Upper limb Conditions

Question 1

What do the terms ‘intrinsic’ and ‘extrinsic’ muscles of the hand mean?

Answer 1

The intrinsic muscles of the hand are those muscles that both originate and insert within the hand.

The extrinsic muscles of the hand are those muscles that originate in the forearm and insert into structures in the hand.

Question 2

Name this condition, clinical feautures?

Answer 2

Olecroneon bursitis!

inflammation of the bursa due to Trauma or Prolonged pressure,infection

Normally, the olecranon bursa is flat. If it becomes irritated or inflamed, more fluid will accumulate in the bursa and bursitis will develop.

Soft, cystic & transilluminates

w/ light since its filled with fluid!

Question 3

 State 2 soft tissue complications that may occur after a closed Colles’ fracture.

Answer 3

•  median nerve palsy and post-traumatic carpal tunnel syndrome (see below)
•  tear of the extensor pollicis longus tendon (by attrition of tendon over a sharp fragment of bone)

Question 4

what sign might one look for when diagnosing radial head/neck fractures?

Answer 4

fat pad sign

Question 5

what is this?

which muscles have been paralyzed here?

Answer 5

Distal Ulnar Claw

long standing damage to the ulna nerve at the wrist

-Hyperextension at the MCP + flexion of the DIP & PIP of the 4th and 5th digits.

Question 6

what is the most common cause of elbow pain?

what is the most common type of elbow fracture?

Answer 6

Tennis elbow>> Lateral tendinopathy

Radial Head fractures!

( kl shay laterally)

Question 7

what is Guyon’s canal?

what happens if that area got compressed?

Answer 7

Question 8

In a proximal clavicular fracture, auscultation of the chest must be performed and a chest X-ray may also be needed. What rare but important complication needs to be excluded?

Answer 8

Pneumothorax due to proximity of apex of lung to middle third of clavicle

Question 9

what is the ‘anatomical snuff box’? what is its function?

Answer 9

indication of a SCAPHOID FRACTURE!

u feel tenderness upon palpation,

Question 10

What complications may occur after anterior dislocation of the shoulder?

Answer 10

axillary artery and other structure of brachial plexus! & Rotator cuff injury.

Question 11

this is sometimes known as popeye’s muscle,

what is the more sensible term?

Answer 11

long head of biceps rupture!

Question 12

state 3 classical features of colle’s fracture, which additional fracture is seen in approx 50-60% of all cases of colle’s?

describe how the fall would look like?

Question 13

what would injury of the radial nerve result in?

think of the muscles it innervates

Answer 13

paralysis of brachioradialis and all extensor muscles of the wrist and fingers.

“wrist drop” (i.e. inability to actively extend the wrist) and inability to actively extend the fingers.

The wrist is flexed because of unopposed flexor muscles and gravity.

Question 14

Monteggia vs. Galeazzi Fractures

Answer 14

Question 15

describe the route of the ulnar nerve after it leaves the arm

Answer 15

Question 16

what is known as the students elbow?

Answer 16

Olecroneon bursitis!

inflammation of the bursa due to Trauma or friction!

Question 17

risk factors of carpel tunnel?

Answer 17

Pregnancy

Thyroid disorders

Acromegaly

Diabetes

Menopause

Obesity

Question 18

What complication can occur following a scaphoid #?

Answer 18

Avascular necrosis of proximal segment

Question 19

Boxer’s fracture?

Answer 19

“drunk man hits wall”

break in neck of 5th metatarsel

Meta btyeen?! u know what i dont give 5 fucks

-nuckle descends

Question 20

Why can superficial lacerations at the wrist result in loss of sensation in the palm of the hand and NOT in the digits?

Answer 20

At the wrist, the median nerve becomes superficial in the midline and gives off a palmar cutaneous branch which supplies the skin of the mid-palm.

• The digital nerves, however, arise from the median and ulnar nerves in the hand and hence are spared in very superficial lacerations at the wrist.*
• (shoofay alaa, the palmar branch 7ail yay to the surface, more prone to be damaged, ama il bajy shway deeper)*

Question 21

In clavicle fractures,

Which parts of the brachial plexus are at most risk of injury i.e. which parts lie immediately posterior to the fracture point of the clavicle?

