Ga Glavicie: > Types of fractures: Note: Underlined and bold words are important and often asked by teachers in vivas. Some frequently ‘asked questions are also. mentioned here. ‘These are maximum Clinicals ‘of Upper limb put together from different books and internet by Umer Shehroz ‘Khan (Kemcolian) Clavicle fractures are classified into three types based on the location of the fracture: 1) near the sternum (least common) 2) near the acromioclavicular joint (AC) joint (second most common) 3) in the middle of the bone between the sternum and AC joint (most common)> Most common fracture: The fracture in the middle of the bone between the sternum and AC joint which is the junction between two curvatures of the bone is the most common fracture of clavicle. Cause: © Fracture ofthe clavicle results from a fallonthe shoulder or outstretched hand. ‘+ Whenthe infant presses against the maternal pubic symphysis during its passage through the birth canal. Effects: Its results in upward displacement of the proximal fragment by the sternocleidomastoid muscle and downward displacement of the distal fragment by the deltoid muscle and gravity. It may cause J)injury tothe brachial plexus (lowertrunk), causing paresthesia (sensation of tingling, burning, and numbness) in the area of the skin supplied by medial Seen brachial andantebrachialcutaneousnervesand — 2) It mayelsocausefatal hemorrhage fromthe subclavian vein. 3) It isresponsible for thrombosis of the subclavian vein, leading ta pulmonary embolism. > Cleidocranial dysostosis (CCD): Cleidocranial dysostosis (CCD), also called Cleidocranial dysplasia, is a birth defect that mostly affects the bones and teeth. The clavicles may be congenitally absent, or imperfectly developed in this disease which allows the shoulders to droop or to be brought clase together in front of chest.= Mostaggie ~Geleaasi head of cade 1 head of ulna didocres * dicltates > prtimd det = ictal chat of eodius Injured > Colles’s fracture: Colles’s fracture ofthe wrist isa distal radiusfracture in which the distal fragment is displaced (tilted) upward and backward and the radial styloid process comes to lie proximal to the ulnar styloid process, praducinga characteristic bump described as dinner (silver) fork: deformity because the forearm and wrist resemble the shape of a dinner fork. > Smith’sfracture: Ifthe distal fragments displacedanteriorly, itis calleda | Smith’s fracture (reverse Colles's fracture). This | fracture may show styloid processes of the radius and | ulnaline up ona radiograph. The ulna is the stabilizing bone of the forearm, with its trochlear notch gripping the lower end of humerus. Dislocation of elbow is produced by fall on outstretched hand with the elbowslightly flexed > In an extended elbow, the tip of the olecranon lies in a horizontal line with the two epicondyles of the humerus; and in the flexed elbow the three bony points from an equilateral triangle. These relations are disturbed in elbow dislocation. > Fracture of the olecranon is common and is caused by a fall on the point of the elbow. Fracture of the coronoid process is uncommon, and usually accompanies dislocation of the elbow. > Radioulnar synostosis is also a rare condition in which the radius and ulna are fused. > Madelung's deformity: It is dorsal subluxation (displacement) of the lower end of the ulna, due to retarded growth of the lower end of the radius.becauset the shoulderis separated from the clavicle with rupture of the coracoclavicular ligament. Dislocation of shoulder joint usually occurs when the arm is abducted, Dislocation occurs in the anterioinferior direction because of lack of support of SITS tendons, & this may damage axillary nerve and posterior humeral circumflex vessels. Thus almost always the dislocation is primarily subglenoid. the arm is abducted by 45-90 degrees to treat It. > The shoulder joint is most commonly approached (surgically) from the front. However, for aspiration the needle may be introduced either anteriorly through the deltopectoral triangle (closer to the deltoid), or laterally just below the acromion > Shoulder tip pain: Irritation of the diaphragm from any surrounding pathology causes referred pain in the sho lying the_diaphra} This is so because the phrenic nerve (su ulder. and the supraclavicular nerves (supplying the skin over the shoulder) both arise from the same spinal segments C3, C4. > Frozen shoulder: The two layers of the synovial membrane become adherent to each other. Clinically, the patient (usually 40-60 years of age) complains of progressively increasing pain in the shoulder, stiffness, in the joint and restriction of all movements. The surrounding muscles show disuse atrophy. The disease is self-limiting and the patient may recover spontaneously in about two years > Aspiration is done posteriorly on any side of the olecranon because here the capsule Is weak and the covering deep fasciais thin. > Dislocation of the elbow is usually posterior, and is often associated with fracture of the coronoid process, The triangular relationship between the olecranon and the two flexed humeral epicondyles in position is lost. > The optimal position of elbow is flexion between 30 and 40 degrees which is sufficient to perform common activities