Clinical Correlations Flashcards
(116 cards)
1
Q
Name the most commonly broken bone and where this occurs within the bone. Describe what the fracture may look like after and any pathology this may cause.
A
- broken clavicle between the medial 2/3 and lateral 1/3
- medial 2/3 may be elevated by the sternocleidomastoid muscle and the lateral 1/3 may be depressed by the body weight of the limb or adducted by the pectoralis major
- ventral rami of C8-T1 may be lacerated
2
Q
Shoulder trauma may cause a _________ of the acromion at the acromioclavicular joint. Why doesn’t a complete dislocation occur?
A
- subluxation
- the coracoacromial ligament prevents dislocation at the AC joint
3
Q
At the glenohumeral joint, the head of the humerus articulates with what?
A
-glenoid fossa of the scapula
4
Q
For every ___ degree(s) of abduction of the humerus, there is ____ degree(s) of lateral rotation of the scapula.
A
- 3
- 1
- in full abduction, there is approximately 60 degrees of lateral rotation of the scapula
5
Q
Tendons of the rotator cuff may become torn or inflamed. Which tendon of the SITS muscles is most commonly affected?
A
-Supraspinatus
6
Q
Patients with rotator cuff tears experience what symptom(s)?
A
-pain anterior to the glenohumeral joint during abduction
7
Q
In a dislocation of the humerus at the glenohumeral joint, the head of the humerus can usually be found where? What pathology may this cause?
A
- commonly displaced inferiorly and anteriorly and be comes positioned just inferior to the coracoid process
- may stretch the axillary or radial nerve
8
Q
What issues may be caused from a fracture of the surgical neck of the humerus?
A
-axillary nerve may be lesioned and the posterior circumflex humeral artery may be lacerated
9
Q
What issues may be caused from a fracture of the greater tubercle of the humerus?
A
- avulsion of the greater tubercle and deattachment of the rotator cuff muscles from the humerus
- the remaining rotator cuff muscle, the subscapularis, medially rotates the humerus at the glenohumeral joint
10
Q
What issues may be caused by a transverse fracture of the humerus distal to the deltoid tuberosity?
A
-may result in abduction of the proximal fragment by the deltoid fragment
11
Q
What issues may be caused in a midshaft (spiral) fracture of the humerus?
A
-the radial nerve may be lesioned and the profunda brachial artery may be lacerated
12
Q
What issues may be caused by a supracondylar fracture of the humerus?
A
- contractions of the triceps and the brachialis may shorten the arm
- median nerve may be lesioned as a result of an intercondylar or supracondylar fracture at the distal end of the humerus
13
Q
Lateral epicondylitis
A
- tennis elbow (LET pneumonic)
- an inflammation of the common extensor tendon that results from forced extension and flexion of the forearm at the elbow
- patients exhibit pain over the lateral epicondyle which may radiate down the posterior aspect of the forearm
14
Q
Medial epicondylitis
A
- Golfer’s elbow
- an inflammation of the common flexor tendon that results from repetitive flexion and pronation of the forearm at the elbow
15
Q
What issues may be caused by a fracture of the medial epicondyle?
A
-ulnar nerve may be lesioned
16
Q
Colles’ Fracture
A
- fracture of the distal radius that may cause avulsion of the styloid process from the shaft of the radius
- radius may be shortened and the styloid process of the ulna may project further distally than the styloid process of the radius
- dinner fork deformity as a result of the posterior displacement of the distal part of the radius
17
Q
What bone in the wrist is most commonly dislocated and what syndrome may it cause and why?
A
- lunate
- typically dislocated anteriorly into the carpal tunnel causing carpal tunnel syndrome
18
Q
What/where is the Canal of Guyon and what traverses it?
A
- situated between the pisiform and the hook of hamate superficial to the carpal tunnel
- ulnar nerve, ulnar artery, and ulnar vein cross the wrist and pass into the hand after traversing it
19
Q
Most commonly fractures bone in wrist and what issues may arise because of it.
A
- scaphoid
- pain over anatomic snuffbox
- proximal part of scaphoid may undergo avascular necrosis because the blood supply to the bone supplies the distal part first and then the proximal part
20
Q
What anastomoses would occur if an occlusion of the first or second part of the axillary artery would occur?