Answer 21

Trunks and divisions of brachial plexus.

Question 22

Given its muscular attachments, into which position is the lateral clavicular fragment most likely to be displaced in a midclavicular fracutre? Explain your answer.

Answer 22

Question 23

Osteoarthritis of the hand

Answer 23

Osteoarthritis of the hands usually affects the base of your thumb and the joints at the ends of your fingers, although other finger joints can also be affected.

Question 24

Name the fracture:

state the side of the body,

name of the bone that is fractured,

part of the bone that is fractured

fracture pattern

If this is untreated, whilst chronic deformity may develop?

is the joint is involved? (articular) or not (extra-articular).

what structures can be ruined as well?

Answer 24

Supracondylar fracture in distal humerus (extra-articular)

• young children
• swelling, Bruising!

Ulnar nerve, median nerve, radial nerve, brachial artery

Volkmann’s ischaemic contracture

Neurovascular complicaitons!

most commonly u may injure the anterior interosseous nerve whch arises formt he median nerve,> check for “OK” sign!

Question 25

Which nerve is most at risk during dislocation of the humeral head from the glenoid cavity? How would you examine the patient to determine the integrity of this nerve? What would you not do and why?

Answer 25

Axillary nerve Test for sensation in the 'regimental badge area' on the upper lateral part of the arm (area supplied by the cutaneous branch of the axillary nerve). Do not test motor function in the acute situation, as this could lead to increased soft tissue damage and may damage the nerve you are trying to test.

Question 26

Distal Radial fractures?

Answer 26

colles and smith

Question 27

De Quervain's tenosynovitis what could of caused this? what is it?

Answer 27

- Pain and swelling in radial side - occurs due to inflammation, thickening & stenosis of **synovial sheath** - more common in **women** * -twisting turning wet towels * -playing piano * -hammering

Question 28

how do we test for carpel tunnel syndrome?

Answer 28

**Positive Phalen's test**: flexing the wrist for 60 seconds causes pain or paraesthesia in the median nerve distribution. **Positive Tinel's sign:** tapping lightly over the median nerve at the wrist causes a distal paraesthesia in the median nerve distribution.

Question 29

Which artery and vein are most at risk of damage from a clavicular fracture? What is their anatomical relationship to the nerves of the brachial plexus at this point?

Answer 29

Anterior to posterior: clavicle\>subclavian vein\>subclavian artery\> trunks of brachial plexus.

Question 30

Medial nerve lesion What muscles will be paralysed? Describe the consequences in hand movements

Answer 30

​ * Loss of opposition of the thumb * Loss of sensation to the thumb, adjacent 2.5 fingers (gunshot move)

Question 31

Name this condition, how did it occur? which sites r they most commonly found?

Answer 31

Gouty Tophi ## Footnote Disorder of nucleic acid metabolism leading to ***Hyperuricaemia*** * nodular masses of **_monosodium urate crystals_** deposited in the **soft tissues** of the body* - develop in more than half of patients with untreated gout. common in : Ear, Achilles tendon, elbow

Question 32

Clawing of hand is less severe in - proximal ulnar nerve lesion - distal ulnar nerve lesion choose and explain

Answer 32

**proximal ulnar nerve lesion!** ***_ulnar paradox!_*** **High ulnar nerve injury**\> there is paralysis of the flexor digitorium PROFUNDUS ( suppose to do punch move) and so u cant do punching finger move at DIP. (less clawing) get it? **Distal ulnar nerve injury**\> we still have our Flexor dijitorum profundus, and so there more clawing!

Question 33

Name this condition

Answer 33

**Dupuytren's Contracture** common in caucasians! - (mostly genetic) - alchololism - diabetes - epilepsy - liver disease

Question 34

What is the fat pad?

Answer 34

Question 35

what is the function of the lumbricals?

Answer 35

flexes MCP and extends PIP andDIP in ulnar nerve injury vise versa occurs and u get clawing!

