final blue boxes Flashcards
(142 cards)
1
Q
Back Strains, Sprains, and Spasms
A
Back Sprain = only ligamentous tissue or attachment of ligament to bone is involved
Usually due to excessive extension or rotation of the vertebral column
Back Strain = stretching or microscopic tearing of muscle fibers
Common in sports, due to overly strong muscle contraction
Usually erector spinae muscles of lumbar region
Back Spasms = protective mechanism of the muscles
In response to injury/inflammation
2
Q
Arterial Anastomoses Around Scapula
A
Sudden occlusion doesn’t allow enough time for adequate collateral circulation to develop and reach the arm/forearm
3
Q
Compression of Axillary Artery
A
Axillary artery can be palpated inferior to lateral wall of axilla
Can compress axillary artery against humerus
Axillary artery can be compressed by pushing downward in angle between clavicle and SCM m.
4
Q
Aneurism of Axillary Artery
A
Enlargement of first part of axillary artery that may compress the brachial plexus
Common among baseball pitchers and football quarterbacks because of rapid and forcefull arm movements
5
Q
Cervical trauma: fracture or dislocation of atlas
A
=Burst fractures (Jefferson fracture)
o Lateral masses of C1 are compressed btwn the occipital condyles and tha axis (C2), fracturing anterior and/or posterior arches of C1
o May involve rupture of transverse ligament (which keeps the dens in place → dislocation
o Causes: sudden, forceful compression of C1 (diving accidenst, roll-over car accidents
6
Q
Occipital Neuralagia
A
irritation of greater occipital (dorsal rami C2) and lesser occipital n (ventral rami C2-C3) Causes: o Osteoarthritis of cervical vert o Neck injury o Disk disease o Muscle spasms in neck o Swollen bvs put pressure on occipital n o Tumors, infection, gout, diabetes Symptoms o Brief episodes of burning/stabbing pian that is triggered by neck mvmt and radiated over the C2 dermatome region o Scalp tenderness o Pain behind eye o Headache
7
Q
Dislocation of cervical vertebrae
A
- Articulated cervical vert are less tightly interlocked, making them more prone to dislocation
- Cervical dislocation if severe enough, can cause trauma to the spinal cord
8
Q
cervical trauma: fracture/dislocation of axis: Fracture of vert arch (hangman’s fracture)
A
=Fracture of pars interarticularis (traumatic spondylolysis of C2)
Causes:
• Hyperextension of the neck
• Judicial hanging, some severe cases of acceleration/deceleration syndrome where head and neck are hyperextended, etc
9
Q
cervical trauma: fracture/dislocation of axis: Fracture of dens
A
Fracture at base of dens (most common) or along body of axis
Causes:
• Horiz blow to head
Can happen at multiple locations:
• Type 1 – frac at upper part dens
• Rare, unstable
• Type 2 – frac at base of dens
• Most common
• Unstable – may not heal well - dont repair bc transcverse ligament gets in the way –> lose vascular supply –> avascular necrosis
• Type 3 – frac thru dens and into lateral masses of C2
• best prognosis for healing bc have vascular supply
10
Q
Cervical trauma: soft tissue injury
A
- Acceleration/deceleration synd occurs when the head is forced fwd and then snaps back (aka during a rear-end collision)
- Result in whiplash injuries
- These usu only involve damage to soft tissue, may also involve fractures
11
Q
Vertebral Artery Impingement (specifically, lumbar spinal stenosis)
A
Reduced blood supply to brainstem Aka cervical vertigo/vertebral artery compression Vertebral a becomes blocked/narrowed (stenosis) when head is turned (mvmt at atlantoaxial joint) May be age related Causes: o Trauma o Cervical spinal column abnormalities o Degenerative dis o Arterial stenosis assoc w CVD Signs and Symp o Dizziness/vertigo o Confusion o Nystagmus Treated surgically with laminectomy
12
Q
Ossification of Clavicle
A
• First long bone to completely ossify (embryonic weeks 5-6; intramembranous ossification)
• Ends of clavicle then go thru a cartilaginous phase (endochonfdrial ossification)
• Complete fusion of intramembranous and endochondrial portions completes at 25-31 yrs
• Significant bc:
o Congenital pseudoarthritis (“nonunion”; “false joint”) of the clavicle
o Sometimes the fusion of the diff ossification centers of the clavicle fails
o A congenital defect like this can present like a poorly healed fracture
o Most often involves right clavicle but can be bilateral (rare)
13
Q
frac of clavicle
A
o Frequent
o Common in children
• Greenstick = look like greenstick on tree breaking
o Weakest parts: btn middle and lateral third
• Lateral frac: 15%
• Middle frac: 80%
• Medial frac: 5%
o Muscular attachments to the clavicle can pull fractured portions out of alignment
• Sternocleidomastoid elevates medial fragment
• Trapezius action is counteracted bt wt of limb
• Adductors of the arm (deltoid, pec major) can pull lateral fragment medially
• Coracoclavicular ligament prevents dislocation of acromioclavicular joint
14
Q
frac of scapula
A
o Typically result of injury/trauma:
• Falling on outstretched hand or landing on shoulder
• Direct blow to shoulder/upper back
o Mostly occurs across body of scapula, but scapular neck can also be fractured
• Acromion often involved
o Will just let it heal bc much muscle and soft tissue
o Often, ribs are cracked too
15
Q
palpation of scapula
A
o Scapular spine
o Acromial angle
o Medial border
o Inferior border (rim of latissimus dorsi here)
16
Q
Isolated subscapularis tears =
A
rare
17
Q
common injury in pichers (pwrful throwing motion)
A
Rotator cuff tendonitis
18
Q
Subscapularis injuries can also lead to
A
bicipital tendon instability and biceps tendonitis
19
Q
Paralysis of Serratus Anterior
A
Injury to the long thoracic n.
Causes winged scapula
May prevent abduction of upper limb above horizontal position
When limbs are elevated (knife fight) long thoracic nerve is vulnerable
20
Q
Injury of Spinal Accessory Nerve
A
Ipsilateral weakness of elevating shoulders (shrugging) against resistance
21
Q
Injury of Thoracodorsal Nerve
A
Injury in inferior axilla puts thoracodorsal nerve at risk
Also susceptible to injury during mastectomies and surgery on scapular lymph nodes
Pt. unable to raise trunk with upper limbs
22
Q
Injury to Dorsal Scapular Nerve
A
Causes scapula on affected side to mover further from midline
23
Q
Injury to Axillary Nerve
A
Usually injured during fracture/dislocation of the humerusor from rotator cuff surgery
Can be injured during misuse of crutches
-Loss of sensation on lateral side of proximal arm (Superior lateral cutaneous nerve of the arm)
-Difficulty abducting arm (bc paralysis of deltiod)
-Diminished lateral rotation of arm
-Deltoid m wasting (prolonged injury)
24
Q
Triangle of Auscultation
A
Good for listening to posterior segments of lungs
Triangle enlarges when scapluae are drawn anteriorly and trunk is flexed
25
Fracture-Dislocation of Proximal Humeral Epiphysis
Joint capsule + rotator cuff muscles is stronger than epiphyseal plate
Seen in children
26
Cervical ribs (supernumerary ribs)
• An extra rib (or pair of ribs) arising fom the 7th cervical vertebra
• 3 common vairities:
o rudimentary
o fused with first thoracic rib
o fully developed
• Can result in thoracic outlet synd (but not always)
27
thoracic outlet synd
o =impingement of the large vessels and nerve (brachial plexus)
o can attach to the 1st thoracic rib vy dense fibrous band
o elevates the lowest cord of brachial plexus
o Other cuases:
• Fractured clavicle
• Extra muscle.scar tissue in the region of the scalene muscles
• Poor posture of the neck and shoulder regiont
28
injuries to thoracic vert due to
everyday wear and tear :(
29
Herniated discs in lumbar region
* most freq occur here Bc region that bears the most wt
* Freq bending, twisting, improper lifting increases load on tedons that reinforce this region, as well as intervertebral discs
* How/where the pain/dysfunction presents itself indicates the level at which a lumbar herniation has occurred
30
Herniated discs in thoracic region
* Usu as a result of wear and tear; disc degeneration
* Sudden and forceful twisting of the midback region
* Other conds that predispose an indiv (abnormal kyphosis (Schererman’s dis)
31
herneated discs usu occur in the...
