Upper limb Conditions Flashcards
What do the terms ‘intrinsic’ and ‘extrinsic’ muscles of the hand mean?
The intrinsic muscles of the hand are those muscles that both originate and insert within the hand.
The extrinsic muscles of the hand are those muscles that originate in the forearm and insert into structures in the hand.
Name this condition, clinical feautures?
Olecroneon bursitis!
inflammation of the bursa due to Trauma or Prolonged pressure,infection
Normally, the olecranon bursa is flat. If it becomes irritated or inflamed, more fluid will accumulate in the bursa and bursitis will develop.
Soft, cystic & transilluminates
w/ light since its filled with fluid!
State 2 soft tissue complications that may occur after a closed Colles’ fracture.
- median nerve palsy and post-traumatic carpal tunnel syndrome (see below)
- tear of the extensor pollicis longus tendon (by attrition of tendon over a sharp fragment of bone)
what sign might one look for when diagnosing radial head/neck fractures?
fat pad sign
what is this?
which muscles have been paralyzed here?
Distal Ulnar Claw
long standing damage to the ulna nerve at the wrist
-Hyperextension at the MCP + flexion of the DIP & PIP of the 4th and 5th digits.
what is the most common cause of elbow pain?
what is the most common type of elbow fracture?
Tennis elbow>> Lateral tendinopathy
Radial Head fractures!
( kl shay laterally)
what is Guyon’s canal?
what happens if that area got compressed?
In a proximal clavicular fracture, auscultation of the chest must be performed and a chest X-ray may also be needed. What rare but important complication needs to be excluded?
Pneumothorax due to proximity of apex of lung to middle third of clavicle
what is the ‘anatomical snuff box’? what is its function?
indication of a SCAPHOID FRACTURE!
u feel tenderness upon palpation,
What complications may occur after anterior dislocation of the shoulder?
axillary artery and other structure of brachial plexus! & Rotator cuff injury.
this is sometimes known as popeye’s muscle,
what is the more sensible term?
long head of biceps rupture!
state 3 classical features of colle’s fracture, which additional fracture is seen in approx 50-60% of all cases of colle’s?
describe how the fall would look like?
what would injury of the radial nerve result in?
think of the muscles it innervates
paralysis of brachioradialis and all extensor muscles of the wrist and fingers.
“wrist drop” (i.e. inability to actively extend the wrist) and inability to actively extend the fingers.
The wrist is flexed because of unopposed flexor muscles and gravity.
Monteggia vs. Galeazzi Fractures
describe the route of the ulnar nerve after it leaves the arm
what is known as the students elbow?
Olecroneon bursitis!
inflammation of the bursa due to Trauma or friction!
risk factors of carpel tunnel?
Pregnancy
Thyroid disorders
Acromegaly
Diabetes
Menopause
Obesity
What complication can occur following a scaphoid #?
Avascular necrosis of proximal segment
Boxer’s fracture?
“drunk man hits wall”
break in neck of 5th metatarsel
Meta btyeen?! u know what i dont give 5 fucks
-nuckle descends
Why can superficial lacerations at the wrist result in loss of sensation in the palm of the hand and NOT in the digits?
At the wrist, the median nerve becomes superficial in the midline and gives off a palmar cutaneous branch which supplies the skin of the mid-palm.
- The digital nerves, however, arise from the median and ulnar nerves in the hand and hence are spared in very superficial lacerations at the wrist.*
- (shoofay alaa, the palmar branch 7ail yay to the surface, more prone to be damaged, ama il bajy shway deeper)*
In clavicle fractures,
Which parts of the brachial plexus are at most risk of injury i.e. which parts lie immediately posterior to the fracture point of the clavicle?
Trunks and divisions of brachial plexus.
Given its muscular attachments, into which position is the lateral clavicular fragment most likely to be displaced in a midclavicular fracutre? Explain your answer.
Osteoarthritis of the hand
Osteoarthritis of the hands usually affects the base of your thumb and the joints at the ends of your fingers, although other finger joints can also be affected.
Name the fracture:
state the side of the body,
name of the bone that is fractured,
part of the bone that is fractured
fracture pattern
If this is untreated, whilst chronic deformity may develop?
is the joint is involved? (articular) or not (extra-articular).
what structures can be ruined as well?
Supracondylar fracture in distal humerus (extra-articular)
- young children
- swelling, Bruising!