A
- the circumflex scapular artery and thoracodorsal branches of the subscapular artery contribute to collateral circulation which may bypass blockage
- anastomoses may develop superior and posterior to the scapula between the thoracodorsal and circumflex scapular branches of the subscapular artery and the suprascapular, dorsal scapular, and posterior intercostal arteries.
21
Q
What causes Volkmann’s ischemic contracture and what would a patient present with?
A
- may be caused by a supracondylar fracture of the humerus
- displacement of the humerus as a result of the fracture may compress the brachial artery and result in ischemia of the forearm and hand
- in these patients, the hand is severely flexed at the wrist and the fingers are severed flexed at the interphalangeal joints
22
Q
Dupuytren’s contracture
A
- caused by fibrosis and shortening of the palmar aponeurosis
- thickening and shortening of the bands of the aponeurosis over the flexor tendons results in flexion of the ring and little fingers
23
Q
Describe the gradient of innervation of the brachial plexus
A
-ventral rami of the brachial plexus exhibit a proximal to distal gradient of innervation
24
Q
Muscles in the anterior arm, anterior forearm, and hand that act mainly as _______ are innervation by ___________. Muscles in the posterior arm and forearm that act mainly as _______ are innervated by _______________.
A
- flexors
- nerves that contain anterior division fibers
- extensors
- posterior division fibers
25
Preplexus injuries
-affect ventral rami or trunks of the brachial plexus proximal to the formation and branching of terminal and collateral nerves and have a more widespread effect than lesions to individual collateral or terminal nerves
26
What can cause suprascapular nerve lesions and what symptoms do patients present with?
- may be compressed as it courses through the scapular notch
| - experience shoulder pain, weakness of abduction of the arm at the GH joint and lateral rotation at GH joint
27
Surgical procedures of the axilla may result in a lesion of the __________ nerve. Patients may have difficulty doing what?
- thoracodorsal nerve
| - difficulty in elevating the trunk (climbing or pull-up) and difficulty in using a crutch
28
What nerve of the brachial plexus is most commonly lesioned and why? What do patients present with?
- long thoracic nerve because it courses superficial to the serratus anterior on the lateral wall of the thorax
- patients cannot hold the vertebral border of the scapula flat against the black and may have a "winging" of the vertebral bordeer of the scapula
- patients also have issues protracting scapula and raising their arm above their head
29
Lesions of musculocuteanous nerve
- uncommon, but can happen as it passes through the coracobrachialis muscle
- weakness in flexion of the forearm at the elbow and weakness in supination
30
What is compressed in carpal tunnel syndrome and where?
-median nerve as it courses through the carpal tunnel between the flexor tendons and the flexor retinaculum
31
Symptoms of carpal tunnel syndrome
- numbness and pain, particularly at night, over the palmar aspects of the thumb, index, and middle fingers
- ape hand due to weakness of thenar muscles (thumb cannot be opposed and is adducted and extended)
- lateral 2 lumbricals may be weakened, resulting in slight clawing of the index and middle fingers due to reduced ability to flex the MP joint and extend interphalangeal joints of these digits
32
Why may cutaneous sensation from the lateral aspect of the palmar be conserved in carpal tunnel syndrome?
-the palmar branch of the median nerve does not traverse the carpal tunnel
33
Where else may the median nerve be compressed and what additional symptoms may be in these patients?
- may be compresses proximal to cubital fossa in a supracondylar fracture or the humerus, or disal to cubital fossa as it passes between the 2 heads of the pronator teres
- in addition to altered sensation in the lateral part of the hand and a loss of thumb opposition, these patients experience weakness in pronation and weakness in ability to flex the thumb, PIP and DIP joints of index and middle fingers. and PIP joints of the ring and little fingers
- hand of benediction
34
Hand of Benediction
- proximal or distal median nerve lesions to cubital fossa
| - index and middle fingers remain extended when the patient attemps to flex those digits to make a fist
35
Lesion of recurrent branch of the median nerve
- distal to carpal tunnel
| - affects thenar muscles, resulting in ape hand with no cutaneous deficits
36
Anterior interosseus nerve lesions
- may be compressed near interosseus membrane deep in the anterior forearm
- result in weakness of pronation (pronator quadratus) and weakness in flexion at index and middle fingers at DIP joints
- weakness in ability to flex the distal phalanx of thumb (flexor pollicis longus) and an inability to form the letter o by touching the tip of the thumb to tip of index finger
37
Patients with an ulnar nerve lesion at the wrist may have a __________ which is caused by a _________.