of daily = en a= wa i TT ncaa ‘Opened ftps vow eZ oe wat go me etn thy Jon nd Lent> Pulled Elbow: aoe elbow, also known as a radial head subluxation, is when the ligament that wraps around the radial head (annular ligament) slips off which results in dislodging the head of the radius from ‘the grip of annular ligament (The head of the radius slips out from the annulzr ligament.) It may be due to a sudden powerful jerk on the hand of the child. > Tennis Elbow: Tennis elbow (lateral epicondylitis) is 2 painful condition that occurs when tendons in your elbow, attached to lateral condyle of humerus i.e. common extensor origin are overloaded, usually by repetitive motions of the wrist and arm. Despite its name, athletes aren't the only People who develop tennis elbow. Tennis elbow results from Abrupt pronation may lead to pain and tenderness over the lateral epicondyle. This is possibly due to: Sprain of radial collateral ligament, 2. Tearing of fibers of the extensor carpi radialis brevis. > Golfer's Elbow: Golfer's elbow is a condition that causes pain where the tendons of your forearm muscles attach to the bony bump (medial epicondyle) on the inside of your elbow. The pain might spread into your forearm and wrist. Itis Inflammation, irritation or trauma’ of medial epicondyle of humerus (common flexor origin). Treatment may include injection of glucocorticoids into the inflamed area Q. What is difference between tennis elbow and golfers elbow? A. 1) The tennis elbow occurs on the outside of the elbow Le, at lateral epicondyle while golfer’s elbow occurs on the inside of the elbow l.e. at medial epicondyle. 2) In tennis elbow extensors of forearm are affected while in golfer’s elbow the flexors of forearm are affected. > Student's elbow (or Miner's elbow) or (dart thrower elbow) (Olecranon Burs! Student's elbow is a condition where a bursa over the subcutaneous posterior surface of olecranon process (tip of shoulder) becomes inflamed and swollen. It is subcutaneous olecranon bursitis (inflammation of bursa). Students during lectures support their head (for sleeping) with their hands with flexed elbows that is why itis called as student elbow.2. Because of communications of the lymph breast may spread to the liver, vessels with those in the abdomen, cancer of the 3. Cancer cells may drop into the pelvis producing secondaries there 4. It can spread into shoulder, 5. Apart from the lymphatics cancer may spread through the veins. In this connection, it Is important to know that the veins draini ing the breast communicate with the vertebral venous plexus of veins. Through these communications cancer can spread to the vertebrae and to the brain, > Mammography is a radiographic examin mammogram is an X-ray picture of the br. ‘ation of the breast to screen tumors and cysts. (A reast.) > Sentinel node (biopsy) procedure is a surgical procedure to determine the extent of spread or the stage of cancer (most commonly breast cancer) by use of an isotope injected into the tumor region. The sentinel lymph node is the first lymph nodes) to which cane: er cells are likely to spread from the primary tumor. > Radical mastectomy is the extensive surgical removal of the breast and its related structures, including the pectoralis major and minor muscles, axillary lymph nodes and Fascia, and part, of the thoracic wall. It may injure the long thoracic and thoracodorsal nerves and may cause postoperative swelling (edema) of the upper limb as 2 result of lymphatic obstruction caused by the removal of most of the lymphatic channels that drain the arm or by venous obstruction caused by thrombosis of the axillary vein. Modified radical mastectomy involves ‘excision of the entire breast and axillary lymph nodes, with preservation of the pectoralis major and minor muscles. (The pectoralis minor muscle is usually retracted or severed near its insertion into the coracoid process.) Lumpectomy (tylectomy) is the surgical excision of only the palpable mass in carcinoma of the breast. > Ifthe axillaryartery is ligated between the. theblood from anastomoses in the scapul thyrocervical trunkand the subscapular artery, then lar region arrives at the subscapular artery > The axilla has abundant axillary hair. Infection of the hair follicles and sebaceous glands gives rise to boils which are common in this area. > When axillary artery is blocked, a collateral circulation is established through anastomosis __around scapula which links the first part of subclavian artery with the third part of axillary artery. Anastomosis around the scapula eerie ee ey nis pare BUR Sey if Beep branch of ’—circumftex seaputar ‘Srenp nen sc everte cervical Thoracadorsal artery> In-case of blockage of inferior vena cava, the blood returns from lower limbs to hearts. vig__| At#0larvenous plemsn thoracoepigastric vein which is 9 —— communication between lateral thoracic vein of upper limb and Tbemevepigast superficial epigastric vein of lower oe limb. The direction of blood flow [ will be upward in this vein in this case. In blockage of superior vena cava, vice versa occurs Superficial epigastric I Vy The axillary ivmph nodes drain lymph from 1) upper limb 2) breast and 3) the anterior and Posterior body walls above the level of the