Ulnar nerve, median nerve, radial nerve, brachial artery
Volkmann’s ischaemic contracture
Neurovascular complicaitons!
most commonly u may injure the anterior interosseous nerve whch arises formt he median nerve,> check for “OK” sign!
Which nerve is most at risk during dislocation of the humeral head from the glenoid cavity?
How would you examine the patient to determine the integrity of this nerve? What would you not do and why?
Axillary nerve
Test for sensation in the ‘regimental badge area’ on the upper lateral part of the arm (area supplied by the cutaneous branch of the axillary nerve).
Do not test motor function in the acute situation, as this could lead to increased soft tissue damage and may damage the nerve you are trying to test.
Distal Radial fractures?
colles and smith
De Quervain’s tenosynovitis
what could of caused this?
what is it?
- Pain and swelling in radial side
- occurs due to inflammation, thickening & stenosis of synovial sheath
- more common in women
- -twisting turning wet towels
- -playing piano
- -hammering
how do we test for carpel tunnel syndrome?
Positive Phalen’s test: flexing the wrist for 60 seconds causes pain or paraesthesia in the median nerve distribution.
Positive Tinel’s sign: tapping lightly over the median nerve at the wrist causes a distal paraesthesia in the median nerve distribution.
Which artery and vein are most at risk of damage from a clavicular fracture?
What is their anatomical relationship to the nerves of the brachial plexus at this point?
Anterior to posterior: clavicle>subclavian vein>subclavian artery> trunks of brachial plexus.
Medial nerve lesion
What muscles will be paralysed?
Describe the consequences in hand movements
- Loss of opposition of the thumb
- Loss of sensation to the thumb, adjacent 2.5 fingers (gunshot move)
Name this condition, how did it occur? which sites r they most commonly found?
Gouty Tophi
Disorder of nucleic acid metabolism leading to Hyperuricaemia
- nodular masses of monosodium urate crystals deposited in the soft tissues of the body*
- develop in more than half of patients with untreated gout.
common in : Ear, Achilles tendon, elbow
Clawing of hand is less severe in
- proximal ulnar nerve lesion
- distal ulnar nerve lesion
choose and explain
proximal ulnar nerve lesion!
ulnar paradox!
High ulnar nerve injury> there is paralysis of the flexor digitorium PROFUNDUS ( suppose to do punch move) and so u cant do punching finger move at DIP. (less clawing) get it?
Distal ulnar nerve injury> we still have our Flexor dijitorum profundus, and so there more clawing!
Name this condition
Dupuytren’s Contracture
common in caucasians!
- (mostly genetic)
- alchololism
- diabetes
- epilepsy
- liver disease
What is the fat pad?
what is the function of the lumbricals?
flexes MCP
and extends PIP andDIP
in ulnar nerve injury
vise versa occurs and u get clawing!
What is the most common direction of dislocation and why?
In what position would the patient typically hold his arm?
it is weak on its inferior aspect. so the head of the humerus usually dislocates inferiorly,
but displaces in an anterior (subcoracoid location) due to the pull of the muscles.
This is referred to as an anterior (or antero-inferior) dislocation.
The arm would be externally rotated and slightly abducted.
what is a rheumatoid nodule? common sites? clinical feautures?
Mainfestation of RA,
FIRM swelling on touch like unripe fruit (that how u distinguish it from bursitis),
common sites: fingers, forearm, elbow
describe this default
what move occured this?
Anterioir dislocation of the arm
ra7 a9ikik kaf
Elbow Osteoarthritis vs Elbow Rheumatoid Arthritis
O>Degenerative disease of articular cartilage
RA> chronic Systemic Autoimmune disease that attacks lininf og the joints> “synovium”
Morning stifness
Describe this sign
how do patients present pain?
Fat pad sign or Sails sign (yellow arrows)
- and there swelling & effusion of the joint capsule! ususally blood collecting in the joint “hemarthrosis” (due to FRACTURE) and this displaces the fat pad & it’ll buldge up off the bone*
- indication that there has been a fracture!*
- Red arrow*> showing radial fracture!
lateral pain, modest swelling
what is shoulder impingment
When you raise your arm to shoulder height, the space between the acromion and rotator cuff narrows. The acromion can rub against (or “impinge” on) the tendon and the bursa, causing irritation and pain.
What clinical term is used to describe the abnormal sensation of ‘pins and needles’?
Paraesthesia (anaesthesia is loss of sensation and is incorrect).
what r the Factors contributing to shoulder stability?
What does gouty tophie affect?
