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Anatomy > Upper Limb II > Flashcards

Upper Limb II Flashcards

1
Q

Borders of the axilla

A

Apex = axillary inlet

  • Lateral border of the 1st rib
  • Superior border of scapula
  • Posterior border of clavicle

Lateral: Intertubercular groove of humerus

Medial: Seraatous anterior and thoracic wall

Anterior

  • Pectoralis major, Pectoralis minor
  • Subclavius muscle
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2
Q

Contents of the axillary inlet

A

Axillary artery

Axillary vein (cephalic and basillic veins)

Brachial plexus

Axillary lymph nodes

Biceps brachii (short head)
Coracobrachialis
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3
Q

Quadrangular space

A 
Borders:
Teres minor superiorly
Teres major inferiorly
Long head of triceps medially
Surgical neck of humerus laterally

Contents:

  • Axillary nerve
  • Posterior circumflex humeral artery (branch of axillary artery)
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4
Q

Clavipectoral triangle

A

Borders:

  • Clavicle
  • Pectroalis major
  • Deltoid

Contents:

  • Medial pectoral nerve
  • Lateral pectoral nerve
  • Cephalic vein
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5
Q

Borders of the antecubital fossa

A

Passageway between arm and forearm

Borders:

  • Lateral: medial border of brachioradialis
  • Medial: lateral border of pronator teres
  • Superior: imaginary line between epicondyles of humerus

Floor: brachialis and supinator

Roof: fascia and fat, reinforced by aponeurosis of biceps brachii –> contains median cubital veinCont

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6
Q

Contents of the antecubital fossa

A

Radial nerve: passes under brachioradialis

Biceps brachii tendon –> radial tuberosity

Brachial artery:bifurcates into the radial and ulnar arteries at the apex of the cubital fossa

Median nerve: leaves the cubital between the two heads of the pronator teres

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7
Q

Supracondylar fractures

A

Usually caused by falling on hyper-extended elbow

Complications:
Volkmann’s ischaemic contracture due to damage to bracial artery
– uncontrolled flexion of the hand, as flexors muscles become fibrotic and short

Median nerve palsy: anterior interosseous (test flexor pollicis longus by OK sign)
Radial nerve palsy

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8
Q

Borders of the carpal tunnel

A

Carpal arch
Lateral: scaphoid and trapezium tubercles
Medial: Hook of hamate and pisiform
Concave palmar surface

Flexor retinaculum
-Originates on lateral side and inserts on medial side

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9
Q

Contents of carpal tunnel

A

Sinlge tendon of flexor pollicis longus
-Has its own sheath

Four tendons of flexor digitorum profundus
Four tendons of flexor digitorum superficialis
-These two tendons lie within same sheath

Median nerve

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10
Q

Tendon running within flexor retinaculum

A

Flexor carpi radialis

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11
Q

Carpal tunnel syndrome

A

Most common mononeuropathy

Compression of the median nerve within the carpal tunnel –> wasting of thenar muscles

Mx:

  • Splint: holding the wrist in dorsiflexion
  • Corticosteroid injections
  • Surgical decompression of the carpal tunnel by dvision of the flexor retinaculum
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12
Q

Borders of the anatomical snuffbox

A

Ulnar / medial border: Tendon of extensor pollicis longus

Radial / lateral border: Tendon abductor pollicis longus AND extensor pollicis brevis

Proximal: styloid process of radius

Floor: scaphoid and trapezius

Roof: Skin

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13
Q

Contents of the anatomical snuffbox

A

Radial artery: runs on floor of snuffbox over scaphoid and trapezius
–> then turns medially and runs between heads of adductor pollicis

Superficial branch of the radial nerve
-Runs in skin and innervates dorsum of hand and back of lateral 3 1/2 fingers

Cephalic vein

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14
Q

Blood supply to the scaphoid

A

Blood supply runs distal to proximal

A fracture of the scaphoid can disrupt the blood supply to the proximal portion

Failure to revascularise the scaphoid can lead to avascular necrosis, and future arthritis

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15
Q

Fractures of the clavicle

A

15% in lateral 1/3

80% in middle 1/3

5% in medial 1/3

Fall onto outstrecthed hand

After a fracture, the lateral end of the clavicle is displaced inferiorly by the weight of the arm, and displaced medially by the pectoralis major

Medial end is pulled superiorly by the sternocleidomastoid muscle

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16
Q

Nerve sacrificed in ORIF or clavicles

A

Supraclavicular nerves:

Resulting in a post-operative numb patch over the shoulder.

