upper limb clinical cases Flashcards
what can cause Rupture of tendon of long head of biceps brachii? In what age this injury usually occurs? From where the tendon is torn typically? What does it look like from the outside? Who typically get this rupture?
The rupture can be caused by wear and tear of an inflamed tendon as it moves back and forth in the intertubercular sulcus of the humerus. It may result from forceful flexion of the arm against extensive resistance, or, more often as a result of prolonged tendinitis (inflammation) that weakens it. This injury usually occurs in individuals over 35 years of age. Typically The tendon Is torn from it attachment to the supraglenoid tubercle of the scapula. The detached muscle belly forms a ball near the center of the distal part of the anterior aspect of the arm. The rupture results from repetitive overhead motions, such as occurs in swimmers and baseball pitchers, that tear the weakened tendon in the intertubercular sulcus.
what is biceps tendinitis? What is biceps tendinosis? What are they caused by?
First its important to understand that the long head of biceps brachii is enclosed by synovial sheath and that it moves back and forth in the intertubercular sulcus (the bicipital groove). tendinits is inflammation of the tendon. It results from microtears that happen when the musculotendinous unit is acutely loaded and is associated with degeneration of the tendon, vascular disruption and an inflammatory repair response. tendinosis is a degeneration within the tendon’s collagen causing disorganization of the collagen in response to poor vascularization, chronic overuse, or aging. There is no inflammatory response in this case.
what is a dislocation of long head of biceps brachii? What else does it cause?
The tendon of the long head of biceps can be partially or completely dislocated from the intertubercular sulcus in the humerus. In young persons it can be caused during traumatic separation of the proximal epiphysis (head of humerus) of the humerus. It can alsooccur in older persons with a history of biceps tendinitis. This condition also causes a tear in either subscapularis and supraspinatus muscles or in the glenohumeral ligament.
What are the consequences of a fracture in the midhumerus?
A mid humeral fracture may injure the radial nerve in the radial groove in the humeral shaft. When this nerve is damaged, the fracture is not likely to paralyze the triceps because of the high origin of the nerves to two of its three nerves. To my understanding a mid humeral fracture can cause a person to not be able to make extension of the palm.
What are the consequences of a fracture in the distal part of the humerus?
A fracture of the distal part of the humerus, near the supra epicondylar ridges, is called a supra-epicondylar fracture. The distal bone fragment may be displaced anteriorly or posteriorly. The actions of the brachialis and triceps tend to pull the distal fragment over the proximal fragment, shortening the limb. Any of the nerves or branches of the brachial vessels related to the humerus may be injured by a displaced bone fragment.
What is the biceps reflex? What does it imply?
The examiner’s thumb is firmly placed on the biceps tendon, and the reflex hammer is briskly tapped at the base of the nail bed of the examiner’s thumb. A normal (positive) response is an involuntary contraction of the biceps, felt as a momentarily tensed tendon, usually with a brief jerk-like flexion of the elbow. A positive response confirms the integrity of the musculocutaneous nerve and the C5 and C6 spinal cord segments.
what is Erb-duchenne plasy (waiter’s tip syndrome)? What is it caused by? What nerves are affected? What muscles? What does it look like?
It usually happens when the head and shoulder are forcibly separated. The C5 and C6 spinal nerves (roots) of the upper trunk are damaged. It affects the axillary, suprascapular and musculocutaneous nerves with loss of the intrinsic muscles of the shoulder and muscles of the anterior arm. The arm is mediallt rotated and adducted at the soulder: Loss of axillary and suprascapular nerves. The unopposed latissimus doesi and pectoralis major muscles pull the limb into adduction and medial rotation at the shoulder. The forearm is extended and pronated: loss of musculocutaneous nerve.
what happens when the lower (C8 and T1) brachial plexus lesion happen? What is it caused by? What does it look like?
Klumpke’s Paralysis Usually occurs when the upper limb is forcefully abducted above the head (e.g., grabbing an object when falling, thoracic outlet syndrome or birth injury) . Trauma will injure the C8 and T1 spinal nerve roots of inferior trunk. Primarily affects the ulnar nerve and the intrinsic muscles of the hand with a weakness of the median innervated muscles of the hand .Sign is combination of “claw hand” and “ape hand” (median nerve). May include a Horner syndrome.
