Upper Limb II

Question 1

Brachial plexus

Answer 1

All of the nerves that innervate the upper limb originate from here, a somatic plexus formed by the anterior rami of C5 to C8 and most of the anterior ramus of T1, originates in the neck, passes laterally and inferiorly over rib 1, enters the axilla and associates with the axillary artery

Question 2

Brachial plexus parts

Answer 2

Roots, trunks, divisions, cords, terminal branches

Question 3

Brachial plexus roots

Answer 3

Posterior rami, anterior rami from C5-T1

Question 4

Brachial plexus trunks

Answer 4

Upper trunk (C5-C6), middle trunk (C7), lower trunk (C8-T1)

Question 5

Brachial plexus cords

Answer 5

Lateral cord (C5-C7), posterior cord (C5-T1), medial cord (C8-T1)

Question 6

Brachial plexus terminal branches

Answer 6

Axillary nerve (C5-C8), musculocutaneous (C5-C7), ulnar nerve (C8-T1), radial nerve (C5-T1), median nerve (C5-T1), provide motor innervation to muscles of the upper limb and sensory innervation to specific regions of the skin

Question 7

Completely severed nerve

Answer 7

Function of nerve proximal to injury is normal, function of the nerve distal to the injury is lost, results in loss of muscle function and regions of numbness on the skin

Question 8

Musculocutaneous nerve

Answer 8

Terminal branch of the lateral cord, enters the anterior compartment of the arm and runs between the brachialis and biceps brachii

Question 9

Median nerve

Answer 9

Terminal branch of both lateral and medial cords in the axilla, runs distally with the brachial artery and medial aspect of the arm, crosses anterior to the elbow joint and enters forearm, gives off a deep branch in the upper part of the forearm (anterior interosseous nerve) and continues into the hand through the carpal tunnel

Question 10

Ulnar nerve

Answer 10

Terminal branch of the medical cord, runs distally with the brachial artery and median nerve in the medial aspect of the arm, passes posterior to the medial epicondyle and enters the forearm, travels down the lateral aspect of the forearm close to the ulna, divides into a superficial and deep branch at the wrist

Question 11

Axillary nerve

Answer 11

Terminal branch of the posterior cord, exits through the posterior wall of the axilla, passes posterior to the surgical neck of the humerus

Question 12

Radial nerve

Answer 12

Terminal branch of the posterior cord, passes out of the axilla into the posterior compartment of the arm along the posterior aspect of the shaft of the humerus, enters forearm posterior to the lateral epicondyle of the humerus, travels to the posterior aspect of the hand, gives off a deep branch in the forearm (posterior interosseous nerve)

Question 13

Loss of nerve to a muscle

Answer 13

Results in atrophy disuse of that muscle

Question 14

Movement accomplished by 2+ muscles innervated by different nerves with single nerve damage

Answer 14

Results in weakness of the movement

Question 15

Movement accomplished by muscles innervated by the same nerve with single nerve damage

Answer 15

Results in complete loss of movement

Question 16

Loss of muscle function

Answer 16

Results in the opposite function/motion being dominant

Question 17

Nerve injury associated with motor deficit and…

Answer 17

Sensory loss

Question 18

Axillary nerve injuries

Answer 18

Anterior dislocation of the humerus, fracture of the surgical neck of the humerus

Question 19

Axillary nerve lesion deficit

Answer 19

Weakness in abduction of the arm, sensory loss on lateral shoulder and upper arm

Question 20

Radial nerve injury

Answer 20

Midshaft fractures of the humerus

Question 21

Radial nerve lesion deficit

Answer 21

Loss of wrist and digit extension, weakness of supination, “wrist drop”, sensory loss on posterior arm and forearm and dorsum of hand

Question 22

Median nerve injuries

Answer 22

Fractures of the elbow and distal humerus or within the carpal tunnel (carpal tunnel syndrome)

Question 23

Median nerve lesion deficit - humerus fracture

Answer 23

Weakened wrist flexion, hand deviates to ulnar side when wrist is flexed, loss of index and middle finger flexion at MP, DIP, and PIP joints, weakness of thumb abduction, loss of thumb opposition and loss of thumb flexion, loss of pronation, cannot make a fist, sensory loss on palmar and dorsal aspects of index, middle, and half of ring fingers and palmar aspect of thumb

Question 24

Median nerve lesion deficit - carpal tunnel syndrome

Answer 24

Weakness of thumb abduction and flexion, loss of thumb opposition (atrophy of thenar pad), sensory loss on palmar and dorsal aspects of index, middle, and half of ring fingers and palmar aspect of thumb

