frozen shoulder" (adhesive capsulitis)
- inner surfaces of the
axillary recess
stick together (axillary recess - inferior "divits" of the
glenohumeral (GH) ligaments
of the GH capsule/joint that allows aBduction of the humerus to occur w. out capsule deformation)
-
inhibits aBduction of should
loss of caracoclavicular ligaments (trapezoid & conoid ligament)
**huge stabilizers of the AC joint (dont actually contact joint but attach clavicle to coracoid process of scapula, medially from joint)
leads to dislocation @ AC joint --> scapula sags leaving sharp edge to shoulder
compression of suprascapular nerve within suprascapular notch (by ligament)
- leads to weakness in both supraspinatus & infraspinatous muscles
- inability to aBduct arm (1st
15-20 degrees)
clavicle break at inflection point
usually, medial 2/3s of clavicle deflect superiorly while laterla 1/3 remains relatively in place
fall on an outstretched hand (FOOSH)
- distal radius fracture
- scaphoid fracture, which could lead to avascular necrosis of the proximal fragment
- injuries to ligaments that hold carpal rows together (overtime can get arthritis)
- coracoacromial ligament (arch) prevents upward displacement
common site of bursitis of the shoulder
- subacromial bursa (btwn acromion of scapular & supraspinatous tendon)
- S&S: tender to palpation & painful when shoulder aBducted approaching 90 degrees)
- bursitis is just the "inflammation" stage of impingement syndrome & is often reversible w. steroi
glenoid labrum tear
- frequently torn during traumatic dislocation of the humeral head
- difficult to prevent recurrent dislocations when the labral tear is not closed and reattached to the glenoid.
glenohumeral dislocations
- anterior displacements 95% of times
- patients present with severe pain and restriction of movement of the shoulder
- frequently associated w. injury to axillary nerve
- less often radial nerve injured (will result in wrist drop)
subluxation (inferior dislocation) of the head of radius
- results from a sudden pull on the upper limb, such as that exerted by an adult to prevent the child from falling
- annular ligaments tears or slips over radial end (which it encircles)
1st carpo-metacarpal joint ("trapeziometacarpal or Kellgren's joint") of the thumb, is often involved in _______
osteoarthritis
Rheumatoid arthritis generally spares the _____ _________ joints, therefore, arthritis here strongly suggests the presence of osteoarthritis or psoriatic arthritis
distal interphalangeal joints (between middle and distal phalanges of fingers 2-5)
Clinically it may contribute to compression of the brachial plexus & subclavian vessels in
thoracic outlet syndrome
subclavius muscle
Weakness or damage to the long thoracic nerve
- innervates Serratus anterior muscle
- causes medial border of the scapula to lift off the thorax ("medial winging")
rupture of the tendon of the long head of biceps brachii
- as a 2 joint muscle - susceptible to injury w. repetitive stress
- typically occurs at it's attachment to the
supraglenoid tubercle
- as the long head resides in the intertubercular groove (sulcus), irritation to the tendon may result in tenosynovitis a
damage/lesion to dorsal scapular nerve (ventral rami of C5)
weakness/inability to retract (lateral shift) scapula & elevate scapula
(innervates rhomboids & levator scapulae)
fracture at the surgical neck of the humerus (or dislocation of shoulder joint)
- damage to
axillary nerve
(which wraps around it)
- innervates deltoid
- weakness/impairment in flexion, aBduction (after 1st 15-20 deg.), extension & external rotation of arm.
- also lack of sensation in lateral deltoid area (where u get shots)
most reliable place to test the radial nerve? (test for neuropathy or injury)
over 1st & 2nd dorsal webspace skin (skin between thumb & pointer finger)
mid-shaft humeral fracture
- damage to
radial nerve
(which follows along radial groove of humerus)
- innervates extensors of forearm & triceps
- everything distal to site will be effected --> wrist-drop, ? sensation in 1st dorsal skin space etc.