Injury of Long Thoracic Nerve and Paralysis of Serratus Anterior
medial border of the scapula moves laterally and posteriorly away from the thoracic wall. This gives the scapula the appearance of a wing, especially when the person leans on a hand or presses the upper limb against a wall. will not be able to elevate normally above the horizontal position The nerve courses on the superficial aspect of the serratus anterior
Injury of Spinal Accessory Nerve
“dropped” shoulder with a marked ipsilateral weakness when the shoulders are elevated (shrugged) against resistance.
Injury to Dorsal Scapular Nerve
winged scapula. If the rhomboids on one side are paralyzed, the scapula on the affected side is located farther from the midline than that on the normal side.
Injury to Axillary Nerve
what muscles are effected?
after what instance it might get harmed?
what will the patient feel?
- deltoid and teres minor atrophy when the axillary nerve (C5 and C6) is severely damaged.
- Injured during fracture of surgical neck of the humerus.
- loss of sensation may occur over the lateral side of the proximal part of the arm
Rotator Cuff Injuries
who gets instable because of this?
what might get ruptured because of this?
- Produces instability of the glenohumeral joint.
- supraspinatus tendon is most commonly ruptured
in what case the bicep brachii is most efficient in
flexion of the arm?
in what case does is supinate strongest
When the elbow is flexed close to 90° and the forearm is supinated, the biceps
.is most efficient in producing flexion
when the forearm is pronated,
the biceps is the primary (most powerful) supinator of the forearm
How can you test the brachialis muscle?
•To test the brachialis, the forearm is semipronated and flexed against resistance. If acting normally, the contracted muscle can be seen and palpated
how do you test the coracobrachialis muscle?
•To test – elbow flexed, arm 15deg abduction – adduct against resistance
how do you test the triceps brachii muscle?
•Test - arm is abducted 90° and then the flexed forearm is extended against resistance
how do you test the pectoralis major muscle?
- Test - To test the clavicular head arm is abducted 90°; the individual then moves the arm anteriorly against resistance. If acting normally, the clavicular head can be seen and palpated.
- To test the sternocostal head the arm is abducted 60°…
how do you test the rhomboids muscles?
•Test: place hands posteriorly on the hips and push the elbows posteriorly against resistance provided by the examiner.
how do you test the teres major muscle?
•To test the teres major, the abducted arm is adducted against resistance.
how do you tst the infraspinatus?
•To test the infraspinatus, the person flexes the elbow and adducts the arm. The arm is then laterally rotated against resistance.
how do you test the teres minor muscle?
To test – external rotation strength in 90 deg abd
how do you test the subscapularis muscle?
•Test strength – lift off or bellypress test
how is it called?
what is the problem?
name: wrist drop
cause: radial nerve injury
this picture was taken while trying to close.
whats the name of the condition?
what is the problem?
name: hand of benediction
problem: median nerve injury
what is the name of this condition? what is the problem?
not a nerve problem. fingers all work but tight on
extension
name:dupuytren’s contracture
this picture was taken while at rest.
what is the name of the condition?
what is the problem?
name: claw hand
problem: ulnar nerve injury
what happens when someone with a median nerve injury tries to make a fist?
•when the person attempts to make a fist, the 2nd and 3rd fingers remain partially extended “hand of benediction”
in what nerve is there a problem?
- When the anterior interosseous nerve is injured, the thenar muscles are unaffected, but paresis (partial paralysis) of the flexor digitorum profundus and flexor pollicis longus occurs.
- When the person attempts to make the “okay” sign, opposing the tip of the thumb and index finger in a circle, a “pinch” posture of the hand results instead owing to the absence of flexion of the interphalangeal joint of the thumb and distal interphalangeal joint of the index finger
what is pronator syndrome?
what causes it?
what are the clinical signs?
after what sort o activities it might happen?
