Which muscle abducts to about 15 degrees and then what muscle takes over when you continue to abduct
Supraspinatus (with the help of the deltoid) and then deltoid
If the axillary A is cut at a certain region that we talked about, direction of blood flow in the __ artery is reversed which allows blood to flow to the distal portion of the axillary artery and the rest of the arm due to the scapular anastomoses
Subscapular
Name what is found in each space.
1) Quadrangular space
2) Triangular space
3) Triangular interval
1) Axillary nerve and posterior circumflex humerul artery
2) Circumflex scapula artery
3) Radial nerve and deep brachial artery
Which imaging technique is best to study rotator cuff and labrum injuries?
MRI
Which scapulohumeral muscle attaches to the ribs?
Serratus Anterior
Which ribs are vertebrocostal? (AKA they have their own costal cartilaginous anterior attachments to some part of the sternum)
Which ribs are vertebrochondral (AKA they have a convergence onto the cartilage of rib 7, but not their own)
True ribs (1-7)
False ribs (8-10)
The breast sits on top of pectoral fascia, which is right above which muscle? Also, between the breast and the pectoral fascia is a loose tissue plane or potential space called the __ space (bursa)
Also, what innervates the breast?
Finally, the breast attaches the mammary glands to the dermis of overlying skin via __ ligaments
Pectoralis Major, retromammary
Anterior and lateral branches of Intercostal nerves (4th-6th)
Suspensory (also referred to as Coopers ligaments)
What are the two origin arteries for blood supply to the breast?
Subclavian and axillary artery
What is the major venous drainage system of the breast?
Lateral thoracic vein to axillary vein (although internal thoracic vein to subclavian vein does a little as well)
What is the main lymph drainage system, especially in the superior lateral quadrant and center of breast?
Axillary lymph nodes (pectoral, central, apical) - which get drained by the subclavian lymphatic trunk
What do we see in the deltopectoral triangle?
The cephalic vein (Which can be seen traveling up from the arm and dumping into the confluence between the subclavian and axillary veins), deltopectoral lymph nodes, deltoid branch of thracoacromial A, and clavipectoral fascia
What artery would you expect to find in the shoulder region?
Axillary (the subclavian would be above the clavicle more towards the head and the brachial artery is more towards the arm)
The axillary artery starts just below the clavicle and ends around the surgical neck of the humerus. It is divided into 3 portions based on which muscle?
What divides the subclavian artery into 3 parts?
Pectoralis minor
Anterior scalene muscle
All veins in the hands eventually dump into the superficial veins of the arm and forearm and the deep brachial veins also called vena commitantes. For the superficial veins, the __ vein is more lateral in the arm and the __ vein is more medial in the arm. Then, these 3 veins dump into the axillary vein
Cephalic vein
Basilic vein
Name the fascia in the pectoral region
1) Descends from the clavicle, enclosing the subclavius and then pectoralis minor becoming continuous inferiorly with the axillary fascia (aka between deep cervical superiorly and axillary fascia inferiorly)
2) Surrounds the pectoralis major and continuous inferiorly with the fascia of the anterior abdominal wall
3) The pectroal fascia and clavipectoral fascia form this fascia
Also, the clavipectoral fascia becomes the __ ligament of axilla which merges to form the axillary fascia inferiorly
1) Clavipectoral fascia
2) Pectoral fascia
3) Axillary fascia
suspensory
Impingement syndrome is associated which what muscle? Also, what activities would you most likely see this in?
Supraspinatus (supraspinatus tendon can cause tendonitis and it can also involve the subacromial to cause bursitis)
Repetitive overhead activites (like tennis, pitching, swimming)
Subscapularis tears can lead to bicipital instability because of its connection to the ___ over the long tendon of biceps brachii
transverse ligament of the humerus
Although isolated ___ tears are rare since it’s such a big and strong muscle, it can be a common sports injury in pitchers, causing rotator cuff tendonitis.
subscapularis
What is the most commonly injured rotator cuff muscle?
Supraspinatus
The cervico-axillary canal that allows large arteries and nerves into the axilla can be found at what part of the Axilla?
Apex
What muscles form the anterior axillary fold?
What about the posterior axillary fold?
Pectoralis major
Latissimus dorsi, and teres major
What are the contents of the axilla?