Joints - recurrent attacks of arthritis
Soft tissues - ear, elbows, achilles tendon
name the condition?
PRESENTATION?
Ulnar nerve neuropathy> ‘funny bone’
‘Cubital Tunnel Syndrome’
- Compressive neuropathy of Ulnar Nerve at Elbow
- Ulna 1 1⁄2 digits > cause tingling sensation
- Paraesthesiae, numbness and weakness
cUbital tunnel> Ulnar nerve
Describe what this is?
what is this an indication of?
can they appear elsewhere? if so where?
- Heberden’s nodes- DIP distal interphalangeal joint (H-D) (High Definition)
- Bouchard nodes- PIP proximal interphalangeal joint (B-P) ( Blue Picture)
firm knobbly swellings form on the finger joints. These are caused by osteophytes.
they r clinical signs of osteoarthritis!
Reflex Sympathetic Dystrophy Syndrome
is a rare disorder of the sympathetic nervous system that is characterized by chronic, severe pain.
Name this condition
what complication follows this?
Scaphoid fracture!
- FOOSH
- Tenderness in ‘anatomical snuff box’
- hard to see on initial X-Rays!!
- bc the scaphoid as poor blood supply > slow healing & avascular necrosis
- risk of arthritis!
what happens if u get cubital tunnel syndrome?
tingling sensation of the 1 1/2 part of ur hand
what should one be aware when diagnosing lateral epicondylitis?
might be radiating pain from neck or shoulder
What diagnostic test can be performed to diagnose tenosynovitis?
Finkelstein’s test
Pulled Elbow? how does it occur? what is another name for it? who is it more common in and why? presentation?
nursemaids elbow!
Subluxation from annular ligament
Head of radius slips under annular ligament!
common in kids( 2-5 yr old)> cuz their ligaments arent that strong yet!
sudden pull in babies arm
- “la la la la bukuk bukuk”*
- Due to sublaxation and pain, the child keeps arm immobile and lets it hang downwards ( doesn’t use it) > chna paralyzed*
what is the most frequent carpal bone fracture?
scaphoid!
describe this condition
Calcific tendinitis
calcium hydroxyapetite deposit,
u can get a subacromial impingment if its large! (hard to abduct the arm)
if it bursts…..
Acute calcific tendonitis!
State two ‘common’ causes of posterior dislocation of the shoulder. In what position would the patient typically hold his arm?
seizures and electric shocks
Patients usually present with their arm internally rotated and adducted.
They demonstrate flattening / squaring of the shoulder with a prominent coracoid process.
The arm cannot be externally rotated into the anatomical position.
golfers elbow vs tennis elbow
what causes it?
which one is most common?
Theyre both forms of TENDINOPATHY!
Lateral Epicondylitis>> Tennis Elbow>>extesnor muscles problem
Medial Epicondylitis>> Golfer’s Elbow >>Flexor muscles probelms
TENNIS IS MORE COMMON
i mean c’monnn who plays golf anyways?? ;P
Lateral elbow tendinopathy (tennis elbow) most commonly results from microtears in which specific muscle?
Where is the pain experienced and which movement is most painful?
Extensor carpi radialis brevis (ECRB)
Lateral epicondyle, extension of the wrist (against resistance)
a patient comes in complaining of lateral elbow pain, what is the most common diagnosis?
what is the problem?
why dis it occur?
which ppl is is most common in?
Tennis elbow> lateral elbow tendonopathy
a problem with tendon attachting to the Lateral epicondyle!
extensor muscle problem!
Mostly manual workers!
“Tennis>extensor muscle”
BEWARE (salfat mama) : not all pain felt in elbow is tennis elbow! it might not be eblow pain, it could be pain coming from somewhere else! pain in subacromial region & deltoid is often felt in the upper arm, u get pain radiating down from the neck in the C5-C6 distribution, can also give u problems around the lateral region of the elbow too!
which type of fracture is commonly called the “dinner fork’?
“im calling u at the dinner table”
describe this fracture
Which nerve is most likely to be injured & why?
What would be the effect of this neurological injury on movement at the elbow?
what will happen to the wrist and fingers?
Comminuted fracture of the mid-shaft of the left humerus
Radial nerve; the nerve runs in the radial (or spiral) groove on the posterior surface of the shaft of the humerus
Flexion of the elbow will be normal. There will also be no effect or mildly compromised extension of the elbow.
wrist drop (cant extend wrist) and finger extension
The profunda brachii artery is also at risk in a midshaft humeral fracture.