can be injured with handcuffs
superficial radial nerve (loss of sensation to part of the hand)
pain with palpation in the anatomical snuffbox
strongly suggects a scaphoid fracture (even in the absence of radiographic findings)
1. weakness in extension of wrist with intact dorsal web space sensation
2. weakness in extension of wrist with numbness over 1st-2nd dorsal webspace
1. injury to nerve distal to radial nerve bifurcation at elbow (injury to deep radial nerve/PIN, superficial radial nerve still intact)
2. injury to radial nerve proximal to bifurcation at elbow
wrist drop"
(unable to extend/dorsiflex wrist)
general radial nerve neuropathy (injury)
1. medial epicondylar fractures
2. lateral epicondylar fractures
1. ulnar nerve injury
2. radial nerve injury
medial epicondylar fracture
ulnar nerve injury
- numbness in pinky & medial half of ring finger & palm below them
- weakness of instrinsic muscles of the hand
- inability to abduct or adduct fingers (hard to grip)
ulnar claw hand
- loss of innervation to ulnar lumbricals (digits 4 & 5)
- patient tries to open hand, cannot extend 4th & 5th digits
at I.P joints (hyperextended at MC-P joints)
patient cannot extend 4th & 5th digitis (permanent position of hand at rest)
claw hand
- damage to ulnar nerve
- loss of innervation to ulnar 2 lumbricals (digitis 4&5)
ape hand
- injury to median nerve
- thenar muscles loose innervation
- thumb pulled into same plane as fingers (at rest)
thumb pulled into same plane as fingers (while at rest)
ape hand
- injury to median nerve
- thenar muscles loose innervation
Sign of Benediction ("proximal median claw hand")
- injury to median nerve
- ask patient to make a fist
- partial flexion of digitis 4 & 5 (while digits 1-3 remain extended)
- all flexors loose innervation except ulnar 1/2 of FDP which helps to flex digits 4 & 5
*
patient will have "ape hand" while at re
When attempting to make a fist,
there is partial flexion of digitis 4 & 5 (while digits 1-3 remain extended)
sign of benediction
- injury to median nerve
- all flexors loose innervation except ulnar 1/2 of FDP which helps to flex digits 4 & 5
*
patient will have "ape hand" while at rest (because median nerve also innervates thenars)
*
distal median claw hand
(lesion of distal median nerve)
- loss of 2 lateral lumbricals
- patient asked to open hand, 2nd & 3rd stay flexed
compression of ulnar nerve occurs where?
Sx?
Rx?
Guyon's tunnel
- numbness in pinky & medial half of ring finger
- roof: volar (palmar) carpal ligament (can be cut to relieve pressure)
compression of median nerve occurs where?
Sx?
Rx?
Carpal Tunnel
- numbness in 1st 3 fingers & lateral half of ring finger
roof: transverse carpal ligament (flexor retinaculum) (can be cut to relieve pressure)
Roots
1. axillary nerve
2. radial nerve
3. ulnar nerve
4. musculocutaneous nerve
5. median nerve
1. C5-C6
2. C5-T1
3. C8-T1
4. C5-C6
5. C6-T1
Pin-prick points to test if root is in tact:
1. C6
2. C7
3. C8
1. pad of thumb
2. pad of middle finger
3. pad of pinky
supracondylar fracture of the humerus (right above elbow joint)
- may injure median nerve
- thenar atrophy
- loss of thumb option
lunate dislocation
may injure median nerve
numbness
tingling & sensory loss
atrophy of thenar eminence
carpal tunnel syndrome
- tendonitis of flexor retinaculum from overuse
- entrappment of median nerve
saturday night palsy"
(compression of nerve in axilla) or using improperly adjusted crutches
radial nerve
- results in 'wrist drop'
- limb hanging by side
- medially rotated
- pronated forearm
Erb D
u
chenne Palsy
-
u
pper trunk lesion (C5-C6)
- can be caused by trauma or traumatic birth
- loss of all lumbricals (all fingers clawed)
- forearm flexors & extensors lost
Klumpke's Palsy
- lower trunk lesion (C8-T1)
-
RUM
(radial, ulnar, median nerves)
- caused by pancoast tumor or traumatic birth
median nerve innervates
- anterior flexors/pronators (except flexor carpi ulnaris & 4th/5th digits of FDP)
- thenar hand muscles
- radial 2 lumbricals (4th & 5th digits)
radial nerve innervates
- posterior extensors/supinators
--> deep radial nerve (PIN) in forearm
ulnar nerve innervates
- flexor carpi ulnaris
- 4th/5th digits of FDP
- hypothenar hand muscles (5th finger)
- palmar hand muscles (interossei, adductor pollicis & ulnar 2 lumbricals)
Mnemonic for wrist bones
Straight Line To Pinky, Here Comes The Thumb"
(going in a circle from the scaphoid towards pinky)
Scaphoid, Lunate, Triquetrium/Pisiform
Hamate, Capitate, Trapezoid, Trapezium
collateral circulation is provided by what arteries?