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17
Q

Ligaments of the clavicle

A

Costoclavicular ligament (sternoclavicular joint)

Conoid ligament –> conoid tubercle

Trapezoid ligament –> trapezoid line

Coracoclavicular ligament

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18
Q

Muscles attaching to the clavicle

A

Deltoid

Trapezius

Subclavius

Pectoralis major

Sternocleidomastoid

Sternohyoid

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19
Q

Content of intertubercular sulcus

A

Tendon of long head of biceps brachii runs in sulcus

Attachment to lips
“a lady between to majors”

Pectoralis major –> lateral
Latissimus dorsi
Teres major –> medial

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20
Q

Muscles attaching to greater tubercle of humerus

A

Supraspinatus

Infraspinatous

Teres minor

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21
Q

Structures damaged during fracture of surgical neck of humerus

A

Axillary nerve –> paralysis of deltoid and teres MINOR muscle
+ anaesthesia to regimental badge area

Posterior xircumflex humeral artery

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22
Q

Structrues running in spiral groove of humerus

A

Radial nerve –> results in unopposed flexion of the wrist, known as ‘wrist drop’.
+ sensory loss over the dorsal (posterior) surface of the hand, lateral 3 and a half fingers dorsally

Profunda brachii artery

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23
Q

Muscles attaching to the shaft of the humerus

A 
Anterior
Coracobrachialis 
Deltoid to deltoid tuberosity
Brachialis
Brachioradialis

Posterior: Medial and lateral heads of triceps

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24
Q

Fossae of the humerus

A

Coronoid, radial anetriorly

and olecranon fossae posteriorly

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25
Q

Gartland classification

A

Used for classifying supracondylar fractures of the humerus

The Gartland classification:

  • Type 1 is minimally displaced
  • Type 2 is displaced with but with an intact posterior cortex
  • Type 3 is completely off-ended.

Type 1 can usually be managed conservatively with an above elbow cast whereas types 2 and 3 typically require surgical fixation with crossed, bi-cortical k-wires.

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26
Q

Monteggia’s fracture

A

Usually caused by force from behind the ulna

  • Fracture of the proximal ulna
  • Dislocation of the radius from capitulum, anteriorly at elbow
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27
Q

Galeazzi’s fracture

A

Fracture of the dista radius

Dislocation of ulna at distal radioulnar joint

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28
Q

Colle’s fractue

A

The most common type of radial fracture.
A fall onto an outstretched hand causing a fracture of the distal radius.

The structures distal to the fracture (wrist and hand) are displaced posteriorly. It produces what is known as the ‘dinner fork deformity’.

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29
Q

Smith’s fracture

A

A fracture caused by falling onto the back of the hand.

It is the opposite of a Colles’ fracture, as the distal fragment is now placed anteriorly.

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30
Q

Boxer’s fracrure

A

Fracture of the 5th metacarpal neck. It is usually caused by a clenched fist striking a hard object.

The distal part of the fracture is displaced anteriorly, producing shortening of the affected finger

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31
Q

Bennet’s fracture

A

Fracture of the 1st metacarpal base, caused by forced hyperabduction of the thumb.

This fracture extends into the first carpometacarpal joint leading to instability and subluxation of the joint. As a result, it often needs surgical repair.

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32
Q

Surface level scapula

A

2nd - 7th rib posteriorly

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33
Q

Acromioclavicular joint

A

Incomplete disc in joint

34
Q

Sternoclavicular joint

A

Articular disc in joint

35
Q

First bone to ossify in fetus

A

Clavicle

36
Q

Only bone to develop in a membane

A

Clavicle

37
Q

Most commonly fractured bone in bod

A

= clavicle

Most commonly fractured at junction between middle and outer 1/3

38
Q

Attachments of flexor retinaculum

A

Scaphoid - trapezium = lateral attachment

Pisiform - hook of hamate = medial attachment

39
Q

2nd metacarpal articulation

A

Three carpal bones

  • trapezium
  • trapezoid
  • capitate
40
Q

Capitate articulates distally with…

A

3 metacarpals

2nd
3rd
4th

41
Q

Abduction of shoulder

A

0-15 = supraspiantous

15 - 90 = deltoid

90 - 180 = rotation of scapule by trapezius and serratous anterior

42
Q

Retraction of the shoulder

A

Rhomboids
Middle fibres of trapezius

=retraction

43
Q

Clinical features of a fractured clavicle

A

Trapezius unable to hold weight of arm
- patient supports arm with contralateral hand

