakness of flexion and ulnar deviation of wrist

What nerve supplies the skin of central palm and branches proximal to carpal tunnel?

palmar cutaneous branch of median n.

What are the 4 ways that the axillary n. can get injured?

fracture of surgical neck, dislocation of glenohumeral joint, compression by improper use of crutches, intramuscular injections

What supplies the medial aspect of the forearm (anterior and posterior)?

medial antebrachial cutaneous n.

Where does the superficial branch of the radial n. innervate?

skin of lateral 1/2 dorsal aspect of hand and thumb, proximal portions of dorsal aspects of digits 2-3 and lateral half of digit 4

Injury to the musculocutaneous n. leads to sensory loss on the lateral surface of forearm, what nerve is also damaged?

lateral antebrachial cutaneous n

If the radial n. was injured in the radial groove, triceps brachii will typically just be weakened not paralyzed, why?

only medial head is affected

Hand of benediction is characteristic of what nerve injury?

median n.

Describe Colle's fracture.

complete transverse fracture of the distal 2cm of the radius

What does Erb-Duchenne clinically appear as?

waiter's tip position: ADD upper limb, MR arm, extended elbow

Describe the dinner fork deformity (from fracture of radius and ulna)

distal fragment of radius is displaced posteriorly and overrides the rest of the bone

Where does posterior antebrachial cutaneous n. innervate?

skin of posterior aspect of forearm to wrist

What does the posterior brachial cutaneous n. supply?

skin of posterior arm

What palsy involves lower brachial plexus injuries involve injury to inferior trunk (C8-T1)?

Klumpke

What is simian hand?

emaciation of thenar eminence, thumb is ADD and ext

One of the actions of the __________ is to ‘hold’ the scapula against the ribcage. If the \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_is damaged (and the serratus anterior therefore paralysed), a specific clinical sign is produced. In cases such as this, the scapula is no longer held against the ribcage – and protrudes out of the back. It is said to have a ‘winged’ appearance. \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_is thought to most commonly occur from traction injuries, where the upper limb is stretched violently.

serratus anterior long thoracic nerve Long thoracic nerve palsy

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_refers to inflammation of the tendons of the \_\_\_\_\_\_\_\_\_\_\_. This usually occurs secondary to the repetitive use of the shoulder joint. The muscle most commonly affected is the \_\_\_\_\_\_\_\_\_\_\_. During abduction, it ‘rubs’ against the coracoacromial arch. Over time, this causes inflammation and degenerative changes in the tendon itself. Conservative treatment of \_\_\_\_\_\_\_\_\_\_\_\_\_involves rest, analgesia, and physiotherapy. In more severe cases, steroid injections and surgery can be considered.

Rotator cuff tendonitis rotator cuff muscles supraspinatus rotator cuff tendonitis

The most common cause of accessory nerve damage is \_\_\_\_\_\_\_\_\_\_\_. In particular, operations such as cervical lymph node biopsy or cannulation of the internal jugular vein can cause trauma to the nerve. To test the accessory nerve, _____________ function can be assessed. This can be done by asking the patient to shrug his/her shoulders. Other clinical features of accessory nerve damage include muscle wasting, partial paralysis of the sternocleidomastoid, and an asymmetrical neckline.

iatrogenic (i.e. due to a medical procedure) trapezius

A complete rupture of any tendon in the body is rare. However, the _____________ is one of the more common tendons to rupture. This produces a characteristic sign on flexing the elbow – a bulge where the muscle belly is, called the ‘Popeye Sign’. The patient would not notice much weakness in the upper limb due to the action of the brachialis and supinator muscles.

long head of the biceps brachii

Clinical Relevance: Wrist Drop Wrist drop is a sign of _________ injury that has occurred proximal to the elbow. There are two common characteristic sites of damage: \_\_\_\_\_\_\_ – injured via humeral dislocations or fractures of the proximal humerus. \_\_\_\_\_\_\_\_\_ – injured via a humeral shaft fracture. The _________ innervates all muscles in the extensor compartment of the forearm. In the event of a \_\_\_\_\_\_\_\_\_\_\_\_, these muscles are paralysed. The muscles that flex the wrist are innervated by the median nerve, and thus are unaffected. The tone of the flexor muscles produces unopposed flexion at the wrist joint – wrist drop.

radial nerve Axilla Radial groove of the humerus radial nerve radial nerve lesion