Question 36

What is the most common direction of dislocation and why? In what position would the patient typically hold his arm?

Answer 36

it is weak on its **inferior** aspect. so the head of the humerus usually dislocates inferiorly, but displaces in an **anterior** (subcoracoid location) **due to the pull of the muscles**. This is referred to as an ***_anterior (or antero-inferior) dislocation._*** The arm would be externally rotated and slightly abducted.

Question 37

what is a rheumatoid nodule? common sites? clinical feautures?

Answer 37

Mainfestation of **RA**, FIRM swelling on touch like unripe fruit (t*hat how u distinguish it from bursitis),* common sites: fingers, forearm, elbow

Question 38

describe this default what move occured this?

Answer 38

Anterioir dislocation of the arm ra7 a9ikik kaf

Question 39

Elbow Osteoarthritis vs Elbow Rheumatoid Arthritis

Answer 39

O\>Degenerative disease of articular cartilage RA\> chronic Systemic Autoimmune disease that attacks lininf og the joints\> "synovium" Morning stifness

Question 40

Describe this sign how do patients present pain?

Answer 40

**Fat pad sign or Sails sign** *(yellow arrows)* * and there swelling & effusion of the joint capsule! ususally **blood** collecting in the joint "hemarthrosis" (due to FRACTURE) and this displaces the fat pad & it'll buldge up off the bone* * indication that there has been a fracture!* * Red arrow*\> showing **radial** fracture! lateral pain, modest swelling

Question 41

what is shoulder impingment

Answer 41

When you raise your arm to shoulder height, the space between the acromion and rotator cuff narrows. The acromion can rub against (or "impinge" on) the tendon and the bursa, causing irritation and pain.

Question 42

What clinical term is used to describe the abnormal sensation of 'pins and needles'?

Answer 42

Paraesthesia (anaesthesia is loss of sensation and is incorrect).

Question 43

what r the Factors contributing to shoulder stability?

Answer 43

Question 44

What does gouty tophie affect?

Answer 44

Joints - recurrent attacks of arthritis Soft tissues - ear, elbows, achilles tendon

Question 45

name the condition? PRESENTATION?

Answer 45

Ulnar nerve neuropathy\> ‘funny bone’ 􏰁 **‘Cubital Tunnel Syndrome’** 􏰁 * Compressive neuropathy of Ulnar Nerve at Elbow * 􏰁 Ulna 1 1⁄2 digits \> cause tingling sensation * Paraesthesiae, numbness and weakness *c**U**bital tunnel\> **U**lnar nerve*

Question 46

Describe what this is? what is this an indication of? can they appear elsewhere? if so where?

Answer 46

* **Heberden's nodes**- DIP distal interphalangeal joint (H-D) (High Definition) * **Bouchard nodes**- PIP proximal interphalangeal joint (B-P) ( Blue Picture) *firm knobbly swellings form on the finger joints. These are caused by **osteophytes.*** they r clinical signs of osteoarthritis!

Question 47

Reflex Sympathetic Dystrophy Syndrome

Answer 47

is a rare disorder of the sympathetic nervous system that is characterized by chronic, severe pain.

Question 48

Name this condition what complication follows this?

Answer 48

**Scaphoid fracture!** * FOOSH * Tenderness in ‘anatomical snuff box’ * **hard to see on initial X-Rays!!** * **bc the scaphoid as poor blood supply \> slow healing & avascular necrosis** * **risk of arthritis!**

Question 49

what happens if u get cubital tunnel syndrome?

Answer 49

tingling sensation of the 1 1/2 part of ur hand

Question 50

what should one be aware when diagnosing lateral epicondylitis?

Answer 50

might be radiating pain from neck or shoulder

Question 51

What diagnostic test can be performed to diagnose tenosynovitis?

Answer 51

Finkelstein's test

Question 52

Pulled Elbow? how does it occur? what is another name for it? who is it more common in and why? presentation?