Lateral fragment depressed and drawn medially
-shoulder adductors e.g. pectoralis major

Fragements overlap

Medial fragment: slight elevation due to action of sternocleidomastoid

44
Q

Supraspinatus tendinitis

A

Painful arc between 60 - 120

45
Q

Joints of the elbow joint

A

3 joints, 1 synovial cavity

Hinge joint: humeroulnar at trochlear and trochlear fossa

Ball-and-socket joint: humeroradial joint at capitulum and radial head

Pivot joint: proximal radioulnar joint at radial notch of ulna and head of radius

46
Q

Flat hand abduction

A

The abductor/adductor actions of extensor digitorum and the long flexors are eliminated by placing the hand flat on a table

Abduction/adduction then become the actions of the intrinsic muscles only

47
Q

Divisions of the axillary artery

A

First part = pre prectoralis minor
-Superior throacic artery

Second part = under pectoralis minor

  • acromiothoracic artery
  • lateral thoracic artery

Third part = post pectoralis minor

  • subscapular artery
  • anterior circumflex artery
  • posterior circumflex artery
48
Q

Start and end of brachial artery

A

Starts: Lower border of teres major

Ends: Head of radius

49
Q

Medial nerve and brachial artery

A

The medial nerve crosses from lateral to medial

at mid-humerus

L –> M
lemon meringue

50
Q

Course of radial artery

A

Commences radial neck

Overlapped by brachioradialis upper 1/2

Distal forearm: lies between brachioradialis and flexor carpi radialis where it can be palpated at the wrist.

Distal to the wrist the branches given off contribute
to the superficial palmar arch.

Passes deep to tendons of abductor pollicis longus
and extensor pollicis brevis to enter the anatomical
snuffbox where it is palpable.

Pierces first dorsal interosseous and adductor pollicis
to contribute to deep palmar arch

51
Q

Course of ulnar artery

A

Commences at level of neck of radius

Passes deep to muscles from common flexor origin.

Lies on flexor digitorum profundus, overlapped by
flexor carpi ulnaris.

Crossed superficially by the median nerve separated
from it by the deep head of pronator teres.

Distally in the forearm it becomes superficial between
the tendons of flexor carpi ulnaris and flexor digitorum
profundus

Crosses in front of the flexor retinaculum to form
the superficial palmar arch with the superficial branch
of the radial artery

The ulnar nerve accompanies the artery on its medial
side in the distal two-thirds of the forearm and across
the flexor retinaculum

52
Q

Positions of the brachial plexus

A

Roots: between scalenus anterior and scalenus medius

tTunks: in the posterior triangle of the neck

Divisions: behind the clavicle

Cords: in the axilla

53
Q

Nerve braches of roots of brachial plexus

A

Nerve to rhomboids

Nerve to subclavius

Long thoracic nerve of Bell
-serratous anterior, C5, C6, C7

54
Q

Nerve braches of trunks of brachial plexus

A

Upper trunk

Suprascapular nerve

  • Supraspinatous
  • Infraspinatous
55
Q

Nerve braches of cords of brachial plexus

1 , 2, 3

A

Lateral
• Lateral pectoral

Medial
• Medial pectoral nerve
• Medial cutaneous nerve of the arm and forearm

Posterior
• Thoracodorsal nerve (to latissimus dorsi)
• Subscapular nerve
• Axillary nerve

56
Q

Axillary nerve

A

C5, C6

Posterior cord

Winds around surgical neck
-accompanied by cirucmflex humeral arteries

Motor: deltoid, teres minot

Sensation: Cutaneous branch supplying sensation to skin over deltoid (Regimental)

57
Q

Radial nerve

A

C5 - T1

Posterior cord

Passes posteriorly between long head and medial head of triceps
-accompanied by profuna brachii artery

Lies in spiral groove

Pierces lateral intermuscular septum at lower 1/3 of humerus to enter anterior compartment

Lies between brachialis and brachioradialis

Gives off POSTERIOR INTEROSSEOUS branch at level of lateral epicondyle
–> Radial nerve continues as superficial branch to
brachioradialis.

