Upper Limb Anatomy

Question 1

What veins in the upper limb are considered suitable for cannulation?

Answer 1

Basilic vein
Cephalic vein
Median cubital vein and the median vein of the forearm.

Question 2

What are the relevant structures in this image?

Answer 2

Radial nerve
Musculocutaneous nerve
Lateral cutaneous nerve
Medial cutaneous nerve
Ulnar nerve
Median nerve (associated with brachial artery)

Question 3

Label the relevant nerves in this image

Answer 3

Radial nerve
Median nerve
Ulnar nerve

Question 4

On ultrasound how to differentiate the external and internal carotids

Answer 4

External is medial
Internal is lateral.

Question 5

Draw the brachial plexus

Answer 5

Question 6

What does the radial nerve innervate?

Answer 6

All posterior muscle groups in brachiam and antebrachium
All posterior skin sensation

Question 7

What does the axillary nerve innervate?

Answer 7

Muscles: deltoid and teres minor
Skin: Superolateral arm

Question 8

What does the median nerve innervate?

Answer 8

Muscles: anterior forearm and radial hand LOAF
Skin : Lateral hand

Question 9

What does the ulnar nerve innervate?

Answer 9

Flexor carpi ulnaris
Medial 1/2 flexor digitorum profundus
Hand muscles (minus LOAF)
Skin - medial hand (Palmar and dorsal)

Question 10

Define carpal tunnel syndrome

Answer 10

Compression of the median nerve at the wrist
Most common nerve entrapment.
Typically non-traumatic

Question 11

What are the typical symptoms of carpal tunnel syndrome?

Answer 11

Pain (burning), tingling, numbness in median nerve area = often at night
Palmar branch and digital branch - - digits 3.5
Weakness of opponents policies, abductor policic brevis + Flexor PB, index and middle lumbricals (thenar eminence atrophy if chronic)

Question 12

Where are the anchor points of the carpal ligament?

Answer 12

Hook of hamate
Pisiform
Ridge of trapezium
Tubercle of Scaphoid
Roof = flexor retinaculum

Question 13

What is the pathophysiology of carpal tunnel

Answer 13

Median nerve trapped - creates local nerve ischemia
Overuse syndrome - swelling of tendons and synovium

Question 14

What are the risk factors for carpal tunnel syndrome?

Answer 14

Females (smaller tunnel)
Genetic (smaller tunnel)
Older age
Pregnancy - resolve with delivery
Heavy manual work and vibrating machinery
Thyroid disease
Trauma
Rheumatoid arthritis
Ganglion cyst

Question 15

What are the tests for carpal tunnel?

Answer 15

Tinels sign - tap over median nerve at wrist - tingling in 50%
Phalens test - hold flexion for 60second - tingling (70%)
Durkans test - press over carpal tunnel for 30seconds (87%)

Question 16

What is the diagnosis of carpal tunnel based on?

Answer 16

Clinical diagnosis
May also do nerve conduction tests: confirm, localise, select for surgery, baseline/prognosis, complex/other neuropathies, persistent or recurrent symptoms

Question 17

What is the first treatment for carpal tunnel syndrome?

Answer 17

Night splints - hold slightly extended/neutral
Activity modification - avoid flexion and extension

Question 18

What is the second line treatment for carpal tunnel syndrome?

Answer 18

Steroid injection (area NOT nerve) - temporary improvement -> pregnancy or mild
Surgery

Question 19

What surgery is used for carpal tunnel syndrome?

Answer 19

Cut flexor retinaculum slightly
Relieve pressure and increase size of carpal tunnel
Keep incision to ulnar side of thenar crease (reduces risk to variable palmar branches)

Question 20

Why are tendon lacerations dangerous?

Answer 20

Slow healing with frequent disability
Difficult to treat

Question 21

What is the epidemiology of tendon laceration in the hand?

Answer 21

Younger men
Relatively rare
Most commonly little fingers are affected
33% digital nerve also cut

Question 22

What structures assist in finger flexions?

Answer 22

Tends run through pulleys
Pulleys contrain tendons
Increased mechanism advantage in grip
Pulley/tendon is lubricated so able to glide through

Question 23

How to test for damage to FDP and FDS?

Answer 23

FDP - ask to bend at distal interphalangeal joint whilst holding proximal straight
FSP - hold other fingers flat - flex middle finger

Question 24

What is the sign of lacerated tendon on fingers?

Answer 24

Pointing sign - fingers not in line when hand relaxed - one finger (the damaged one points in the wrong direction

Question 25

What restrictions on movements should be put on after tendon fixation in the fingers?

Answer 25

Flexor tendon damage - limit extension Extensor tendon damage - limit flexion.

Question 26

What is the clinical sign wrist drop?

Answer 26

Radial nerve palsy Unable to extend the wrist

Question 27

What is claw hand a clinical sign of?

Answer 27

Ulnar nerve palsy Unable to extend the fingers in the ulnar region (little and fourth) - due to weakened intrinsic muscles compared to extrinsic flexors -> presents with flexion at the PIP

Question 28

What is hand of benediction a clinical sign of?

Answer 28

Median nerve palsy Unable to flex the median LOAF

Question 29

The brachial plexus if formed by the XXXX rami of spinal nerve roots XXXX

Answer 29

Anterior C5-T1

Question 30

The cords of the brachial plexus are named relative to their position to the xxxxx

Answer 30

Axillary artery

Question 31

Which nerves runs over the medial epicondyle of the arm?

Answer 31

Ulnar nerve

Question 32

What is the relationship between hte brachial artery and the median nerve?

Answer 32

Arises from posterior cord Initiallt runs lateral to the brachial artery then crosses over anteriorly to run medially through the ACF.

Question 33

Related to the brachial plecus what is the function of the long thoracic nerve?

Answer 33

Originates from routes C5 to C7 Innervates the serratus anterior muscle Damage leads to winging of the scapula

Question 34

What muscles are responsible for shoulder abduction and which nerve supplies these?

Answer 34

Deltoid Axillary

Question 35

What is the difference between a nerve rupture and a nerve avulsion?

Answer 35

Avulsion = near root torn awat from spinal cord Rupture - nerve torn into two

Question 36

A gymnast presents with a medially rotated arm after injury? What may cause this? - nerve and muscles

Answer 36

C5,6,7 are injured Suprascular and axillary nerve Supraspinatours, infraspinatous and terest minor (the lateral rotators) are not functional.

Question 37

What is Erbs Palsy?

Answer 37

Also called brachial plexus palsy - injury to C5/C6 Arm weakness resulting from traumatic damage to the brachial plexus e.g during birth or gymnastics Presents - with waiters tip appearance - internally rotates shoulder, extended elbow, flexed wrist pronated, lack of movement

Question 38

What abnormality is shown in this image? What muscles and nerve is responsible for this?

Answer 38

Claw hand Unopposed extension from extension digotirum on 4th and 5th digits Due to loss of ulnar nerve damage proximal to elbow = flexor digitorum profundis medially.

Question 39

What sign is shown in this hand when asked to form a fist? What muscles and nerves are responsible for this?

Answer 39

Hand of benediction Median nerve damage Commonly at carpal tunnel -> unable to flex 1st and 2nd digit