Question 25

Deep branch of the median nerve injury

Answer 25

Anterior interosseous syndrome

Question 26

Deep branch of the median nerve lesion deficit

Answer 26

Weakness of thumb flexion, loss of flexion of the DIP joint of the index and middle fingers, weakness of pronation, can’t make the “OK” sign, no sensory loss associated

Question 27

Ulnar nerve injuries

Answer 27

Fractures of the medial epicondyle or compression of the nerve against the bone (tennis elbow) or with fractures or lacerations to the medial side of the wrist

Question 28

Ulnar nerve laceration deficit - medial epicondyle fracture

Answer 28

Loss of abduction and adduction of fingers, loss of thumb adduction, loss of flexion of 4th and 5th digits at DIP joint, hand deviates to radial side when flexed, cannot make fist, sensory loss on medial side of hand and aspects of 4th and 5th digit

Question 29

Ulnar nerve laceration deficit - wrist fracture

Answer 29

Loss of abduction and adduction of fingers, loss of thumb adduction, sensory loss on medial side of hand and aspects of 4th and 5th digit

Question 30

Musculocutaneous nerve injury

Answer 30

Not common

Question 31

Musculocutaneous nerve lesion deficit

Answer 31

Weakness of forearm flexion, weakness of hand supination, weakness of arm flexion, sensory loss on lateral forearm

Question 32

Upper brachial plexus injuries

Answer 32

Birth injury or fall on the shoulder, separation of the head from the shoulder, Erb’s palsy

Question 33

Upper brachial plexus lesion deficits

Answer 33

Affects musculocutaneous, axillary, and suprascapular nerves, arm hangs by the side and is adducted and medially rotated, forearm is extended and hand pronated, loss of abduction and lateral rotation of the arm, loss of flexion and supination of the forearm, loss of sensations over a small area over the lower part of shoulder

Question 34

Lower brachial plexus injuries

Answer 34

Birth injury or sever abduction of the arm, Klumpke’s palsy

Question 35

Lower brachial plexus lesion deficits

Answer 35

Affects ulnar and possibly median nerves, results in ulnar claw hand due to the unopposed action of the long flexors and extensors of the fingers (hyperextension of the MP joints and flexion at the IP joints), loss of function of the intrinsic muscles of the hand, loss of function of the ulnar flexors of wrist and fingers, loss of sensation over a small area along the ulnar border of the forearm and hand

Question 36

Vascular supply to the upper limb

Answer 36

Originates from the subclavian artery in the root of the neck, continues posterior to the clavicle to enter the axilla (now called axillary artery), then branches off in the neck (thyrocervical trunk)

Question 37

Axillary artery

Answer 37

Gives off 5 branches in the axilla: superior throacic, thoracoacromial, lateral thoracic, subscapular, anterior humeral circumflex, posterior hand circumflex, then becomes the brachial artery in teh arm

Question 38

Brachial artery

Answer 38

One major branch, the deep brachial, which supplies the posterior compartment of the arm, splits into the radial and ulnar arteries anterior to the elbow

Question 39

Radial and ulnar arteries

Answer 39

Run to the hand to anastomose with one another as teh superficial and deep palmar arches

Question 40

Collateral branches around joints

Answer 40

Bypass any blockages of the main arteries to still get blood to the hand, also allow for planned ligation of the main artery at specific locations that would not result in serious consequences for the limb

Question 41

Collateral circulation around the shoulder

Answer 41

Blockages of axillary artery proximal to the subscapular artery can be bypassed by anastomoses between branches of the thyrocervical trunk and the subscapular artery

Question 42

Collateral circulation around the elbow

Answer 42

Blockages of the brachial artery distal to the origin of the superior and inferior ulnar collaterals may be bypassed by anastomoses between recurrent branches of the radial and ulnar arteries and the brachial and deep brachial arteries

Question 43

Collateral circulation around the wrist

Answer 43

Blockages of either the radial or ulnar artery in the distal forearm may be bypassed by the anastomoses established between the two arteries through the superficial and deep palmar arches

Question 44

Shoulder exam - inspection

Answer 44

Look for swelling, asymmetry, scars, ecchymosis, bruising, note posture and any deformities present (muscular atrophy, scapular winging, etc)

Question 45

Shoulder exam - palpation

Answer 45

Palpate the sternoclavicular joint, clavicle, acromioclavicular joint, subacromial bursa, coracoid process, bicipital groove, greater tubercle, lesser tubercle, scapula (spine, medial and lateral borders)