Above wrist emerges posteriorly from under brachioradialis and supplies sensation by cutaneous
branches to posterior aspect of radial three and a
half digits.

Main radial nerve supplies triceps, anconeus,
brachioradialis, extensor carpi radialis longus and
part of brachialis

Posterior interosseous branch supplies supinator,
abductor pollicis longus and all remaining extensor
muscle.

Cutaneous supply is to the back of the arm, the
flexor and radial aspects of the dorsum of the hand.

58
Q

Motor innervation of posterior interosseous branch of radial nerve

A

Posterior interosseous branch arise sat lateral epicondyle:

Abductor pollicis longus

Extensor carpi radialis brevis—deep branch of radial nerve

Extensor digitorum

Extensor digiti minimi

Extensor carpi ulnaris

Supinator muscle—deep branch of radial nerve

Abductor pollicis longus

Extensor pollicis brevis

Extensor pollicis longus

Extensor indicis

59
Q

Motor innervation of main radial nerve

A

Triceps

Anconeus

Brachioradialis

Extensor carpi radialis longus

Part of brachialis

60
Q

Musculocutaneous nerve

A

C5, 6, 7.

Lateral cord

Pierces coracobrachialis and runs between biceps
and brachialis

Supplies biceps, brachialis and coracobrachialis

Innervates the skin of the lateral forearm

61
Q

Course of median nerve in forearm

A

Enters the forearm between the heads of pronator
teres.
–> At this level it gives off the anterior interosseous
branch

Median nerve then lies on the deep aspect of flexor digitorum superficialis

Superficial at the wrist lying to the ulnar side of
flexor carpi radialis in the midline

Gives off palmar cutaneous branch at the wrist,
which passes superficial to the flexor retinaculum and supplies the palmar skin over the thenar eminence

Passes deep to the flexor retinaculum, giving
a branch to the thenar muscles beyond the distal
skin crease

MOTOR: all muscles of the flexor aspect of the forearm (except flexor carpi ulnaris and the ulnar half of flexor digitorum profundus)
AND muscles of the thenar eminence and the radial two lumbricals = LOAF

Supplies sensation to the radial three and a half digits and skin of the radial side of the palm

62
Q

Nerve roots of median nerve

A

C6 - T1

63
Q

Nerve roots of ulnar nerve

A

C8 - T1

64
Q

Ulnar nerve

A

C8 - T1

Medial cord

Lies medial to axillary and brachial artery up to mid-humerus

Pierces medial intermuscular septum –> descending on anterior surface of triceps

Passes behind medial epicondyle at elbow

Descends between flexor carpia ulnar and flexor digitorum profundus

Lies superficial on radial side of flexor carpi ulnaris

Accompanies ulnar artery in distal 2/3rds forarm

  • Ulnar artery lies on its RADIAL side
    i. e. lateral side

Gives off a dorsal cutaneous branch 5 cm above
the wrist, which is sensory to the dorsal aspect of
the ulnar one and a half fingers.

Crosses the flexor retinaculum superficially

Supplies:

  • flexor carpi ulnaris
  • medial half of flexor digitorum profundus
  • hypothenar muscles
  • interossei
  • medial two lumbricals
  • adductor pollicis
65
Q

Positions of ulnar nerve and artery

A

The ulnar artery lies on the raidal side to the ulnar nerve

i.e. ulnar nerve is closer to the body vs artery in anatomical position

66
Q

Erb’s paralysis

A

= forced head and shoulder apart

  • forced downward traction of upper limb during delivery
  • fall on head forcing head away from shoulder

C5 and C6

Paralysis

  • Deltoid
  • Supraspinatous
  • Infraspinatous
  • Brachialis
  • Biceps

= arm hangs limp by side as abductors paralysed,
with forearm pronated (brachialis and biceps flex and
supinate paralysed) and palm facing backwards

–>waiter’s tip position

67
Q

Kulmpke’s paralysis

A

= upper limb forced towards head

  • -> upward traction on uper limb
    e. g. breach delivery
    e. g. falling form tree and catching self causing severe upward traction

T1 = tree 1

Intrinsice muscle of hand paralysed

  • –> claw han
  • unapposed action of long flexors and long extensors
  • extends extend metacarpophalangeal joints
  • flexors flex interphalangeal joints
  • – extensors at interphalangeal joints from lumbrical and interossei lost

Hence clawing occurs owing to unopposed action of the long flexors

Area of numbness along inner and upper arm and forearm centred on elbow joint level

+/- associated with Horner’s syndrome due to
traction on sympathetic chain

Wasting of small muscles of hand; ‘channels’ between metacarpals, wasting of first dorsal interosseus

Similar lesions may occur with Pancoast’s tumour or a cervical rib.