- ulnar claw hand
- due to a weakness of the medial 2 lumbricals that flex at the MP joint and extend at the IP joints of ring and little finger
- weakness in abduct or adduct fingers or adduct thumb at MP joints (interosseus muscles and adductor pollicis) so they are unable to hold a piece of paper between the thumb and index finger or between adjacent finger
38
What occurs when ulnar nerve is lesioned at the elbow?
- as it courses adjacent to the medial epicondyle of the humerus, or compressed between 2 heads of the flexor carpi ulnaris
- in addition to ulnar claw and weakness in abduction and adduction of digits, patients may experience a weakness in the ability to flex the DIP joints of the ring and little fingers and a weakness in ability to flex the hand at the wrist
- pain and paresthesia in medial 1.5 digits
39
What can cause an axillary nerve lesion and what are the symptoms?
- result of dislocation of the head of the humerus from the glenoid fossa or by a fracture of the surgical neck of the humerus
- weakness in ability to abduct the arm at the GH joint because of loss of deltoid and altered sensation in skin covering the deltoid
- may be weakness in lateral rotation because of weakness of teres minor muscle
- deltoid may undergo atrophy resulting in a loss of the rounded contour of the shoulder
40
How is the radial nerve commonly lesioned and what do patients present with?
- spiral fracture of midshaft of the humerus
- wristdrop: weakness in ability to extend the hand at wrist and less of extension at MP joints of all digits
- supination may be weakened, but not lost bc biceps brachii is unaffected (musculocutaneous n)
- extension of forearm at elbow is spared because the triceps receives its innervation proximal to fracture
- pain and paresthesia in skin over first dorsal interosseus muscle
41
Distal to the elbow, which part of the radian nerve may be lesioned? how? symptoms?
- deep branch of radial nerve as it courses through the supinator by a subluxation of head of the radius
- wristdrop and weakness in ability to extend the MP joints but no serious sensory deficits
42
What part of the femur is a common site of fracture? Why is the worrisome?
- neck of the femur
| - worry about avascular necrosis of the head of the femur due to disruption of the medial circumflex femoral artery
43
In patients with fractures of the femoral neck, the thigh is _________ by the short lateral rotators of the thigh at the hip and by the _______.
- laterally rotated
| - gluteus maximus
44
A dislocation of the head of the femur at the hip joint occurs most commonly in the ______ direction. The thigh is ____________ due to what muscles? What nerve may be compressed and with what symptoms?
- posterior
- shortened and medially rotated by gluteus medius and minimus muscles
- sciatic nerve: weakness of muscles in posterior thigh, leg, and foot and paresthesia over posterior and lateral leg and dorsal and plantar surfaces of the foot
45
Terrible Triad of knee injuries
- tibial collateral ligament
- medial meniscus
- ACL
46
Patients with a medial meniscus tear have pain when ___________.
-the leg is medially rotated at the knee
47
How can one possibly tear only the ACL?
-blow to anterior aspect of the flexed knee
48
Patients with a torn ACL exhibit an ___________. Explain what this is.
- anterior drawer sign
| - tibia may be displaced anteriorly from the femur in the flexed knee
49
What type of ankle sprains are the most common and what is most commonly torn in these kinds of ankle sprains?
- inversion ankle sprains
| - anterior talofibular ligament
50
Dorsalis pedis pulse may be evaluated by compressing the ________________.
-dorsal artery of the foot against the tarsal bones lateral to the tendon of the extensor hallucis longus
51
During development, the lower limb undergoes a _________ so that the flexor muscles that were anterior in the embryo become situated posteromedially and extensor muscles that were posterior become anterolateral.
-medial rotation
52
Medial and posterior part of thigh, posterior part of the leg, and the plantar muscles of the foot are innervated by ___________.
-obturator or tibilar nerves, which contain anterior division fibers
53
Muscles in the anterior compartment of the thigh and the anterior and lateral compartments of the leg and the dorsum of the foot are innervated by _________.