If this artery is occluded, what effect, if any, would you expect to see on perfusion of the forearm and hand? Explain your answer.
No effect
bc the profunda brachii supplies the deep tissues of the arm but does not extend below the elbow
A 65 year old man falls onto his outstretched right hand (FOOSH), dorsiflexing her pronated wrist as she lands. She immediately develops pain, swelling and deformity of the right wrist. X-rays are obtained.
Name this condition
COLLES FRACTURE
Describe 3 feautres of this fracture that can be seen here!
Name the fracture
Boxer’s fracture!
Transverse
on attempt to make a fist, maham fails to do so, and instead the following poisiton is shown for her
what is this called?
what is it an indicaiton of?
when median nerve is injured at elbow, hand forms hand of benidiction upon attempting to make a fist!
Name this condition?
what is it caused by?
Posterior elbow dislocation
FOOSH
Pain / deformity / loss of function
(posterior is most common)
what is carpel tunnel syndrome?
Compression of the median nerve at the wrist due to increased pressure in the carpal tunnel
thenar muscle wasting!
Name these 2
which one is a functional problem which one is a cosmetc?
Varus> is a cosmetic problem
but valgus> is the functional ( problem cuz u can compress on ulnar nerve here)
what Anatomical lesions can follow an anterior dislocation?
Which condition, common in post-menopausal women, leads to increased risk of Colles fracture?
Osteoporosis
what is Allens test?
when do we do it?
measures arterial competency, and should be performed before taking an arterial sample
- Compress on both radial and ulnar to stop blood flow ( hand blanches)
- release hand from ulnar and see how long it takes to restore BF a colour
- if the hand remains blanched for longer than 15 secs, it means theres inadequete collateral cirulation btw the 2*
In Carpel tunnel syndrome why does the patient not decribe tingling in the palm of her hand?
bc the sensation to pam already branched wayyy before!
what is the ulnar paradox?
damage to the ulnar nerve at the elbow results in less clawing as compared to similar lesion at the wrist.
List some NVT assessments you might perform following a supracondylar fracture of the distal humerus
Parasthaesia
OK Sign
Radial pulse
Capillary return
u suspect either RA or OA,
how can u differentiate btw the 2 in this casE?
it is sclerotic!
which is a feautre of Osteoarthritis
which nerve & artery is at most risk of injury?
Median and brachial artery
A 55 year old woman has had a painful right shoulder for the past two weeks. She says that the pain is particularly bad when she tries to brush her hair or put on her coat. On examination, a painful arc is detected between 60 and 120 degrees of abduction. She is diagnosed with inflammation in a tendon that is impinging against the coracoacromial arch of the scapula.
The tendon of which muscle most likely to be inflamed?
(a) Deltoid
(b) Infraspinatus
(c) Subscapularis
(d) Supraspinatus
(e) Teres minor
The patient has supraspinatus tendonitis.
lateral fragment is displaced inferiorly and medially.
The action of which muscle is primarily responsible for the medial displacement?
Pectoralis major
Which nerve has been damaged ?
what do u call this appearence?
Long thoracic nerve
winging of the scapula
the serratus anterior is paralysed so is no longer able to pull the scapula forward
An 80 year old woman falls and lands on the lateral aspect of her right flexed elbow. She describes complete loss of sensation in her ring and little fingers
Which movement of her right thumb is most likely to be impaired?
The ulnar nerve runs posterior to the medial epicondyle in the cubital tunnel. Here it is susceptible to damage in medial epicondylar fractures.
Adduction
adductor pollicus
A 70 year old woman falls onto her outstretched left hand. She develops severe pain and deformity of the wrist.
After reduction of the fracture, the pain is improved and she now complains of numbness and tingling in her thumb, index and middle fingers.
Which of the following movements of her hand is most likely to be impaired?
(a) Abduction of the fingers
(b) Adduction of the fingers
(c) Flexion of the index finger at the distal interphalangeal joint
(d) Flexion of the index finger at the proximal interphalangeal joint
(e) Palmar abduction of the thumb
Palmar abduction of the thumb
Abductor pollicis brevis is supplied by the median nerve in the hand so will be paralysed.
i) On the outline of the dorsum of the hand below, shade the sensory distribution of the radial nerve.
ii) Mark with an X the most reliable place for testing sensory loss in a radial nerve lesion. what is this space called
X>> dorsum of the first web space