Axillary A and V, Axillary lymph nodes, and brachial plexus
It the brachial plexus ventral or dorsal rami?
Ventral (C5-T1)
Which portion of the brachial plexus is supraclavicular? AKA if you have a supraclavicular brachial plexus legion it will affect this part of the plexus
What about the infraclavicular part of the brachial plexus?
Roots and trunks
Divisions, cords, and branches
Which artery is very closely related to the brachial plexus?
Axillary artery
The Ulnar nerve innervates primarily what?
The median nerve innervates primarily what?
The hand
The thumb
Anterior compartment does what function and involves which cords?
Posterior compartment does what function and involves which cords?
Flex elbow joint, Lat and medial cords
Extend elbow joint, posterior cord
Injuries to superior trunk (also known as Erbs Palsey) occurs in what vertebra?
Also how does this injury mostly occur and what are the clinical presentations?
C5 and C6
Excessive increase in the angle between neck and shoulder (Falls onto shoulder or grab head of baby)
“Waiters tip” aka arms adducted, medially rotated, pronation, and extension of elbow
What specific nerves are affected for C5 and C6 of a superior trunk injury (Erb’s Palsey)?
C5: Axillary, Suprascapular, Musculocutaneous nerves
SAM^
C6: Radial nerve
Injuries to inferior trunk (also known as Klumpke’s Palsey) occurs in what vertebra?
Also how does this injury mostly occur and what are the clinical presentations?
Finally, what nerves are affected?
C8 and T1
Forceful abduction of the arm (like pulling a baby out by the hand or holding on to a tree branch and the arm stretching) and often associated with Horner’s syndrome (which involves T1 sympathetic stuff)
Wrist is extended, claw hand
Median and ulnar nerves
What vertebra are affected in radial nerve injuries?
What is the clinical presentation for a radial nerve injury in the axillary region?
If you injure the humerus at the spiral groove by fracturing it, or compress the radial nerve due to “saturday night palsy” what clinical presentations do you expect to see?
C5-T1
Wrist drop due to nerve injury before it supplies the triceps (This can be due to improper crutch use) **Note that if the posterior cord was injured before the radial and axillary nerve split, this could also cause wrist drop
Problems with extension (since you affected the radial nerve) so difficulty extending the wrist or extending the fingers. Also wrist drop is seen
If one were to fracture their surgical neck of the humerus, dislocate the glenohumeral joint anteriorly, or have a rotator cuff repair surgery what possible injury could have resulted? Also what vertebra would this come from?
What clinical presentations would this cause?
Axillary nerve, C5 and C6
Numbness in posterior deltoid, difficulty abducting arm (due to deltoid fucked), diminished lateral rotation (due to teres minor fucked), etc.
A penetrating wound to the axillary region or surgical removal of axillary lymph nodes could cause what injury? Also, what vertebra are affected?
What are clinical presentations?
Long thoracic nerve, C5-C7
Can’t raise arms above 90 degrees since serratus anterior is injured. Also, winged scapula is seen
Fractures to medial epicondyle of humerus or entrapment of nerve in cubital tunnel can cause what nerve injury? And which vertebra are affected?
What would be the clinical presentations?
*** Note that another injury can cause this problem, which is mentioned in a later flash card
Ulnar nerve, C8 and T1 (and sometimes C7)
Numbness in 4th and 5th fingers (since remember, the ulnar nerve supplies the medial portion of the hand), weaking of grip, loss of ab and adduction in fingers
*Damage will involve flexors of wrist, digits, and intrinsic hand muscles
Fracture of the humerus above the condyles, entrapment of nerve by pronator teres (IMPORTANT), or carpal tunnel syndrome can result in injuries to which nerve? Also, what vertebra are affected?
What clinical presentation is seen?
Median nerve, C6-T1
Pain and tenderness in anterior-proximal forearm and decreased sensation along course of median nerve, along with affecting 1st digit. Also hand of benediction can occur because 2nd and 3rd digits can no longer flex
Hand of benediction injury is due to what nerve lesioned? What about a hand claw?
