Practical 6- upper limb pathologies and recap

Question 1

Clavicle- common injuries

Answer 1

Commonly through direct impact or an outstretched hand, often middle 3rd/midshaft fractures
Arms tend to be displaced inferiorly and medially

Question 2

Humerus- common injuries

Answer 2

Simple and compound (open) fractures

• ‘greenstick’ fractures common in infants and young children (more elastic, less ossified bone)
• location can determine presentation- transverse, oblique, spiral, comminuted ( fragmental bone) and segmetal fractures

ARM (proximal to distal)
Axillary (t.minor,deltoid), Radial (radial groove), Medial (medially, supracondylar ridge) nerves

Question 3

Radius and ulna- fractures

Answer 3

Radius- Colles’ fracture: most common type, falling onto outstretched hand causing a dinner fork deformity

Smith’s fracture of radius- opposite of colles’ from compression of dorsal hand- distal fragment displaced anteriorly

Ulnar- usually impact fractures
Most likely site is shaft, olecranon can be damaged by impact

Fractures of both R+U
Monteggia’s- proximal shaft fractured, radial head dislocates anteriorly
Galeazzi fracture- distal shaft fractured with ulnar head dislocating at distal RU joint

Question 4

Scapula and winged scapulae

Answer 4

Damage to muscles affecting medial scapula- serratus anterior
Most commonly the long thoracic nerve is involved- treatment conservative

Question 5

Rupture of biceps and triceps brachii, and axillary artery aneurysm

Answer 5

BB- involves long head/distal insertion and more common in older patients- “popeye’s sign”, requires surgical repair

TB- relatively uncommon but most commonly caused by humerus/ olecranon fracture
- 30-50 year old males

Axillary artery may enlarge/ dilate compressing BP trunks, pain and anaesthesia and areas of skin supplying affected nerves

Question 6

Wrist drop

Answer 6

• Inability to extend wrist and/or digits, caused by damge to RADIAL nerve/branches
  Area of lesion can affect presentation:
  Humeral midshaft- elbow extension affected, wrist drop and numbness on posterior forearm/hand dorsum

Forearm- elbow extension possible, wrist drop and posterior numbness in forearm/hand still possible

Question 7

Tennis and golfer’s elbow

Answer 7

Tennis elbow, also known as lateral epicondylitis
Common extensor origin- commmon where wrist extensors are forced to work

Golfer’s elbow- medial epicondylitis- common flexor origin where wrist flexors are forced to work

Question 8

Carpal tunnel syndrome

Answer 8

Involves the median nerve (affects lateral 1, 2, 3 and 1/2 4th finger), distal and palmar branches
Atrophy of thenar and hypothenar eminences seen
Surgery done to release the transverse carpal ligament

Question 9

Dupuytren’s contracture

Answer 9

• Palmar aponeurosis- a strong, triangular membrane that is continuous with palmaris longus when present, and is anchored to anterior flexor retinaculum
• Aponeurosis continues distally as pre-tendinous bands
• thickening/ shortening of palmar aponeurosis can cause flexor deformity- severe cases usually treated with excision of PA

Question 10

Upper brachial plexus and associated injuries

Answer 10

Upper brachial plexus injuries- C5 + C6

UBP- Erb’s palsy- excess displacement of head to opposite side/depression of shoulder on same side
If C5 + C6 affected then
Nerves affected- musculocutaneous, axillary, suprascapular and nerve to subclavian
Muscles- supraspinatus, infraspinatus, subclavian, biceps brachialis, brachialis, coracobrachialis, deltoid and teres minor

Question 11

Lower brachial plexus and associated injuries

Answer 11

Klumpke’s palsy (C8 + T1)
Usually occurs through trauma injuries- infants if a baby’s upper limb is excessively pulled during delivery and in adults with falling from a height, grasping something to break fall
Nerves- peripheral T1 nerves- ulnar and median
Muscles- all intrinsic muscles of hand

Question 12

Median nerve damage

Answer 12

Median nerve damage leads to loss of flexors (not ulnar), thenar eminence and lateral lumbricals

• Damage can cause weak wrist flexion ( due to loss of Flexor Carpi Radialis, Flexor Digitorum Superificialis and lat 1/2 Flexor Digitorum Profunda
• Forearm may be supine (pronators also affected)

Hand of Benediction when making a fist: Ulnar innervation preserved

Ape hand- due to unopposed action of adductor pollicis: inability to oppose thumb (loss of opponens pollicis motor function)

Question 13

Ulnar nerve damage

Answer 13

Weak wrist flexion (loss of FCU + medial half FDP)

• loss of flexion of digits 4 + 5 ( FDP affected, so distal interphalangeal joints affected)
• loss of sensation (palmar/dorsal medial hand affected as well as medial 1.5 fingers)
• loss of thumb adduction ( adductor pollicis affected)