68
Q

C5 C6 paralysis

A

Erb’s palsy

Waiters tip

69
Q

T1 paralysis

A

Klumpke’s palsy

Claw hand

70
Q

Axillary nerve paralysis

A

Damaged during fractured surgical neck of humerus

–> deltoid

= inability to abduction shoulder
+
Small patch of anaesthesia over the insertion of deltoid Regimental area

71
Q

Radila nerve palsy

A

= wrist drop

Damaged in fractures of midshaft of humerus, or
compression of nerve against humerus - Saturday night palsy

If solely posterior interosseous nerve damaged e.g. at raidal head, wrist extension preserved by innervation of extensor carpi longus

Anaesthesia on the skin on dorsum

72
Q

Posterior interosseous radial nerve palsy

A

May be damaged during fractures or dislocations of radial HEAD

Damage to posterior interosseous branch allows
extension of the wrist
–> intact extensor carpi radialis longus, which is supplied by the main radial nerve before the posterior interosseous branch is given off

Small area of anaesthesia on the skin on dorsum
of first web space

73
Q

Damage to median nerve

A

Supracondylar fracture of humer
Wrist injuries / lacerations

Damage at elbow:

  • Loss or pronation (pronator teres)
  • Weakness of wrist flexion (flexor carpia radialis + flexor digitorum profundus)
  • Loss of sensation lateral plam and radial 3 1/2 digits

AND

Damange at wrist
-Paralysis of thenar muscles
-Paralysis of radial two lumbricals
-Loss of sensation over radial three and a half
digits.

Damage of the nerve at both sites causes loss of
accurate opposition, and the loss of cutaneous
innervation makes this a serious injury with loss of
tactile response.

74
Q

Ulnar nerve palsy

A

Fracture medial epicondyle
Dislocation of elbow

Damage at wrist

  • Clawing of hand similar to Kulpke’s
  • Less clawing at 2nd and 3rd digits as median nerve supply to lumbricals intact
  • Sensory loss over medial 1 + 1/2 fingers

Damage at the elbow results in:

  • similar lesion to wrist except less clawing in fourth and fifth fingers, as flexor digitorum profundus to those fingers is paralysed
  • flexor carpi ulnaris is paralysed, therefore a tendency to radial deviation at the wrist.

Confirmation of the diagnosis is by testing
for lack of sensation of the medial one and a half
digits, and loss of abduction and adduction of the
fingers with the hand flat on a table (excludes trick
movements of long flexors and extensors)

75
Q

Synvoial sheaths of digits

A

Second, third and fourth fingers have synovial
sheaths that close proximally at the metacarpal head.

Synovial sheaths of thumb and little finger extend
proximally into the palm.

Synovial sheath of long flexor of the thumb extends
through the palm deep to the flexor retinaculum to
2.5 cm proximal to wrist (radial bursa).

Synovial sheath of fifth finger forms the ulnar bursa,
which encloses all finger tendons in the palm and
extends proximally deep to the flexor retinaculum
for 2.5 cm above the wrist.

76
Q

Infection in synovial sheaths to digits

A

If synovial sheath of 2 - 4 becomes infection –> confined to fingers

If 1st or 5th digits synovium infectiosn –> spreads to entire palm

77
Q

Sparing of proximal base of distal phalanx necrosis

A

Pulp space infection increases the pressure in the
space
This may result in arterial thrombosis and
necrosis of distal phalanx with the exception of its
base, which is spared because of the proximal branch.

78
Q

Dorsal oedema of hand

A

May indicate PALMAR infection

This is caused by the thick palmar skin being firmly
bound down to the underlying palmar aponeurosis. In
contrast, the skin of the dorsum of the hand is loose
and fluid can readily collect deep to it.

Thenar space
Midpalmar space
Both sites of potential infection

79
Q

Levels of axillary nodes

A

Level 1: below and later to inferolateral border of pectoralis MINOR

Level 2: behind pectoralis MINOR

Level 3: above the upper border of pectoralis MINOR

80
Q

Subclavian lymph trunk

A

Emergences from axillary lymph node drainage

Anatomy (22 decks)

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