umbilicus. Therefore, infections or malignant growths in any part of their territory drainage give rise to involvement of the axillar lymph nodes. > Anabscessin the axilla may arise from infection and suppuration of particular groups of lymph. Nodes&it can be incised through floor of axilla midway between anterior & posterior axillar foldsnearertomedial wall in order to avoid injury to vessels > Axillary arterial pulsations can be felt against the lower part of the lateral wall of the axilla. In order to check bleeding from the distal part of the limb (in injuries, operations and amputstions) the artery can be effectively compressed against the humerus in the lower pert of the lateral wall of the axilla. Next to the popliteal artery, the axillary artery is the second most common artery of the body to be lacerated by violent. > Apex of axilla is called as cervico-axillary canal and gives passage to axillary vessels and lower part of brachial plexus. Axillary sheath is derived from prevertebral fascia. Prefixed brachial plexus: When superior most root of plexus is C4 & inferior most root is C8. Postfixed brachial plexus: When superior root is C6 & inferior root is 72. iz | Erb's paralysis: Klumpke's Paralysis: | Site of injury: | The region of the upper trunk of the | Lower trunk of the brachial plexus | brachial plexus where six nerves meet is called Erb's point. Injury to the upper trunk causes Erb's paralysis.Cause of | Undue separation of the head from | Undue abduction of the arm, as in. injury: the shoulder, which is commonly | clutching something with the hands encountered in: (i) birth injury, (ii)fall | after a fall from a height, or on the shoulder, and (iii) during | sometimes in birth injury. anesthesia. Nerve roots | Mainly C5 and partly C6. Mainly Tl and partly C8. involved: Muscle Mainly biceps brachii, deltoid, | L.Intrinsic muscles of the hand (TI). Paralyzed: brachialis and brachioradialis. Partly | 2.UInar flexors of the wrist and supraspinatus, infraspinatus and | fingers (C8). supinator. Deformity: | Arm Hangs by the side; itis adducted | Claw hand due to the unopposed and medially rotated. Forearm: | action of the long flexors and Extended and pronated. The | extensors of the fingers. In a claw deformity is known as ‘policeman's | hand there is hyperextension at the tip hand’ or ‘porter's tip hand! metacarpophalangeal joints and flexion at the interphalangeal joints. Disability: The following movements are lost. | 1. Complete Claw hand 1, Abduction and lateral rotation of the arm (shoulder) 2. Flexion and supination of the forearm. 3.Biceps and supinator jerks are lost. 4.Sensations are lost over a small area over the lower part of the deltoid 2.Cutaneous anesthesia and analgesia in anarrow zone along the ulnar border of the forearm andhand. 3.Horner's syndrome. 4. Biceps and supinator jerks are lost Vasomotor changes: The skin areas with sensory loss is warmer due to arteriolar dilation. It is also drier due to the absence of sweating as there Is loss of sympathetic activity. Trophic changes: long-standing case of paralysis leads to dry and scaly skin. The nails crack easily with atrophy of the pulp of fingerstendon comes in contactwithinferiorsurface of acromioncausingpain.-Duringadduction, painfullesionisawayfrom acromion. » Rupture of rotator cuff may occur by a chronic wear and tear or an acute fall on the outstretched arm and is manifested by severe limitation of shoulder joint motion, chiefly abduction. Aruptureoftherotatorcuff, most frequentlyattrition ofthe supraspinatustendon by friction among middle-aged persons may cause degenerative inflammatory changes (degenerative tendonitis) of the rotator cuff, resultingina painful abduction of the arm or a painful shoulder. > Calcification of the superior transverse scapular ligament may trap or compress the suprascapularnerve as it passes through the scapular notch under the superior transverse scapular ligament, affecting functions of the supraspinatus and infraspinatus muscles. > Injury to the musculocutaneous nerve results in weakness of supination (biceps) and flexion (biceps and brachialis) of forearm and loss of sensation on the lateral side of forearm. > in radial nerve injuries in the arm, the triceps brachii usually escapes complete paralysis because the two nerves supplying it, arise in the axilla. > Brachial pulsations are felt or auscultated in front of the elbow just medial to the tendon of biceps for recording the blood pressure. > Popeye's deformity: When a tendon of biceps muscle tears, due to forceful flexion, the muscle can bunch up and form a large, painful ball on upper arm. This bulge is called a Popeye deformity or Popeye sign. It’s named after the ball-shaped biceps of popular cartoon character i.e. Popeye. Possible causes of Popeye deformity include: Overuse of your biceps muscle, repetitive motion of your biceps, sports injury, injury from a fall.