* Usu posteriorlateral direction
| * Bc the posterior longitudinal ligament is not broad → hernia take path of least resistance
32
Spondylolysis
* Broken vert
* Trauma or degenerative dis
* Common cause of spondylolisthesis
33
Pars interarticularis
* Located btwn the inferior and superior articular facets, btwn the lamina and pedicles of vert
* Fractures at this point assoc w spondylolysis
* Radiographic image : “Scottie dog”, w the pars frac indicated by the dog’s collar
34
Spondylolisthesis
• Anterior/ventral displacement of one vert on adjacent
• Common progression from spondylosysis, can also be congenital
If at L5-S1 IV joint, may result in pressure of the spinal nerves of the cauda equina
35
Hyperkyphosis
• Abnormal/exaggerated thoracic curvature (convexity
• Can result from developmental abnormalities, trauma, degen dis
Dowager's Hump - name for excessive thoracic kyphosis in older women due to osteoporosis
Leads to increase in AP diameter of thorax and reduction in dynamic pulmonary capacity
36
Hyper lordosis
* Abnormal/exaggerated lumbar curvature (concavity)
* Can predispose to spondylosysis and can be assoc w herniation of intervert disk
* Assoc w congenital abnormalities, musculo-skeletal probs, degen dis, weakened trunk musculature
37
Lumbar lordosis and sexual dimorphism
* Sexual dimorphism (morphological diffs btwn M&F) is apparent in the lumbar region of the numan vc
* An evol resp to changes in center of mass that occur during preg that are assoc w obligate bipedalism
38
Compression frac
* Collapse of bone of vert body
| * Can be caused by trauma or degenerative dis
39
Osteopenia
* Process of thinning/decreasing in bone mass
| * degen
40
Osterporosis
* Cond of having diminished bone density making bones prone to fracture
* Degen
41
Scoliosis
• Abnormal/exaggerated lateral curvature of spine
• Congenital, neuromuscular, idiopathic in origin
Asymmetrical weakness of intrinsic back muscles, difference in length of lower limbs may lead to "functional" scoliosis
Habit Scoliosis = habitual standing or sitting in an improper position
When scoliosis is entirely postural, it disappears during maximum flexion of the vertebral column
42
Sacralization
* Fusion or partial fusion of L5 to the sacrum
| * Congenital
43
Vertebral Body Osteoporosis
Metabolic disease detected during routine radiographic studies
Radiograph shows diminished radiodensity of spongy bone making compact bone look more prominent
44
Laminectomy
Excision of the spinous process to gain access to vertebral canal and exposure of the spinal cord
Often performed to relieve pressure within the spinal cord
45
Caudal Epidural Anesthesia
Anesthetic injected into fat of sacral canal surrounding proximal sacral nerves
46
Injury of Coccyx
Fall on buttocks may cause coccyx to break or sacrococcygeal joint to dislocate
Coccygodynia often follows coccygeal trauma
47
Lumbarization =
S1 fused with L5 and separate from the sacrum
48
Effects of Aging on Vertebrae
Lumbar body height increases 3 fold between birth and age 5
Between ages 5-13 they increase another 50%
Osteophytes (bony spurs) develop around margins of vertebral bodies in older age
49
Anomalies of Vertebrae
Spina Bifida Occulta - usually in L5/S1 vertebrae
Indicated by tuft of hair
Spina Bifida Cystica - herniation of the meninges
50
Aging of Intervertebral Discs
Nucleus pulposos loses elastin and gains collagen with age causing IV's to lose their turgor, becoming stiffer
IV increases in size with age, become more convex, and thicken
51
Herniation of Nucleus Pulposis
In young persons, vertebral fracture occurs before IV herniation because the IV's are so strong
Herniations usually occur posterolaterally
Lumbar herniations usually at L4/L5 or L5/S1
Sciatica often caused by herniation of lumbar IV compressing L5/S1 component of sciatic nerve
When an IV disc protrudes, it usually compresses the nerve root numbered one inferior to the herniated disc
Sudden hyperflexion of the cervical region can cause IV disc protrusion
Head on collision or illegal football tackle
52
Rupture of Transverse Ligament of Atlas
Rupture allows dens to be "set free" resulting in atlanto-axial subluxation
People with Down syndrome exhibit laxity or agenesis of this ligament