Median nerve
Ulnar nerve and median n
What stabilizes the shoulder joint? (AKA muscles that provide support for the joint)
The tendons from the rotator cuff (more-so than the joint capsule itself)
What nerves travel through the medial inter-muscular septa? AKA in the anterior compartment
What nerves travel through the lateral intermuscular septa? AKA the posterior comparment
Median and ulnar nerve
Radial nerve
The lateral antebrachial cutaneous n is a branch from what nerve?
Musculocutaneous n
If you hit your humerus posterior to the medial epicondyle aka the funny bone, what nerve did you hurt?
In other words, WHAT NERVE RUNS POSTERIOR TO THE MEDIAL EPICONDYLE OF HUMERUS?
Ulnar nerve
Which arch branches off the ulnar A? What about the radial A?
Superficial palmar arch
Deep palmar arch
Adduction????? is easier because of the __ of the radius
styloid process
All of the superficial 1st layer of muscles in the anterior compartment of the forearm attach to __
medial epicondyle of humerus
If the ulnar nerve becomes compressed by the humeral and ulnar heads of ___ musle in the region of the elbow, tingling and numbness in the medial part of the palm and medial digits can occur
Flexor carpi ulnaris
What nerve runs posterior to the medial epicondyle?
Ulnar N
A wrist drop would be due to breaking which part of the humerus and which nerve is affected?
Mid-shaft of humerus and radial N
Which muscle grouped in with the superficial extensors is a flexor of the elbow joint?
Brachioradialis
What are the two arteries in the forearm?
Ulnar and radial
Medial epicondyle of humerus is sometimes called the common __ origin, and the lateral epicondyle is the common __ origin
flexor
extensor
If the humeral shaft is fractured, what nerve can be injured due to its relationship to the spiral groove?
Radial nerve
What three muscles make up the anatomical snuff box, and what artery runs with it?
Also what is the floor and roof?
APL, EPL, EPB (the three outcropping muscles of the deep layer)
radial artery (scaphoid bone and superficial radial nerve branches are also inside it)
Floor is scaphoid bone, roof is superficial radial nerve branches
Give the full name of the joint, what type of joint it is (hinge, pivot, etc.), and what type of axial it is **Also note that all of these joints are synovial and diarthrotic (full movement possible)
1) Acromion process of scapula and clavicle
2) Scapula and humerus
3) Ulna (and radius) with humerus
4) Radius and ulna (give both)
5) Sternum and clavicle
1) Acromioclavicular, plane, No axial given
2) Glenohumeral (shoulder), Ball and socket, multiaxial
3) Elbow, hinge, uniaxial
4) Radioulnar proximal or distal, pivot, uniaxial
5) Sternoclavicular, saddle (with articular disc), multiaxial
The only “true” boney articulation between the upper limb and thorax is what joint?
Sternoclavicular joint
What are the four ligaments that reinforce the sternoclavicular joint?
Anterior SC lig
Posterior SC lig
Costoclavicular lig
Interclavicular lig
What 3 ligaments support the acromioclavicular joint?
Acromioclavicular ligament
Trapezoid ligament and Conoid ligament (both are parts of the coracoclavicular ligament that attach the coracoid process to the clavicle )
A separated shoulder would result from what joint being separated?
Also, list which grade shoulder separation each is
1) Acromioclavuclar ligament tear
2) Both AC and coracoclavicular ligaments torn
3) AC ligament sprain
Acromioclavicular
1) Grade 2
2) Grade 3
3) Grade 1
What is a cartilaginous rim that extends the surface area of the glenoid (to make it a little deeper)
Glenoid labrum
What holds the humeral head and glenoid cavity together? (Muscles and ligaments)
Also, what muscle pierces the capsule and originates on the supraglenoid tubercle located on the scapula?
Tendons of the rotator cuff muscle (SITS - mneumonic)
The ligaments are:
glenohumeral ligaments (three of them: superior, middle, and inferior)
Coracohumeral ligament,
transverse humeral ligament
coracoacromial ligament (although this does not really do anything since it attaches from the corocoid process to the acromion)
Biceps Brachii
Which 2 bursa are most likely to cause bursitis in the shoulder?
What are two other important bursa we are suppose to know?
Subacromial into the subdeltoid bursa
Subscapular bursa and subcoracoid bursa
What bursa facilitates movement of the supraspinatus tendon under the coracoacromial arch and of the deltoid over the joint capsule of the glenohumeral joint and the greater tubercle of the humerus?