-femoral or common fibular nerves, which contain posterior division fibers
54
Femoral nerve lesions: causes and symptoms
- may be damaged in the abdomen by an abscess of the psoas major
- weakness in ability to flex thigh at the hip, weakness in ability to extend the leg at the knee, and diminished patellar tendon reflex
55
Saphenous nerve lesions: cause and symptoms
- may be lesioned during a surgical procedure of the leg to remove part of the great saphenous vein or lacerated as it pierced through the wall of the adductor canal
- pain and parasthesia in the skin of the medial aspect of the leg and foot
56
Obturator nerve lesions: common locations and symptoms
- commonly lesioned in the pelvis
| - patients are unable to adduct the thigh at the hip and may have paresthesia in skin of the medial thigh
57
Lateral femoral cutaneous nerve lesions: cause and symptoms
- may be compressed as it passes posterior to the lateral part of the inguinal ligament just medial to the ASIS
- patients with compression have meralgia paresthetica present with pain and paresthesia in the anterolateral thigh
58
What does the superior gluteal nerve innervate?
-gluteus medius, minimus, and tensor fasciae latae muscles
59
Patients with a lesion of the superior gluteal nerve have a weakness in the ability to _______. What do these patients experience?
- abduct the thigh at the hip
- waddling or trendelenburg gait, in which the pelvis sags on the side of the unsupported limb
- pelvis sags on side that is opposite of lesioned nerve
60
What does the inferior gluteal nerve innervate?
-gluteus maximus
61
Patients with a lesion of the inferior gluteal nerve have a weakness in the ability to ___________. What kind of gait will these patients have?
- laterally rotate and extend thigh at hip (esp from flexed position like in walking up stairs, standing from a chair)
- gluteus maximus gait in which they thrust their torso posteriorly in an attempt to counteract the weakness of the gluteus maximus
62
What does the tibial nerve course with and where does it enter the sole of the foot?
- courses in posterior part of the leg with the posterior tibial artery
- passes through the tarsal tunnel and into the sole of the foot after coursing behind the medial malleolus
63
Tibial nerve innervates muscles in the posterior thigh, posterior leg, and plantar foot. It divides into _________ distal to the tarsal tunnel.
-medial and lateral plantar nerves
64
medial plantar nerve innervates what 4 muscles of the sole of the foot
1. flexor digitorum brevis
2. flexor hallucis brevis
3. abductor hallucis
4. first lumbrical
65
2 ways to lesion sciatic nerve
- intramuscular injection in the lower medial quadrant of the gluteus maximus muscle
- posterior dislocation of the femur
66
In patients with tibial nerve lesions in the gluteal region, weakness may be evident in the ability to ___________.
- flex leg at knee
| - plantar flex at ankle
67
The tibial nerve may be compressed at the ankle as it courses through the tarsal tunnel adjacent to the ________. Patients with tarsal tunnel syndrome have ___________.
- medial malleolus
| - pain and paresthesia in the sole of the foot
68
The common fibular nerve enters the _______ and divides into the _________.
- fibularis longus muscle
| - superficial and deep fibular nerves
69
What is the most frequently lesioned nerve in the lower limb? Where does this happen?
- common fibular nerve
| - as it passes around the neck of the fibula
70
Symptoms of patients with common fibular nerve lesions
- -patients experience footdrop which results form loss of dorsiflexion at the ankle, and a loss of eversion
- pain and parasthesia in lateral leg and dorsum of foot
71
Patients with footdrop may have a ___________, which means?
- steppage gait
| - raise their affected leg high of the group and their foot slaps the group when walking
72
Piriformis syndrome
-common fibular nerve may be compressed by the fibers of the piriformis muscle when the nerve passes through the piriformis rather than anterior to it with the tibial nerve
73
Superficial fibular nerve lesions: cause and symptoms
- lesioned as the nerve emerges from the lateral compartment of the leg
- patients experience pain and parasthesia in dorsal aspect of foot (except for first space between big toe and 2nd toe)
74
Deep fibular nerve lesions: cause and symptoms
- may be compressed in anterior compartment of leg
| - may have footdrop and paresthesia in skin of webbed space between big toe and 2nd toe
75
What is whiplash and what can result from it?
- cause cervical vertebrae to be strongly extended and then strongly flexed
- may result in an anterior dislocation of the facet joints
76
T/F There is a vertebral disk between C1 and C2.