Absence of ligament allows for compression of the spinal cord between the dens and posterior arch of the atlas
Causes quadriplegia or death
Steele's Rule of Thirds:
Atlas of ring is occupied by…
1/3 by dens
1/3 by spinal cord
1/3 by fluid-filled space/tissues surrounding spinal cord
53
Rupture of Alar Ligaments
Weaker than transverse ligament of atlas
Combined flexion and rotation of the head may tear one or both alar ligaments
Rupture results in 30% increase in ROM to contralateral sid
54
Fractures and Dislocations of
Vertebrae
Sudden flexion usually produces "crush" or "compression" fracture of the body of vertebrae
Usually accompanied by irreparable injuries to the spinal cord
Sudden extension usually injures posterior parts of vertebrae
Severe hyperextension (whiplash) usually injures anterior longitudinal ligament
T11/T12 are most commonly injured non-cervical vertebrae
55
Injury and Disease of Zygapophysial Joints
Close to IV foramina
Damage to these joints often damages spinal nerves causing pain along distribution of dermatome and myotome
Denervation used to treat back pain caused by disease of the zygapophysial joints
56
Sources of back pain:
```
Fibroskeletal structures - periosteum, ligaments, anuli fibrosi of IV discs
Meninges (rare)
Synovial joints
Muscles (intrinsic muscles of back)
Nervous tissue
```
57
Myelography
Radiopaque contrast procedure allowing visualization of the spinal cord and nerve roots
Contrast injected into subarachnoid space
58
Lumbar Spinal Puncture
Used to determine pathology of the CNS by analyzing CSF
Performed by…
Pt. lying on side with back and hips flexed
Needle inserted between L3/L4 (or L4/L5)
59
Spinal Anesthesia
Injected into subarachnoid space
| May be followed by a headache due to leakage of CSF
60
Epidural Anesthesia
Injected into epidural space via same mechanism as for lumbar puncture, or through sacral hiatus
61
Ischemia of Spinal Cord
Pts. With ruptured aneurysms of the aorta or occlusion of the great anterior segmental medullary artery may lose all sensation and voluntary movement inferior to level of impaired blood supply to spinal cord
Due to death of neurons in part of spinal cord supplied by anterior spinal artery
Termed "iatrogenic paraplegia"
62
Spinal Cord Injuries
Spinal cord shock = protrusion of IV disc into vertebral canal after a neck injury
Lumbar spondylosis = degenerative joint disease
Transection of the spinal cord:
C1-C3 = no function below head level, ventilator required
C4-C5 = quadriplegia, respiration occurs
C6-C8 = lower limb paraplegia and some hand and upper limb paraplegia
T1-T9 = paraplegia of lower limbs
T10-L1 = some thigh muscle function which may allow walking with long leg braces
L2-L3 = retention of most leg muscle function, short leg braces may be required
63
Peau d'orange
blockage of lymphatic ducts --> edema
64
Changes in Breasts
Milk not produced until after birth of child
| Colostrum = rich in protein, immune agents, and growth factors for intestines
65
Breast Quadrants Used to
chart location of masses or skin lesions
66
Mammography
Used to detect masses
Mass appears as large, jagged density
Skin over mass is thickened and nipple is depressed
67
Surgical Incisions of Breast
Made in inferior quadrants because these are less vascular
Mastectomy = removal of breast until retromammary space
Radial mastectomy = removal of breast, pectoral muscles, fat, fascia, and axillary lymph nodes
68
Polymastia, Polythelia, and Amastia
Polymastia - supernumerary breasts
Usually have rudimentary nipples and areolas which may be mistaken for moles
Polythelia - accessory nipples
Amastia - breast tissue, nipple, and areola is absent
69
Breast Cancer in Men
1.5% of breast cancers
Palpable subareolar mass or secretion from nipple may indicate malignant tumor
Tends to infiltrate pectoral fascia, pectoralis major, and apical lymph nodes in axilla
70
Gynecomastia
Slight enlargement of breasts in males at puberty
Must be evaluated to rule out suprarenal or testicular cancers
People with Klinefelter syndrome have higher chance of getting gynecomastia
71
Injuries/Lesions to Superior trunk (C5 & C6) – Erb’s Palsy
```
At the shoulder
• Arm will be adducted
• Arm will be medially rotated
At the elbow
• Pronation
