Clinical Relevance

Question 0

How can a winged scapula occur?

Answer 0

Trauma to the shoulder
Repetitive movements involving the shoulder
Removal axillary lymph nodes - surgery can damage the nerve
Structures becoming inflamed and pressing on the nerve

Question 1

What is a winged scapula?

Answer 1

Occurs when there is damage to the long thoracic nerve, paralysing the serratus anterior
Scapula is no longer held against the rib cage

Question 2

What is compartment syndrome?

Answer 2

If an artery bleeds in a compartment, it can damage the nerve. Symptoms include pain and parasthesia

Question 3

What produces the Popeye sign?

Answer 3

Rupture of the biceps tendon, most commonly the long head

Question 4

Test the dorsal scapula nerve?

Answer 4

Test function of rhomboids

Patient places hands on hips, pushes elbows posteriorly against resistance

Question 5

Test the axillary nerve?

Answer 5

Abduct arm above 15* against resistance - deltoid can be seen and palpated

Question 6

Test for accessory nerve?

Answer 6

Ask patient to shrug shoulders against resistance. Tests the trapezius also

Question 7

If you have a fracture of the surgical neck of the humerus, what structures should you be concerned about?

Answer 7

Axillary nerve and posterior circumflex artery

Question 8

How would you test damage to the axillary nerve?

Answer 8

Patient cannot abduct their arm due to loss of function of deltoid and teres minor
Regimental badge area

Question 9

What structures are we concerned about in a mid shaft fracture of the humerus?

Answer 9

Radial nerve and profunda brachii artery which are tightly bound in the radial groove

Question 10

What do we see if there is damage to the radial nerve?

Answer 10

Wrist drop - it innervates the extensors of the forearm so will be paralysed and there is unopposed flexion of the wrist.

Question 11

How can you get a distal humeral fracture?

Answer 11

Falling on a flexed elbow

Question 12

What can be seen in a distal humeral fracture?

Answer 12

Volkmann’s ischaemic contracture - uncontrolled flexion of the hand due to flexors becoming fibrotic and short

Question 13

What structures are we concerned about in a distal humeral fracture?

Answer 13

Medial, ulnar and radial nerves.

Brachial artery

Question 14

What do you see as a result of damage to the ulnar nerve?

Answer 14

Ulnar claw

Question 15

What is the ulnar claw?

Answer 15

Little and ring fingers are hyperextended at the MCP and flexed at both the IP joints.
This is because the ulna nerve innervates the medial two lumbricals which normally flexes at the MCP joint and extends at the IP joint

Question 16

Someone has come in with a dinner fork deformity. What has happened?

Answer 16

Received a Colles fracture. They have posteriorly displaced the distal fragment of the radius.

Question 17

What happens if you break your scaphoid?

Answer 17

Tenderness over anatomical snuffbox.

Can lead to avascular necrosis

Question 18

How might you anteriorly dislocate your shoulder?

Answer 18

Trauma to a fully abducted arm, usually from a posterior direction

Question 19

What can be injured if you anteriorly dislocate your shoulder?

Answer 19

Axillary nerve

Radial nerve

Question 20

How can an upper brachial plexus injury occur?

Answer 20

A difficult birth or blow to the shoulder

Question 21

Which nerves are affected in an upper brachial plexus injury?

Answer 21

Those derived from C5 and C6

Musculocutaneous, axillary, suprascapular and nerve to subclavius

Question 22

Which muscles are paralysed in an upper brachial plexus injury?

Answer 22

Supraspinatus, infraspinatus, subclavius, biceps brachii, brachialis, coracobrachialis, deltoid and teres minor

Question 23

What movements are lost or greatly weakened in an upper brachial plexus injury? What sensory things are lost?

Answer 23

Abduction of the shoulder, lateral rotation of the arm, supination of forearm and flexion at the shoulder

Lateral side of arm

Question 24

Characteristic sign of an upper brachial plexus injury?

Answer 24

Limb hangs limply, medially rotated, forearm pronates | Known as waiter's tip

Question 25

What can cause a lower brachial plexus injury?

Answer 25

Excessive abduction of the arm

Question 26

Which nerves are affected in a lower brachial plexus injury?

Answer 26

Ulnar and median nerves | Because they are derived from T1

Question 27

What is affected in a lower brachial plexus injury?

Answer 27

Small muscles of the hand | Loss of sensation along medial side of arm

Question 28

Characteristic signs of a lower brachial plexus injury?

Answer 28

Clawed hand, hyperextension at metacarpophalangeal joints, flexion at interphalangeal joints

Question 29

Where does an intracapsular fracture occur?

Answer 29

In the neck of the femur within the joint capsule

Question 30

Who is an intracapsular fracture common in?

Answer 30

The elderly after a stumble

Question 31

What structures are at risk in an intracapsular fracture?

Answer 31

Femoral circumflex artery | Avascular necrosis of the femoral head

Question 32

What does someone who has an intracapsular fracture look like? Why?

Answer 32

Distal fragment is pulled upwards and laterally rotated to give a shorter leg length and lateral pointing toes.

Question 33

Who is an extracapsular fracture more common in?

Answer 33

Young people

Question 34

What is an aneurysm?

Answer 34

Dilation of an artery, greater than 50% of the normal diameter.

Question 36

Where can the femoral pulse be palpated?

Answer 36

As it enters the femoral triangle, midway between the ASIS and the pubic symphysis.

Question 37

How can the popliteal artery be palpated?

Answer 37

Lie patient on their front and ask them to slightly flex their knee. Deep in the popliteal fossa.

Question 38

Where can the dorsalis pedis pulse be palpated?

Answer 38

Dorsum of the foot, just lateral to extensor hallucis longus tendon.

Question 39

What is a strain?

Answer 39

Excessive stretch/tearing of muscle fibres

Question 40

What is an avulsion fracture?

Answer 40

When a fragment of bone breaks away from the main body of the bone

Question 41

6Ps of compartment syndrome?

Answer 41

``` Pain Pulseless Pallor Paralysis Perishingly cold Paraesthesia ```

Question 42

What is compartment syndrome?

Answer 42

Increased pressure within a compartment. Increased impairment of muscle and nerve function and necrosis of soft tissue. Reduced blood flow

Question 43

Causes of compartment syndrome?

Answer 43

``` Fractures Burns Infection Burns Prolonged limb compression ```

Question 44

Which nerve is damaged if someone has foot drop?

Answer 44

Common fibular nerve/deep fibular nerve

Question 45

Patient cannot plantarflexes the foot against resistance and foot is permanently dorsi flexed. Likely diagnosis?

Answer 45

Ruptured calcaneal tendon

Question 46

What is intermittent claudication?

Answer 46

Pain on walking and relived by rest. Due to a build of atherosclerotic plaque Limits flow to muscles causing ischaemia and pain

Question 47

What is piriformis syndrome?

Answer 47

Pain in the buttock resulting from compression of the sciatic nerve by the piriformis muscle.

Question 48

Which artery can be damaged in a neck of femur fracture?

Answer 48

Medial femoral circumflex