Circumflex scapular artery
(branch of subscapular artery) anastomoses with the
dorsal scapular artery
or
suprascapular artery
(from the thyrocervial trunk of subclavian artery)
Acromioclavicular joint injuries
1. Type I
2. Type II
3. Type III
1.
AC ligament: mild sprain
CC ligament: intact
- clavicle not elevated with respect to the acromion
2.
AC ligament: ruptured
CC ligament: sprain
- clavicle elevated but not above the superior border of the acromion
3.
AC ligament: ruptured
CC ligament: r
ROM of the wrist
1. anterior flexion
2. posterior extension
3. lateral (radial) deviation (aBduction)
4. medial (ulnar) deviation (aDduction)
1. Tendinitis
2. Tenosynovitis
1. inflammation of a tendon, often developing after degeneration (tendinopathy)
2. tendinitis with inflammation of the tendon sheath lining.
Symptoms usually include pain with motion and tenderness with palpation.
which muscle attaches at the infraglenoid tubercle?
long head of the triceps brachii
Inflammation of the tendon of the long head of the biceps brachii originates at the ________________ in about 30% of cases
supraglenoid tubercle
The capitelum (humerus) articulates with the _______________ while the trochlea (humerus) articulates with the _______
head of the radius
trochlear notch of the ulna
ANTERIORLY, the ________ receives the _________________________ during full flexion of the elbow, whereas
POSTERIORLY the ___________ receives the _____________________ when forearm is fully extended.
coronoid fossa
coronoid process of the ulna
olecranon fossa
olecranon process of the ulna
The ulnar tuberosity is an attachment site for the...
brachialis muscle
The radial tuberosity is an attachment site for the...
biceps muscle
innervation?
coracobrachialis
musclocutaneous
innervation?
teres major
lower subscapular
innervation?
sternocleidomastoid
spinal accessory nerve
innervation?
serratus anterior
long thoracic nerve
"5,6,7 wings to heaven
innervation?
biceps brachii
musculocutaneous
innervation?
triceps brachii
radial nerve
innervation?
brachialis
musculocutaneous
innervation?
brachioradialis
radial
action?
pectoralis major
adduction, internal rotation,
scapular protraction
action?
sternocleoidomastoid
elevates medial clavicle
action?
serratus anterior
scapular protraction
action?
rhomboids
scapular retraction
innervation?
latissmus dorsi
thoracodorsal
action?
latissmus dorsi
extension, adduction, internal rotation
action?
supraspinatus
aBduction
(1st 15-20 degrees)
action?
infraspinatus
external rotation
action?
teres minor
external rotation
action?
subscapularis
adduction, internal rotation
action?
teres major
aDuction & internal rotation
action?
coracobrachialis
flexion
action?
deltoid
aBduction (15-90 degrees), flexion, extension
provides sensation to medial arm
medial brachial cutaneous nerve (branch of medial cord)
provides sensation to medial forearm
medial antebrachial cutaneous (branch of medial cord)
provides sensation to lateral forearm
lateral antebrachial cutaneous nerve (from musculocutaneous nerve)
innervates the flexors of the anterior arm compartment
musculocutaneous nerve (coracobrachialis, brachialis, biceps)
all attach to greater tubercle of the humerus except:
subscapularis
supraspinatus
infraspinatus
teres minor
subscapularis (lesser tubercle)
bicepital aponeurosis
a broad aponeurosis of the biceps brachii which is located in the cubital fossa of the elbow and separates superficial from deep structures in much of the fossa.