• Extension
”Waiter’s tip” position of affected upper limb
C5 Axillary n (deltoid and teres minor)
Suprascapular n )Supraspinatus and infraspinatus)
Musculocutaneous n (Biceps)
C6 Radial n (Brachioradialis, supinator)
```
72
Injuries/Lesions to Inferior Trunk (C8 & T1) - Klumpke’s Palsey
o Avulsion injury that usu results from excessive, forceful abduction of the arm
o Rare obstetric injury
o Often assoc w Horner’s Syndrome
o Clinical presentation: median and ulnar n’s affected
• Wrist extremely extended (wrist extensors unopposed)
• Hand and fingers
• All intrinsic muscles of the hand affected
• Joints btwn hand bones and finger bones hyper extended
• Joints btwn finger segments flexed
• =claw hand! (when trying to extend digits or at rest)
73
Horner’s Syndrome
(T1 involvement may cause preganglionic interruption of sympathetic pathways)
• This synd results from an interruption of the sympathetic nerve supply to the eye and is chara by theclassic triad of moisis (ie constricted pupil), partial ptosis, loss of hemifacial swelling
*often assoc w klumpke's palsy
74
Injuries to Radial n (C5-T1) in the Axillary region (n injured before it supplies triceps)
• Improper use of crutches can compress and injure the n in the axilla
Clinical presentation
• Weakness when trying to push something away with arm
• Difficulty extending wrist and fingers and in opening the hand
• “Wrist drop” posture
75
Injuries to Radial n (C5-T1) from an Injury at Spinal Groove of humerus
• Compression of radial n along midshaft of humerus in certain portions (“sleep palsy”, “Saturday Night Palsy”
• Humeral fracture at midshaft (spinal groove fracture)
Clinical presentation
• Difficulty extending wrist
• Difficulty extending/straightening fingers and opening the hand
• Triceps retains strength bc nerve fibers entering this m branch off proximal to mid shaft of the humerus
• Also causes wrist drop
76
Injury to Long thoracic n (C5, C6, C7)
```
(innervation to serratus anterior m’s)
Causes
• Penetrating woulnd to axillalary region
• Surgical removal of axillary LNs
Clinical presentation
• Cannot raise arms above 90deg
• Winged scapula
```
77
Injuries to Ulnar n (C8, T1, and often C7)
Causes:
• Frac to medial epicondyle of humerus
• Entrapment of n in cubital tunnel
• Rotator cuff repair surgery
Damage will involve flexors of wrist, digits, intrinsic hand muscles
Clinical presentation
• Numbness/tingling in 4th/5th fingers (worse when elbow bent)
• Weakening of grip w some loss of flexion of fingers
• Loss of ab- and adduction of fingers
also ulnar claw!!
When injured in distal forarm, lateral deviation due to FCR and absence of FCU balance; also, claw hand = not extend IP joints when trying to straighten fingers
78
Injuries to median n (C6-T1)
Causes:
• Fracture of the humerus above the condyles
• Infalmmation or irritation in the carpal tunnel (carpal tunnel synd)
o Damage will involve flexors of wrist, digits, intrinsic hand muscles, particularly those that move digit 1
Clinical presentation
• Decreased sensation and increased Numbness/tingling/pain along course of median n
• Cannot flex PIP in joints 1-3 or DIP in 2-3 = “Hand of Benediction” when making a fist, unable to flex second and third digits)
can happen at forearm or wrist (carpal tunnel - more common)
79
Carpal tunnel synd (assoc w median n injury)
Tingling in palm, pain in extending the wrist,
• “Ape hand” (thenar eminence atrophy and loss of thenar opposition)
*the more common medial n injury
80
if have thoracic pain, can radiate to arm through...
intercostalbrachial n (T12 intercostal n)
81
Arterial Anastomoses Around Scapular
```
Subscapular artery receives blood from…
-Suprascapular a.
-Dorsal scapular a.
-Intercostal as.
Ligation of axillary artery between subscapular and deep brachial a. cuts off blood supply to arm because collateral circulation is inadequate
```
82
Enlargement of Axillary Lymph Nodes
Due to upper limb infection
Usually goes to humeral nodes first
Pectoral, breast, and upper abdominal infections can also go to axillary lymph nodes
Nodes may stick to axillary or cephalic vs. causing need to remove parts of them
83
Dissection of Axillary Lymph Nodes
Two nerves are at risk for injury
Long thoracic n.
Thoracodorsal n.