Answer 52

nursemaids elbow! *Subluxation from annular ligament* Head of **radius** slips under **annular ligament**! common in kids( 2-5 yr old)\> cuz their ligaments arent that strong yet! sudden pull in babies arm * "la la la la bukuk bukuk"* * Due to sublaxation and pain, the child keeps arm immobile and lets it hang downwards ( doesn't use it) \> chna paralyzed*

Question 53

what is the most frequent carpal bone fracture?

Answer 53

scaphoid!

Question 54

describe this condition

Answer 54

**Calcific tendinitis** calcium hydroxyapetite deposit, u can get a subacromial impingment if its large! (hard to abduct the arm) if it bursts..... Acute calcific tendonitis!

Question 55

State two 'common' causes of posterior dislocation of the shoulder. In what position would the patient typically hold his arm?

Answer 55

seizures and electric shocks ## Footnote Patients usually present with their arm internally rotated and adducted. They demonstrate flattening / squaring of the shoulder with a **prominent coracoid process**. The arm **cannot be externally rotated** into the anatomical position.

Question 56

golfers elbow vs tennis elbow what causes it? which one is most common?

Answer 56

Theyre both forms of ***TENDINOPATHY***! **Lateral** Epicondylitis\>\> T**e**nnis Elbow\>\>**e**xtesnor muscles problem **Medial** Epicondylitis\>\> Gol**f**er’s Elbow \>\>**F**lexor muscles probelms TENNIS IS MORE COMMON i mean c'monnn who plays golf anyways?? ;P

Question 57

Lateral elbow tendinopathy (tennis elbow) most commonly results from microtears in which **specific muscle?** Where is the pain experienced and which movement is most painful?

Answer 57

Extensor carpi radialis brevis (ECRB) Lateral epicondyle, extension of the wrist (against resistance)

Question 58

a patient comes in complaining of lateral elbow pain, what is the most common diagnosis? what is the problem? why dis it occur? which ppl is is most common in?

Answer 58

**Tennis elbow\> lateral elbow tendonopathy** a problem with tendon attachting to the Lateral epicondyle! extensor muscle problem! Mostly manual workers! "T**e**nnis\>**e**xtensor muscle" ***_BEWARE_*** (salfat mama) : not all pain felt in elbow is tennis elbow! it might not be eblow pain, it could be pain coming from somewhere else! pain in subacromial region & deltoid is often felt in the upper arm, u get pain radiating down from the **neck in the C5-C6 distribution, can also give u problems around the lateral region of the elbow too!**

Question 59

which type of fracture is commonly called the "dinner fork'?

Answer 59

"im calling u at the dinner table"

Question 60

describe this fracture ## Footnote Which nerve is most likely to be injured & why? What would be the effect of this neurological injury on movement at the elbow? what will happen to the wrist and fingers?

Answer 60

Comminuted fracture of the **mid-shaft of the left humerus** Radial nerve; the nerve runs in the radial (or spiral) groove on the posterior surface of the shaft of the humerus Flexion of the elbow will be normal. There will also be no effect or mildly compromised extension of the elbow. **wrist drop (cant extend wrist) and finger extension**

Question 61

The **profunda brachii artery** is also at risk in a ***midshaft humeral fracture***. If this artery is occluded, what effect, if any, would you expect to see on perfusion of the forearm and hand? Explain your answer.

Answer 61

No effect bc the profunda brachii supplies the **deep tissues of the arm** but does not extend below the elbow

Question 62

A 65 year old man falls onto his outstretched right hand (FOOSH), **dorsiflexing** her pronated wrist as she lands. She immediately develops pain, swelling and deformity of the right wrist. X-rays are obtained. Name this condition

Answer 62

COLLES FRACTURE

Question 63

Describe 3 feautres of this fracture that can be seen here! Name the fracture

Answer 63

**Boxer's fracture!** Transverse

Question 64

on attempt to make a fist, maham fails to do so, and instead the following poisiton is shown for her what is this called? what is it an indicaiton of?

Answer 64

when median nerve is injured at elbow, hand forms ***hand of benidiction*** upon attempting to make a fist!

Question 65

Name this condition? what is it caused by?