Subacromial bursa (also could be called the deltoid bursa)
Shoulder dislocation involves what joint?
Shoulder separation involves which joint?
Glenohumeral joint * Don’t confuse this with shoulder seperation which is due to acromioclavicular problems
What direction are most shoulder dislocations?
Inferior (down) and anterior - this is because the coracoacromial structures and the rotator cuff tend to prevent upward dislocation
What nerve can be damaged with shoulder dislocation that wraps around the surgical neck of the humerus?
So what artery running with nerve could also be damaged?
Axillary nerve
Posterior circumflex humeral artery
If a patient comes in who previously disloacted their glenohumeral joint, between the age of 40-60, limited abduction and compensatory scapular movements; what injury might they have?
Adhesive capsulitis of the glenohumeral joint (also called frozen shoulder) - due to fibrosis between the joint capsule, rotator cuff muscles, and synovial bursa
Forceful and abrupt overhead motion in a baseball player, tennis player, pushing off with arms (like when an elderly is getting out of a chair), falling on an outstretched arm or hand could lead to what kind of injury
rotator cuffs
What joint articulation makes up the true elbow joint?
What remaining two joints make up the elbow?
Humeroulnar articulation
Humeroradial articulation and the proximal radioulnar articulation
What are the 4 ligaments that reinforce the proximal elbow joint?
Ulnar (medial) collateral ligaments, radial (lateral) collateral ligaments, Anular ligament (which wraps around the head of the radius), and the quadrate ligament (helps to reinforce the articulation between the radius and the ulna)
What are the ligaments that make up the proximal radioulnar joint?
What about the distal joint?
Annular and quadrate (even though we mention 4 total on a previous notecard)
Palmar radioulnar ligament and dorsal radioulnar ligament
Subluxation (disloaction of radial head) occurs when the head of the radius slips out of which ligament?
Anular ligament
** Children being suddenly lifted by their upper limb in a jerking motion are prone to this
Lateral epicondylitis, also called tennis elbow, occurs from repetitive use of forearm extensors, in particular the tendon of __ becomes inflamed or torn
Extensor carpi radialis brevis
**Remember, the lateral epicondyle is the common extensor origin ** and carpi radialis brevis attaches there
BBQ*
What nerve is injured when a winged scapula is present. Furthermore, what muscle is also injured and then what motion can no longer be completed?
Long thoracic nerve (C5, C6, C7) and serratus anterior. The upper limb can not be abducted above the horizontal because the serratus anterior lifts the scaupla upwards
BBQ*
What is the most common rotator cuff muscle torn?
Supraspinatus
BBQ*
An injury to the axillary nerve due to incorrect use of crutches, fracture of surgical neck of humerus, or dislocation of glenohumeral joint can cause the __ muscle to atrophy. In addition, loss of sensation can occur over the lateral side of the proximal part of the arm because it is supplied by the __, a branch of the axillary N.
Deltoid
Superior lateral cutaneous nerve of arm
BBQ*
Since breast cancer normally spreads by means of lymphatic vessels, where is the most common place to find a cancer?
If a cancer has invaded the retromammary space, pectoral fascia of the perctoralis major, or metastasized to the interpectoral nodes, a clincal sign would be breast ___ when the muscles contract
Axillary lymph nodes
elevation
BBQ*
If a women or man were to develop supernumeray breasts or nipples (more than 2 nips), what is this called?
Polymastia or polythelia
BBQ*
During subclavian vein puncture, technically the axillary artery is the entry point because the catheter is inserted right below the first rib/clavicle, however once inserted in instantly turns into the subclavian vein. Therefore, it is important that the axillary vein is ___ and inferior (superficial) to the axillary artery and brachial plexus
Anterior
BBQ*
During axillary lymph node dissection, which 2 nerves could possibly be injured
Long thoracic nerve and thoracodorsal nerve
BBQ*
When the superior root of the plexus is C4 and the inferior root is C8, what is this called?
What about when the superior root is C6 and the inferior root is T2
Prefixed brachial plexus
Postfixed brachial plexus
BBQ*
Backpacker’s palsy can result in injury to the superior brachial plexus which results in what nerves being injured?