If cancerous nodes are on nerves, they may have to be sacrificed to ensure complete removal of the cancer
84
Variations of Brachial Plexus
May have small contributions from C4 and T2
Prefixed brachial plexus = C4-C8
Postfixed brachial plexus = C6-T2
Inferior trunk may be compressed by first rib
85
Acute Brachial Plexus Neuritis (brachial plexus neuropathy)
Sudden onset of pain around the shoulder
| Usually nerve fibers from superior trunk
86
Brachial Plexus Block
Can be used in conjunction with a tourniquet for surgery of the UE without using general anesthesia
Approaches = interscalene, supraclavicular, and axillary
87
Bicipital Myotatic Reflex
Biceps reflex
Relax, pronate, and partially extend elbow
Testing for integrity of C5/C6
88
Biceps Tendonitis
Inflammation of biceps tendon within synovial sheath
| Common among throwing sports and racket sports
89
Dislocation of Long Head of Biceps Brachii
Can dislocate from intertubercular groove
| Sensation of popping or catching felt during arm rotation
90
Rupture of Tendon of Long Head of Biceps Brachii
Result of wear and tear from inflamed tendon
Typically torn from attachment on supraglenoid tubercle
Muscle belly forms ball in center of arm
91
Interruption of Blood Flow to Brachial Artery
Best place to compress brachial a. is medial to humerus near middle of arm
Muscles and nerves can tolerate up to 6 hours of ischemia before permanent damage occurs
Ischemic compartment syndrome
92
Fracture of Humeral Shaft
Midhumeral shaft may injure radial n.
Doesn't paralyze triceps
Supra-epicondylar fracture = may cause distal fragment to displace anteriorly and posteriorly
Brachialis and triceps pull distal fragment over proximal fragment, shortening the limb
93
Injury to Musculocutaneous Nerve
Causes weak flexion at glenohumeral joint
Causes weak flexion and supination at elbow joint
Loss of sensation on lateral surface of forearm (lateral antebrachial cutaneus n.)
94
Injury to Radial Nerve in Arm
Radial groove allows triceps to work, but weakend because only medial head is affected
Superior to radial groove knocks out triceps as well
Clinical sign = "wrist drop"
Inability to extend wrist and fingers at MCP joint
Wrist is partly flexed due to unopposed flexor muscles
95
Venipuncture in Cubital Fossa
Usually use median cubital v.
Crosses bicipital aponeurosis separating it from brachial a. and median n.
Grace Deux Tendon = bicipital aponeurosis
Median cubital v. also used for cardiac catheters and coronary angiography
96
Variation of Veins in Cubital Fossa
Median antebrachial v. may divide into median basilic and median cephalic vs. which join basilic and cephalic vs., respectively
97
Dislocation of sternoclavicular joint
• Rare bc such a strong joint
• Direction of force transmission thru the clavicle also prevents fracture
o Forces usu transmitted along length of clavicle -->vclavivle may fracture
• If dislocation, are usuthe result of fractures thru the epiphyseal plate at the sternal endunder 25 yo
• Anterior dislocation from a lateral blow → pop clavicle anteriorly
• Posterioe dislocation from a blow to the upper chest →can press on trachea → (if on L side) can press on esophagus → hard to swallow
o Usu accompanied by a frac
98
Ankylosis of sternoclavicular joint
• Stiffening, fixation, fusion of SC joint
• Arthritic conditions
• SAPHO syndrome (an inflammatory disorder that may include synovitis, acne, pustulosis, hyperostosis, and osteitis)
o Lots of bone grth!
• Shoulder mobility limited
99
shoulder separation as a result of acromioclavicular joint dislocation
tears the ligaments of the clavicle (as opposed to the glenoid)
• Grade 1 separation: AC ligament sprain
• Grade 2 separation: AC ligament tear
• Grade 3 separation: both AC and coracoclavicular ligaments are torn
o Presents with a lump on shoulder
100
Dislocation of Glenohumeral joint
• Commonly dislocated
in downward (inferior) dir (but are described as anterior)- Humeral head forced in infero-anterior dir
• The coracoacroacromial structures and rotator cuff prevent upward dislocation
• often occur in young adults, esp athletes
• Hyperextension w lateral rotation
• Fibrous layer of joint capsule and glenoid labrum may tear
• Result from a hard blow to humerus while fully abducted
o Tilts humeral head inferiorly and pushes it through the weaker part of the joint capsule → joint capsule tears such that the humeral head is positioned inferior to the glenoid cavity and anterior to the infraglenoid tubercle