> Crutch Paralysis: The pressure of crutches can also compress or damage the radial nerve in the region of the radial (spiral) groove. So all the muscles supplied by radial nerve below this level becomes paralyzed and relative movements get lost. This is called as crutch paralysis. > Wrist drop: Wrist drop is a medical condition which is caused by radial nerve injury. In it, the wrist and the fingers cannot extend at the metacarpophalangeal joints. The wrist remains partially flexed due to an opposing action of flexor muscles of the forearm. As a result, the extensor muscles in the posterior compartment remain paralyzed. Wrist Drop (Radial Nerve Injury) = ¢ > The flexor digitorum profundus is most powerful and bulky muscle of forearm. It provides main gripping power to hand. It is a hybrid muscle as it is supplied by two nerves. > The radial artery is used for feeling the arterial pulse at wrist. The ULNAR NERVE is often called the ‘musician's nerve’ because it controls fine movements of the fingers. The ulnar nerve is most commonly injured at following 3 sites aducor pole Flexor potics brows hea modest¢) It results in loss of functi ‘unction in th phalanges. he extensors of the forearm, hand, metacarpals, and d) Triceps is not complete! ‘ed but only weakened because only met pletel s ly paralysed but only ty medial tread €) It produces a weakness of abduction and adduction of the hand. Ul ‘unyguniig “WAND 9¢ BONEDICTION” uses wuniet peop” —\IAGLAW HAND” “yf ‘ sit Pace ts, ante ‘ted Banas ‘eniren rs erate Ane let PATRAS eee EER gh Madd oie ad nds > Thenar eminence include abductor pollicis brevis, flexor pollicis brevis and opponens pollicis. It does not include adductor pollicis muscle. > Allen test: The Allen test is used to assess the arterial blood supply of the hand. © procedure: The radial artery is located by palpation at the proximal skin crease of the ‘wrist and then compressed with three digits. The ulnar artery is similarly located and then compressed with three digits. With both arteries compressed, the sublect /s asked to clench and unclench the hand 10 times. The hand is then held open, ensuring that the ‘wrist and fingers are not hyperextended and splayed out. The palm Is observed to be blanched, The ulnar artery is released and the time is taken for the palm and especially the thumb and thenar eminence to become flush is noted. If the capillary refill time is lees than 6 seconds, the test is considered positive. The test is then completed with the radial artery tested ina similar fashion. Both hands should be tested for comparison © Apositive Allen test means that the patient does not have an adequate dual blood supply to the hand, which would be a negative indication for catheterization, removal of the radial artery, or any procedure which may result in occlusion of the vessel. °Nn the hook of hamate, : handlebar neuropathy results, iro ste: Mich compresses ulnar nerve. This is caled micdeSanee sry loss on medial side of hand &weakness of intrinsic > Volkmann’ contracture: toa claw like deformity of the hand, fingers, and wrist. itis more [tls an ischemic muscular contracture (flexion deformity) of the of the wrist, resulting from ischemic necrosis of the forearm flexor saused BY 2 pressure injury, such as compartment syndrome, ora tight cast, The are replaced by fibrous tissue, which contracts, producing the deformity. muscles, muscles > Tenosynovitis: {tis an inflammation of the tendon and synovial sheath, and puncture injuries cause infection Of the synovial sheaths of the digits. The tendons of the second, third, and fourth digits have Stharate synovial sheaths so that the infection is confined to the infected digit, but rupture of the proximal ends of these sheaths allows the infection to spread to the midpalmar space. The Synovial sheath of the litte finger is usually continuous with the common synovial sheath (ulnar Bursa), and thus, tenosynovitis may spread to the common sheath and thus through the palm and carpal tunnel to the forearm. Likewise, tenosynovitis in the thumb may spread through the synovial sheath of the flexor pollicis longus (radial bursa) > Raynaud syndrome: Its ischemia and cyanosis of digits accompanied by pain due to anatomical abnormality or underlying disease. It is a rare disorder of the blood vessels, usually in the fingers and toes. It causes the blood vessels to narrow when you are cold or feeling stressed. When this happens, blood can't get to the surface of the skin and the affected areas turn white and blue> Trigger finger: ing that interferes with its gliding thro orsnapping: Symptoms are pain at the joints and a cli ugh the pulley, causing an audible clicking icking when extending or flexing the joints. > Mallet finger (baseball finger): Itisa finger with permanent flexion of the distal phalanx due to an avulsion of the lateral bands % the extensor tendon to the distal phalanx. Itis seen in basketball players while catching a all > Hammer finger (Boutonniere deformity): tis a finger with abnormal flexion of the middle phalanx and hyperextension of the distal Bhalanx due to an avulsion of the central band of the extensor tendon to the middle phalanx or rheumatoid arthritis. Beafoeter deform > Weight Transmission in Upper limb: The weight from hand is first transmitted to radius through wrist joint, then from radius to ulna through radio-uInar joints, then from ulna to humerus through elbow jaint, then from humerus to scapula through shoulder joint, then to clavicle through acromioclavicular ligament and, then finally from clavicle to sternum through sternoclavicular joint.