•Pronator syndrome, a nerve entrapment syndrome, is caused by compression of the median nerve near the elbow.
The nerve may be compressed between the heads of the pronator teres as a result of trauma, muscular hypertrophy, or fibrous bands.
Individuals with this syndrome are first seen clinically with pain and tenderness in the proximal aspect of the anterior forearm, and hypesthesia (decreased sensation) of palmar aspects of the radial three and half digits and adjacent palm
Symptoms often follow activities that involve repeated pronation.
what are the 4 places ulnar nerve injuries usually occur?
what will the patient usually feel?
what will an injury to the nerve in the distal part of the forearm cause?
what will happen to the wrist? abduction? adduction?
can he make a fist?
can he usually extend his hand?
- More than 27% of nerve lesions of the upper limb affect the ulnar nerve !
- Ulnar nerve injuries usually occur in four places:
- (1) posterior to the medial epicondyle of the humerus.
- (2) in the cubital tunnel formed by the tendinous arch connecting the humeral and ulnar heads of the FCU.
- (3) at the wrist.
- (4) in the hand.
- Ulnar nerve injury occurs most commonly where the nerve passes posterior to the medial epicondyle of the humerus - The injury results when the medial part of the elbow hits a hard surface, fracturing the medial epicondyle.
- Compression of the ulnar nerve at the elbow (cubital tunnel syndrome) is also common
- Ulnar nerve injury usually produces numbness and tingling (paresthesia) of the medial part of the palm and the medial one and a half fingers
- Uncommonly, the ulnar nerve is compressed as it passes through the ulnar canal
- Ulnar nerve injury can result in extensive motor and sensory loss to the hand.
- An injury to the nerve in the distal part of the forearm denervates most intrinsic hand muscles.
- Power of wrist adduction is impaired and the hand is drawn to the lateral side by the FCR (supplied by the median nerve) in the absence of the “balance” provided by the FCU.
- After ulnar nerve injury, the person has difficulty making a fist because, in the absence of opposition, the metacarpophalangeal joints become hyperextended, and he or she cannot flex the 4th and 5th digits at the distal interphalangeal joints when trying to make a fist.
- Furthermore, the person cannot extend the interphalangeal joints when trying to straighten the fingers. This characteristic appearance of the hand, resulting from a distal lesion of the ulnar nerve, is known as claw hand
- The deformity results from atrophy of the interosseous muscles of the hand supplied by the ulnar nerve. The claw is produced by the unopposed action of the extensors and FDP.
what is cubital tunnel syndrome?
- The ulnar nerve may be compressed (ulnar nerve entrapment) in the cubital tunnel formed by the tendinous arch joining the humeral and ulnar heads of attachment of the FCU
- The signs and symptoms of cubital tunnel syndrome are the same as an ulnar nerve lesion in the ulnar groove on the posterior aspect of the medial epicondyle of the humerus.
injury to the radial nerve in forearm
where is to injury most common to appear?
what is the primary clinical manifestation?
what will and injury to the deep branch cause?
how will we see an injury to the deep branch?
•The radial nerve is usually injured in the arm by a fracture of the humeral shaft.
This injury is proximal to the motor branches to the long and short extensors of the wrist from the (common) radial nerve, and so wrist-drop is the primary clinical manifestation of an injury at this
Injury to the deep branch of the radial nerve may occur when wounds of the posterior forearm are deep (penetrating). Severance of the deep branch results in an inability to extend the thumb and the metacarpophalangeal (MP) joints of the other digits.
If the nerve is intact, the long extensor tendons should appear prominently on the dorsum of the hand, confirming that the extension is occurring at the MP joints rather than at the interphalangeal joints (movements under the control of other nerves).
Loss of sensation does not occur because the deep branch of the radial nerve is entirely muscular and articular in distribution
When the superficial branch of the radial nerve, a cutaneous nerve, is severed, sensory loss is usually minimal. Commonly, a coin-shaped area of anesthesia occurs distal to the bases of the 1st and 2nd metacarpals.
The reason the area of sensory loss is less than expected is the result of the considerable overlap from cutaneous branches of the median and ulnar nerves.