• Damages the axillary n around surgical neck
• Posterior dislocations rare
101
Adhesive Capsulitis of Glenohumeral joint
* Chronic inflammation in the glenohumeral joint can lead to fibrosis btwn the joint capsule, rotator cuff muscles, and synovial bursa
* =”Frozen shoulder”
* 40-60yos
* Abduction affected; compensatory scapular mvmts
* Acromioclavicular joint may become strained
* May be initiated by glenohumeral dislocation, supraspinatus tendinitis, bicipital tendinitis, and/or rotator cuff tears
102
Subluxation and dislocation of radial head
• “Nursemaid’s elbow”
• preschool age children tend to be vulnerable
• Child is suddenly lifted by their upper limb in a jerking motion
• Distal arrachment of annular ligament becomes torn and radial head becomes dislocated
Source of pain is pinched anular ligament
Tx = supination of childs forearm while elbow is flexed
103
Lateral Epicondylitis
* “Tennis elbow”
* tendons of forearm extensors become inflamed and/or torn at their lateral epicondylar attachmend (in particular the tendon of extensor carpi radialis brevis)
* from repteitive use of superficial extensor m's of forearm
104
Radius fractures
* “colles” fracture = complete transverse fracture of the distal 2cm of radius (on styloid process)
* common in adults over 50
* results from forced extension of hand on outstretched limb while breaking fall
* “dinner fork” deformity
105
Calcific Supraspinatus Tendinitis
Calcification of subacromial bursa
Pain during abduction of arm
Radiates to hand
106
Rotator Cuff Injuries
Repetitive use may allow humeral head and rotator cuff to impinge on coraco-acromial arch
Causes degenerative tendonitis of the rotator cuff
Test = lower abducted limb slowly, if limb suddenly drops at ~90˚ abduction if injury is present
If supraspinatus m. is completely torn, person can't initiate abduction
Passive abduction of first 15˚ is necessary and then deltoid will kick in
• Common injury in old ppl
• Bursa irritated
• Relief when raise arm over head
• Repetitive activity irritates it
• Tennis, swimming, pitching, stack boxes, stocking shelves, painting, construc
• Other causes: bone spurs, anatomical variation of the acromion (odd-shaped that limits the space w/in the roof of the glenoid fossa)
107
Glenoid Labrum Tears
Results from sudden contraction of biceps or forceful dislocation of humeral head
108
Bursitis of Elbow
Subcutaneous olecranon bursa gets injured during fall on elbow
--Friction subcutaneous olecranon bursitis = repeated excessive pressure on bursa
"students elbow", "dart throwers elbow", "miners elbow"
Subtendinous olecranon bursitis
--Excessive friction between triceps tendon and olecranon
--Seen in assembly line jobs
--Pain during flexion of forearm
Bicipitoradial bursitis
--Pain when forearm is pronated due to compression of bicipitoradial bursitis
109
Avulsion of Medial Epicondyle
Fall causing severe abduction of extended elbow
Ulnar collateral ligament pulls medial epicondyle distally
Traction injuries of ulnar nerve:
Frequent complication of avulsion of the medial epicondyle
110
Ulnar Collateral Ligament Reconstruction
Common among baseball pitchers
Known as "Tommy John Surgery"
Autologous transplant of tendon of palmaris longus or plantaris
111
Dislocation of Elbow Joint
Posterior dislocation when child falls on hand with elbows flexed
UCL often torn along with fracture of the radial head, coronoid process, or olecranon
May cause injury to ulnar n. resulting in numbness and weak flexion and adduction of wrist
112
anterior interosseous synd
from occluding anterior interosseous a --> cannot make OK sign
113
Mallet or Baseball Finger
DIP suddenly forced into extreme flexion
Causes avulsion of attachment of extensor tendon to base of distal phalanx
Causes:
-baseball injuries
-blunt force trauma to finger
114
Fracture of Olecranon
Typically from fall on elbow with powerful contraction of triceps brachii
115
Synovial Cyst of Wrist
Common on dorsum of wrist
Flexion makes cyst enlarge and may cause pain (named, "ganglion")
Cyst on ventral hand can cause compression of median nerve by narrowing of carpal tunnel
116
High Division Brachial Artery
Ulnar and radial a. appear in middle/superior arm and median n. runs between them
117
Superficial Ulnar Artery
Some people have ulnar a. that runs superficial to flexor muscles
Must be cautious not to inject drugs into it or draw blood from it
118
Variations in Origin of Radial Artery
May be branch of axillary or brachial as.