The ______________ are held open by the axillary fascial sleeve, even if the patient is severely hypovolemic.
subclavian and axillary veins
1. divides the
arm
into its functional anterior and posterior compartments
2. divides the
forearm
into its functional anterior and posterior compartments
1. intermuscular septa's (a medial & lateral) that extend from the
brachial fascia
& attach to the humerus
2. intermuscular septa's (a medial & lateral) that extend from the
antebrachial fascia
& attach to the ulna & radius
- the
interosseous membrane
btw
At the WRIST, the antebrachial fascia thickens and becomes the _______________ ligament, _________________ ligament, & the __________________
1. transverse carpal ligament (flexor retinaculum)
2. volar carpal ligament
3. extensor retinaculum (form the 6 tendon tunnels of the wrist on extensor/posterior side)
radial sided wrist pain that radiates up the forearm with grasping or extension of the thumb (plus possible weakness and paresthesia in the hand)
De Quervain's Tenosynovitis
- inflammation of the extensor pollicis brevis & abductor pollicis longus tendons
Palmar Aponeurosis
- thick & very tough fascia that covers the palm & sends long extensions to the fingers (expansions from the tendon of the palmaris longus muscle)
- attached firmly to skin especially at palmar creases
-
Dupuytren's contracture
: progressive thickening &
tissue on the palm side of the hand thickens and essentially "shrinks" and produces a tightness in the area of the hand which the diseased tissue overlies.
It occurs most often in the 4th and 5th digits
Dupuytren's contracture (disease of the Palmar Aponeurosis & fascia)
prevents superior dislocation of the humerus
coracoacromial ligament (corcoacromial arch)
anterior intrinsic fibrous reinforcement of the GH joint
glenohumeral ligament
The first carpometacarpal joint (Kellgren's joint) allows extensive range of motion of the thumb, and is what type of joint?
saddle (motion in ever plane)_
Which ligament prevents superior dislocation of the humerus?
coracoacromial
A right hand dominant 65 year old female patient is complaining of pain at the base of her right thumb during activities requiring pinch. Because there is no history of injury or paresthesias the most likely diagnosis is:
osteoarthritis of the first carpometacarpal joint
1. wrist aBduction (radial deviation)
2. wrist aDduction (ulnar deviation)
1. flexor carpi radialis & extensor carpi radialis brevis
2. flexor carpi ulnaris & extensor carpi ulnaris
borders of the anatomical snuff box
- Lateral border: EPB & APL tendons
- Medial border: EPL tendon
- Floor: scaphoid bone & trapezium (less distinctly)
- radial artery, superficial radial nerve, cephalic vein
borders of the quadralangular space
Superior border: teres minor
Medial border: lateral margin of long head of the triceps
Bottom border: teres major
Lateral border: shaft of humerus
*axillary nerve & posterior circumflex humeral artery run through
Compression of the following artery at the following site will likely stop entire distal arterial flow.
brachial artery at distal border of teres major
actions?
1. dorsal interossei
2. palmar interossei
1. finger aBduction (DAB)
2. finger aDduction (PAD)
ligaments of the thumb
anterior oblique
dorsal oblique
Boxer's fracture
5th digit MC neck fracture
Metacarpal phalangeal joint (MP joint) ligaments
- Volar plate (keeps from bending backwards)
- Ulnar collateral ligaments (Proper & Accessory)
Skier's thumb (Gamekeeper's)
Rupture of the ulnar collateral ligament(s) (UCL) of the MC-P joint of the thumb
(proper ulnar collateral ligament, accessory ulnar collateral ligament, or both)
action?