Question 46

Palpation of AC joint

Answer 46

Patient’s arm at his/her side, note swelling, pain and gapping, could indicate joint separation/pathology

Question 47

Palpation of bicipital groove

Answer 47

Patient sitting, beginning with arm straight, actively flexes bicep muscle while examiner provides supination and external rotation, palpates groove for pain indicating pathology associated with long head of biceps tendon

Question 48

ROM test - forward flexion

Answer 48

Arm straight and brought upward through frontal plane, move as far as patient can go above head, 0 degrees is straight down at patient’s side, 180 degrees is straight up (160-180 is normal)

Question 49

ROM test - abduction

Answer 49

Arm straight, hand palm up (arm supinated), 0 degrees is straight down at patient’s side, 180 is straight up (170-180 normal)

Question 50

ROM test - external and internal rotation

Answer 50

Arm at side, elbow flexed at 90 degrees and held at waist, examiner externally or internally rotates arms, normal ER is 45 degrees, normal IR is 55 degrees

Question 51

ROM test - Apley scratch test

Answer 51

External rotation and abduction, reach for upper scapula, compare bilaterally, internal rotation and adduction, reach for lower scapula, compare bilaterally

Question 52

Strength tests - flexion and extension

Answer 52

Graded on 5 point scale (5 is ROM against gravity with full resistance by examiner, 1 is no joint motion) and whether pain is present

Question 53

Strength tests - external and internal rotation

Answer 53

Sitting, arms at sides, elbows at 90 degrees, maintain elbow position at sides while external or internal rotation is attempted by patient against resistance, ER tests infraspinatus and teres minor, IR tests subscapularis

Question 54

Strength test - empty can test

Answer 54

Patient sitting with arms straight out, elbows locked, thumbs down and arm at 30 degrees in scapular plane, patient should attempt to abduct arm against examiner’s resistance, tests supraspinatus

Question 55

Strength test - lift off test

Answer 55

Patient rests dorsum of hand on back in lumbar area, attempts to push examiner’s hand away, tests subscapularis

Question 56

Rotator cuff special test - drop arm test

Answer 56

Patient abducts arm then slowly lowers, may be able to lower arm slowly to 90 degrees (deltoid function), arm then drop to side if rotator cuff is injured, tests the supraspinatus muscle primarily

Question 57

Rotator cuff special test - Neer’s sign

Answer 57

Patient seated with arm at side, palm down (pronated), examiner stabilizes scapular and raises the arm (between flexion and abduction), positive test will result in pain, impingement sign is elicited when the patient’s rotator cuff tendons are pinched under the coracoacromial arch

Question 58

Rotator cuff special test - Hawkin’s test

Answer 58

Patient standing, examiner forward flexes shoulder to 90 degrees, then forcibly internally rotates the arm, positive test will result in pain in area of superior glenohumeral joint or AC joint, suggests subacromial impingement or rotator cuff tendonitis

Question 59

Biceps tendon special test - Speed’s test

Answer 59

Forward flex shoulder against resistances while maintaining elbow in extension and forearm in supination, positive test results in tenderness of bicipital groove, indicating bicipital tendinitis

Question 60

Labral tear special test - O’Brien’s active compression test

Answer 60

Patient standing, arm forward flexed 90 degrees, adducted 15-20 degrees, with elbow straight, full internal rotation so thumb is pointing down, examiner applies downward force on arm, patient resists, patient externally rotates arm so thumb points up, examiner applies downward force on arm, patient resists, positive test is pain or painful clicking elicited with thumb down that is decreased with thumb up

Question 61

Labral tear special test - crank test

Answer 61

Shoulder elevated to 160 degrees in the scapular plane, a gentle axial load is applied through glenohumeral joint with one hand, while the other hand does IR and ER, positive test would be pain, catching or clicking in the shoulder

Question 62

Glenohumeral joint stability test - sitting apprehension test

Answer 62

90 degrees of abduction, examiner applies slight anterior pressure to humerus and externally rotates arm, positive test would be patient expresses apprehension (thinks the shoulder will dislocate), indicates loose capsule and/or ligaments

Question 63

Glenohumeral joint stability test - supine apprehension test

Answer 63

Patient in supine position with affected shoulder at edge of table, arm abducted 90 degrees, examiner externally rotates by pushing forearm posteriorly, positive test would be patient showing apprehension

Question 64

Glenohumeral joint stability test - relocation test

Answer 64

Performed after positive result on anterior apprehension test, patient supine, examiner applies posterior force on proximal humerus while externally rotating patient’s arm, positive test would be patient expressing relief