Answer 65

**Posterior elbow dislocation** FOOSH Pain / deformity / loss of function (posterior is most common)

Question 66

what is carpel tunnel syndrome?

Answer 66

Compression of the **median nerve** at the wrist due to increased pressure in the carpal tunnel thenar muscle wasting!

Question 67

Name these 2 which one is a functional problem which one is a cosmetc?

Answer 67

**Varus**\> is a cosmetic problem but **valgus**\> is the functional ( problem cuz u can compress on ulnar nerve here)

Question 68

what Anatomical lesions can follow an anterior dislocation?

Answer 68

Question 69

Which condition, common in post-menopausal women, leads to increased risk of Colles fracture?

Answer 69

Osteoporosis

Question 70

what is Allens test? when do we do it?

Answer 70

***measures arterial competency, and should be performed before taking an arterial sample*** - Compress on both radial and ulnar to stop blood flow ( hand blanches) - release hand from ulnar and see how long it takes to restore BF a colour * if the hand **remains blanched for longer than 15 secs**, it means theres inadequete collateral cirulation btw the 2*

Question 71

In Carpel tunnel syndrome why does the patient not decribe tingling in the palm of her hand?

Answer 71

bc the sensation to pam already branched wayyy before!

Question 72

what is the ulnar paradox?

Answer 72

damage to the ulnar nerve at the **elbow** results in **less** clawing as compared to similar lesion at the **wrist**.

Question 73

List some NVT assessments you might perform following a **supracondylar fractur**e of the distal humerus

Answer 73

Parasthaesia OK Sign Radial pulse Capillary return

Question 74

u suspect either RA or OA, how can u differentiate btw the 2 in this casE?

Answer 74

it is **sclerotic!** which is a feautre of Osteoarthritis

Question 75

which nerve & artery is at most risk of injury?

Answer 75

Median and brachial artery

Question 76

A 55 year old woman has had a painful right shoulder for the past two weeks. She says that the pain is particularly bad when she tries to brush her hair or put on her coat. On examination, a painful arc is detected between 60 and 120 degrees of abduction. She is diagnosed with **inflammation in a tendon** that is impinging against the coracoacromial arch of the scapula. The tendon of which muscle most likely to be inflamed? (a) Deltoid (b) Infraspinatus (c) Subscapularis (d) Supraspinatus (e) Teres minor

Answer 76

The patient has **supraspinatus tendonitis.**

Question 77

lateral fragment is displaced inferiorly and medially. The action of which muscle is primarily responsible for the **medial** displacement?

Answer 77

Pectoralis major

Question 78

Which nerve has been damaged ? what do u call this appearence?

Answer 78

Long thoracic nerve winging of the scapula *the serratus anterior is paralysed so is no longer able to pull the scapula forward*

Question 79

An 80 year old woman falls and lands on the **lateral** aspect of her right flexed elbow. She describes complete loss of sensation in her ring and little fingers Which movement of her right thumb is most likely to be impaired?

Answer 79

The **ulnar** nerve runs posterior to the medial epicondyle in the cubital tunnel. Here it is susceptible to damage in medial epicondylar fractures. **Adduction** adductor pollicus

Question 80

A 70 year old woman falls onto her outstretched left hand. She develops severe pain and deformity of the wrist. After reduction of the fracture, the pain is improved and she now complains of numbness and tingling in her **thumb, index and middle fingers.** **Which of the following movements of her hand is most likely to be impaired?** **(a) Abduction of the fingers** **(b) Adduction of the fingers** **(c) Flexion of the index finger at the distal interphalangeal joint** **(d) Flexion of the index finger at the proximal interphalangeal joint** **(e) Palmar abduction of the thumb**

Answer 80

Palmar abduction of the thumb Abductor pollicis brevis is supplied by the median nerve in the hand so will be paralysed.

Question 82

i) On the outline of the dorsum of the hand below, shade the sensory distribution of the radial nerve. ii) Mark with an X the most reliable place for testing sensory loss in a radial nerve lesion. what is this space called

Answer 82

X\>\> dorsum of the first web space