lumbricals
flex MP joints
extend IPs
Intersection syndrome
- APL & EPB (1st extensor compartment) crossing over ECRL, ECRB (2nd extensor compartment)
- tenderness & crepitance
Mallet Deformity
- Avulsion (tearing off/back) of the extensor tendon from P3 (usually "jamming" type injuries)
- loss of extension at DIP joint
- can usually treat with splint
Boutonierre Deformity
- Avulsion (tearing off/back) of the central slip from the P2 base
- Loss of extension at the PIP joint
Swan neck deformity
- Hyper-extension at the PIP
- Flexion at the DIP
- can be caused by chronic mallet finger, PIP volar plate injury, or most commonly autoimmune diseases
Jersey finger
- FDP avulsion (Tendon pulled back off bone)
- almost always on Ring finger
1- retracts to palm
2- retracts to PIP
3- retracts to A4 pulley
Trigger digits
- Tendonopathy of the flexor tendon (superficialis)
- Tendon enlargement
- Catching/locking at the A1 pulley
- hurts at MP joint
Nerve/roots?
1. Biceps reflex
2. Brachioradialis reflex
3. triceps reflex
1. musculocutaneous n. (C5-C6)
2. radial n. (C6)
3. radial n. (C7)
Origin/Insertion
biceps brachii
origin:
- short head: coracoid process
- long head: supraglenoid tubercle
insertion:
radial tuberosity & biceps aponeurosis
Insertion
latissimus dorsi
intertubercular groove of the humerus
Insertion
teres major
lesser tubercle of the humerus
Origin/Insertion
teres minor
Origin: lateral border of the scapula
Insertion: greater tubercle of the humerus
Innervation:
teres major
lower subscapular n.
Innervation:
deltoid
axillary n.
Origin/Insertion
supraspinatous
Origin: supraspinatous fossa
Insertion: greater tubercle of the humerus
Innervation:
teres minor
axillary n.
Origin/Insertion
Infraspinatous
Origin: infraspinatous fossa
Insertion: greater tubercle of the humerus
Origin/Insertion
subscapularis
Origin: subscapular fossa
Insertion: lesser tubercle of humerus
Origin/Insertion
pectoralis major
Origin: clavicle, sternum, ribs
Insertion: intertubercular groove of humerus
Innervation:
subscapularis
upper & lower subscapular nerves
Origin/Insertion
pectoralis minor
Origin: ribs
Insertion: coracoid process
Innervation:
pectoralis major
medial & lateral pectoral nerves
Innervation:
pectoralis minor
medial pectoral n.
Origin/Insertion
coracobrachialis
Origin: coracoid process
Insertion: medial shaft of humerus
Origin/Insertion
brachialis
Origin: anterior 1/2 shaft of humerus
Insertion: coronoid process of the ulna
Origin/Insertion
triceps brachii
Origin
- Long head: infraglenoid tubercle
- later/medial heads: posterior surface along humerus
Insertion
olecranon process of the ulnar
Origin/Insertion
brachioradialis
origin: lateral supracondylar ridge of the humerus
insertion: styloid process of radius
Origin/Insertion:
flexor digitorum superficialis
Origin: radial head (common flexor tendon)
Insertion: shafts of the middle phalanges of digits 2-5
Origin/Insertion:
flexor digitorum profundus
Origin: proximal ulnar & interosseus membrane
Insertion: base of the distal phalanx of digits 2-5
Origin/Insertion:
flexor pollicis longus
Origin: anterior surface of radius & interosseous membrane
Insertion:
base of the distal phalanx of the thumb
Origin/Insertion:
Lumbricals (hand)
Origin: tendons of FDP of digits 2-5
Insertion: radial side of proximal phalanx of digits 2-5
Action:
Lumbricals (hand)
flex the MP joints
extend IP joints of digits 2-5 ("lumbrical goose")
Action:
palmar interosseous (hand)
flexes MC-P joints, extends proximal & distal IP joints &
aDducts
digits 1, 2, 4, & 5 (midline = 3rd digit)
PAD
Action:
dorsal interosseous (hand)
flexes MC-P joints, extends IP joints of digits 2-4,
aBducts
digits 2-4 (movement away from the midline of the 3rd digit)
DAB
All of the instrinsic hand muscles are innervated by the _____ nerve, except.....
which are innervated by the ______ nerve
ulnar n
except....
"1/2 LOAF"
1/2L
umbricals
O
pponens pollicis
A
bductor pollicis brevis
F
lexor pollicis brevis
which are innerved by
median n.