-False
77
What cervical levels experience herniated nucleus pulposus most commonly?
- disk between C6 and C7, which compresses C7 SN
| - less commonly, C7 and T1 which compresses C8
78
Compression of C7 spinal nerve results in...
- referred pain in the neck and shoulder and pain and parasthesias in the index and middle fingers
- may be a diminished triceps reflex and weakness in extension of the forearm at the elbow (triceps) or weakness in extension of the wrist and fingers (posterior forearm muscles)
79
Compression of C8 spinal nerve result in...
- pain in neck and shoulder
- pain and parasthesias in ring and little fingers
- may be weakness in hypothenar and interosseous muscles of the hand
80
Where does a cervical rib arise and what problems may it cause?
- emerge from costal process of C7
- T1 spinal nerve and subclavian artery may be compressed as they course superior to the rib instead of superior to the first thoracic rib
- patient may present with diminished radial pulse and pain and parasthesias in medial forearm
- signs of horner's syndrome may also be seen
81
In lumbar vertebrae, superior and inferior articular processes are interconnected by an _____________, these structures, combined with the spinous process and a transverse process are in what shape?
- isthmus or pars interarticularis
| - scottish terrier
82
Spondylolysis
- defect or fracture of the isthmus, with no anterior displacement of the vertebral body
- radiographs show that the scottish terrier appears to be wearing a collar at the site of the fracture
83
Spondylolisthesis
- unilateral or bilateral defect or fracture of the isthmus is accompanied by an anterior displacement of the vertebral body
- radiographs show that the head of the scottish terrier (transverse process) appears to be separated from the body
84
Where is spondylolisthesis most common and what are the symptoms?
- most common between L5 and sacrum
- may stretch roots of lumbosacral spinal nerves in the cauda equina
- patients have bilateral lower back pain that radiates into both lower limbs and weakness in muscles of the legs
85
What is spinal stenosis? Where does it occur? What can cause it?
- narrowing of the vertebral canal
- can be caused by spondylosis in which degenerative changes occur in L4 or L5 intervertebral disks or by osteoarthritis at facet joints at this level
86
Where does a disk herniation most commonly occur in the lumbar region?
- Between L4 and L5
| - between L5 and S1
87
Compression of L5 SN
- may result in sciatica, characterized by pain that radiates from back through posterior thigh int leg and foot, combined with pain and parasthesias in anterolateral leg and dorsum of foot
- may be weakness in extension of the great toe (extensor hallucis longus) and weakness in dorsiflexion (tibialis anterior)
88
Compression of S1 spinal nerve
- may result in sciatica, combined with pain and parasthesias in the posterolateral leg, heel, and lateral side of the foot
- may be weakness in flexion of the leg at the knee (hamstrings), weakness in plantar flexion (gastronemius and soleus) and a diminished achilles tendon reflex
89
The sacrum contains 4 pairs of _______ and 4 pairs of ________. What do these do?
- dorsal sacral foramina
- ventral sacral foramina
- transmit dorsal rami and ventral rami of S1-S4 SN respectively
90
Epidural or caudal block
-performed by administering anesthetic through the sacral hiatus, which diffuses through the meninges and anesthetizes the roots of the sacral and coccygeal spinal nerves in the cauda equina
91
What happens first in patients with nerve compressions?
-sensory signs (pain, tingling, numbness) precede motor weakness
92
__________ are often keys to localizing lesion site
-cutaneous deficits
93
Describe the cutaneous innervation of the dorsal aspect of the hand
- median nerve does finger tips of lateral 3.5 digits
- radial nerve superficial branch does skin on 3.5 digits and snuffbox
- ulnar nerve does skin and medial surface of medial 1.5 digits
94
What is the most commonly lesioned nerve of the upper limb?
-median nerve
95
2 types of distal median nerve lesions and their deficits
1. Lacerate recurrent branch: loss of opposition, no sensory deficits, "Ape thumb"
2. carpal tunnel syndrome/lunate dislocation: altered sensation in lateral 3.5 digits, ape thumb, loss of opposition
96
Why can the lateral palmar region be spared in a distal median nerve lesion?
-the palmar branch of median nerve comes off before the carpal tunnel and thus may not be affected
97
What are the 2 proximal types of median nerve lesions? how can they occur?