| May be superficial to deep fascia
119
Median Nerve Injury
If severed in elbow region, flexion of PIP joints of digits 1-3 is lost
Flexion of DIP of digits 2-3 is lost
"Hand of Benediction"
Failed "ok" sign due to anterior interosseous syndrome
120
pronator synd
Compression of median nerve by pronator teres
| Pain/tenderness in proximal anterior forearm and hypesthesia of palmar aspects of radial 3.5 digits
121
Communication Between Median and Ulnar Nerves
Allows muscles to still function partially if there has been ligation of either of the nerves proximal to the communicatory location
122
Cubital Tunnel Syndrome
Compression of ulnar n. under FCU at attachment to ulnar and humeral heads
123
Injury to deep radial n vs superficial radial n
```
deep = no loss in sensation bc deep is purely notor; inability to extend thumb and MP of other digits
superficial = minimal sensory loss bc other cutaneous n's in the same area
```
124
Medial epicondylitis
* Golfer’s elbow
* Inflammation of medial epicondyle
* Repetitive activities the involve wrist flexion
* Restrict activities that involve excessive wrist flexion, stretching
* Cld use wrist brace/certain meds if needed
125
FOOSH injuries: “falling on an outstretched hand”
• most common injury of the hand
can cuase skiiers thumb
• Scaphoid injuries are the most common carpal bone fractures (70%)
-->Dangerous due to risk for avascular necrosis = interrupeted retrograde flow from radial a
-->Radial a!
--> pain over snuff box
--> look normal on x-rays
126
Swan neck deformity
```
• hyper Extension of PIP
• Flexion of DIP
• Causes:
o Rheumatoid arthritis
o Untreated mallet finger
o Trauma
```
127
Boutonniere Deformity
```
• Flexion PIP
• Hyperextended DIP
• Causes:
o Rheumatoid arthritis
o Ehler Danlos syndrome
o Trauma
```
128
Dupuytren’s Contracture
progressive shortening of palmar fascia and aponeurosis
• nodulr thickening of fiberous tissue under skin of palm (palmar aponeurosis)
• Painless
• Causes
o Unknown, but assoc w alch, diabetes, age, seisures
-more in M and N.europeans
-4th and 5th digits in partial flexion at MP ana PIP joints
129
Skier’s thumb
• =damage to ulnar collateral ligament of 1st MPJ --> hyperabduction of MP joint in thumb
• avulsion fracture of head of metacapral in severe cases
• Causes:
o Trauma
o FOOSH
o Skiing
130
Bull Rider’s Thumb
• damage to radial collateral ligament of 1st MPJ
• avulsion fracture of the lateral part of the proximal plalanx of thumb
• Causes:
o Trauma
o sports
131
Anterior dislocation of lunate:
Uncommon but serious
Results from fall on dorsiflexed wrist
Compressed median n.
Avascular necrosis may occur
132
Fracture-separation of distal radial epiphysis:
Common among children due to frequent falls
| Dorsal displacement of distal radial epiphysis
133
Hand Infections
Usually appear on dorsum of hand
| Untreated infection can move from midpalmar space through carpal tunnel and into forearm
134
Tensosynovitis
Infection of digital synovial sheaths
Digits 2, 3, and 4 have separate sheaths so infections are confined to those sheaths only
Digit 5's sheath is continuous with common flexor sheath allowing spread of infection into common flexor sheath and through carpal tunnel into forearm
Pollux sheath is continuous with sheath of FPL
-Quervain tenovaginitis stenosans
-Digital tenovaginitis stenosans (trigger finger)
135
Quervain tenovaginitis stenosans:
Excessive friction due to repetitive forceful gripping and wringing with hands
Pain radiates proximally to forearm and distally to pollux
136
Digital tenovaginitis stenosans (trigger finger)
Enlargement of FDS and FDP at proximal end of osseofibrous tunnel inhibits extension of the digit
Passive extension causes a snapping sound
137
Laceration of Palmar Arches
Profuse bleeding
May need to compress brachial artery proximal to branching to prevent bleeding during hand surgery
Complicated anastomoses in hand with contributions from radial and ulnar as.
138
Ischemia of Digits
Marked by cyanosis and paresthesia and pain
| Raynaud syndrome = cause of disease is idiopathic (unknown)
139
Ulnar Canal Syndrome
Compression where it passes the pisiform and hook of hamate
"ulnar canal" (Guyon tunnel)
Symptoms = hypoesthesia in middle 1.5 digits and weakness of intrinsic hand muscles
"clawing" of digits 4/5 may occur
140
Handlebar Neuropathy
Puts pressure on hooks of hamate compressing ulnar n.
| Results in sensory loss to medial side of hand and weakness of intrinsic hand muscles
141
Dermatoglyphics
Study of ridge patterns on the palm
Trisomy 21 individuals have highly characteristic dermatoglyphics
-Have single transverse palmar crease (simian crease)
142
Palmar Wounds and Surgical Incisions
Superficial palmar arch in same level as distal end of common flexor sheath
Wounds along medial surface of thenar eminence may injure recurrent branch of median n