Musculocutaneous and radial nerves (the end of SAM R- mnemonic)
BBQ*
Biceps tendinitis occurs in which head of the bicep since it is enclosed in a synovial sheath?
Furthermore, if a patient comes in with the “popeye deformity” aka a ball near the center of the distal part of the anterior aspect of the arm, what injury has most likely occurred?
Long head
Rupture of tendon of long head in biceps
BBQ*
If one were to have a mid-humeral fracture or a supra-epicondylar fracture, and injury the radial nerve, what muscles would NOT be affected?
Triceps (even though they are supplied by this nerve, the origin of the nerves to two of its three heads is so high that it probably wouldn’t be affected
BBQ*
If one were to be stabbed in the axilla, the musculocutaneous nerve could be injured. What kind of sensation would be lost in the skin?
Lateral surface of forearm due to the lateral antebcrachial cutaneous nerve being injured (since it is a direct branch of the musculocutaneous nerve)
BBQ*
Patients with tennis elbow have pain that is felt over the __ epicondyle and radiates down the __ surface of the forearm.
This is caused by repeated extension and flexion of the wrist, which injures the common extensor tendon (aka the tendon that which four superficial extensors are attached to?)
Lateral, posterior
ECRB, ED, EDM, ECU
BBQ*
If one were to break their olecranon process on their ulna, what muscle would pull it away from the bone due to tonic contraction?
Triceps, since they attach to the olecranon
BBQ*
What nerve is compressed in carpal tunnel syndrome
Median
BBQ*
If one were to injure the median nerve, which digits could no longer flex at the distal interphalangeal joints?
If you tell someone to make an “OK” sign but they can only make a pinching sign instead, which specific nerve is injured? And which muscles?
2nd and 3rd since FDS and the part supplied by the median nerve of FDP is destroyed. However, 4th and 5th could still flex because even though FDS also supplies the 4th and 5th, FDP is innervated by the ulnar nerve for the 4th and 5th digits, so they would not really be affected. This is why hand of benediction occurs (you can flex your thumb, 4th and 5th fingers, but not your 2nd and 3rd)
Anterior interosseous nerve (from the median nerve) due to flexor pollicis longus and FDP
BBQ*
What nerve could become entrapped in pronator teres and results in pain in the anterior compartment of the forearm (since that’s where pronator teres exists), and palmar aspects of radial three and half digits with pain (because that’s the area that this nerve supplies)
Median nerve
BBQ*
If one were to injure the deep branch of the radial N, what kind of sensation would they feel and where?
None, because the deep branch is solely musculature. It’s the superficial branch that does cutaneous sensation
BBQ*
A good place to draw blood is the median cubital vein. However, it’s not a good place to inject drugs because which artery could possibly be punctured and injected with the drugs instead?
Brachial A
BBQ*
__ is when the SC joint becomes stiff or fixed and can be called SAPHO syndrome (Synovitis, acne, pustulosis, hyperostosis, and osteitis)
Ankylosis
Fixed by removing part of the clavicle
BBQ*
SC joint dislocations are extremely rare, however when they do happen in patients less than 25 years old, it occurs at the __
Epiphyseal plate
BBQ*
A patient comes in complaining of pain in the shoulder and when images are taken it becomes obvious the calcification of the ___ bursa has occurred. This is called calcific scapulohumeral bursitis
Subacromial
BBQ*
A person is told to hold out their arms and lower them, when they get to about 15 degrees from their body the arms suddenly drop. What is injured?
A rotator cuff muscle, specifically supraspinatus
BBQ*
Minners elbow also called dart thrower elbow occurs from friction of subcutaneous __ bursitis
olecranon
BBQ*
SC joint dislocations are extremely rare, however when they do happen in patients less than 25 years old, it occurs at the __
Epiphyseal plate
BBQ*
A patient comes in complaining of pain in the shoulder and when images are taken it becomes obvious the calcification of the ___ bursa has occurred. This is called calcific scapulohumeral bursitis
Subacromial
BBQ*
A person is told to hold out their arms and lower them, when they get to about 15 degrees from their body the arms suddenly drop. What is injured?
A rotator cuff muscle, specifically supraspinatus
BBQ*
Minners elbow also called dart thrower elbow occurs from friction of subcutaneous __ bursitis
olecranon