1. compressed by supracondylar fracture of humerus; pronator teres syndrome
2. anterior interosseous nerve compressed in deep forearm
98
Symptoms of a proximal median nerve lesion
- can't oppose thumb, can't make a fist, weakness of pronation, altered sensation in palm and lateral 3.5 digits
- Sign: Hand of benediction or preacher's hand; ulnar deviation of wrist
99
What test is done to determine damage to the anterior interosseous n? Why?
- "O" test
- cannot make an O with index finger and thumb
- cannot flex at distal phalangeal joints due to weakness of flexor pollicis longus and lateral half of flexor digitorum profunus
100
How does one acquire a distal ulnar nerve lesion?
- lesioned by trauma to heel of hand
- fracture hook of hamate
- compression in canal of guyon
101
Symptoms of distal ulnar nerve lesion
- altered sensation in medial palm and medial 1.5 digits
- ulnar claw hand: weakness of lumbricals to ring and pinkie
- difficulty abducting 2-5 and adducting all fingers
102
How does one acquire a proximal ulnar lesion?
- fracture of medial epicondyle or cubital tunnel compression
- fracture of clavicle
103
Symptoms of proximal ulnar lesion
- ulnar claw plus weakness in wrist flexion and flexion of medial fingers
- radial deviation because flexor carpi radialis is still intact
104
How does one acquire a proximal radial nerve lesion?
- midshaft humeral fracture
| - compression in axilla by incorrect use of crutch
105
Symptoms of proximal radial nerve lesion due to compression in axilla compared to midshaft humeral fracture
compression: wrist drop with altered sensation in forearm and hand, triceps weakness
midshaft: wrist drop with altered sensation in forearm and hand. TRICEPS intact; may lacerate deep brachial artery
106
How does one acquire an axially nerve lesion? What will be the symptoms?
- lesioned by fracture of surgical neck; dislocation of the humerus; intramuscular injections
- weakened teres minor and deltoid; slight weakness in lateral rotation but not much due to infraspinatus in tact
- weakness in deltoid results abduction weakness but supraspinatous still in tact
- may lacerate posterior circumflex humeral vessels
107
Signs of lower trunk compression and fibers affected
- affects combined median and ulnar lesion
- thumb is abducted and extended
- fingers cannot be flexed at any point, all fingers clawed, sensory deficits include medial forearm
- simian hand
108
What is the most commonly lesioned nerve in the lower limb and where does this occur?
- common fibular nerve
| - most commonly lesioned in lower limb as it cross neck of fibula
109
Symptoms of common fibular nerve compression
- "foot drop" and loss of eversion
- altered sensation in lateral leg and dorsum of foot e
- WEAKness of inversion because tibialis posterior is still intact
110
Symptoms of tibial nerve lesion
- posterior thigh, hamstrings, posterior leg, achille tendon, toe flexors, inversion WEAKNESS
- patients cannot stand on tiptoes
111
Cause of obturator lesion, altered cutaneous sensation, and muscle weaknesses
- pelvic neoplasm, pregnancy
- medial thigh
- adduction at hip
112
Cause of femoral nerve lesion, altered cutaneous sensation, and muscle weaknesses
- diabetes, pelvic neoplasm, psoas abscess
- anterior thigh, medial leg to medial malleoulus
- flexion of hip, extension of leg at knee
113
Common fibular nerve lesion causes, altered cutaneous sensation, and muscle weaknesses
- compression at neck of fibula, hip fracture, dislocation of femur, piriformis syndrome
- anterior and lateral leg, dorsum of foot
- dorsiflexion, eversion of foot: foot drop and steppage gait
114
Tibial nerve lesion causes, altered cutaneous sensation, and muscle weaknesses
- diabetes, hip fracture, dislocation of femur
- posterior leg, sole, and lateral foot
- plantar flexion, flexion of toes: can't stand on tiptoes
115
Superior gluteal nerve lesion causes and muscle weaknesses
- misplaced gluteal injection and pelvic neoplasm
- abduction at hip
- pelvic tilt, waddling gate
116
Inferior gluteal nerve lesion causes, weaknesses
- pelvic neoplasm
- extension at hip from flexed position and very slight medial rotation
- cannot get up from chair
