Anatomy Lect 7 Ue

Anatomy Lecture 7 Upper Extremities Physician Assistant Program Miami Dade College

“ I will persist until I succeed”.
Og Mandino

Shoulder

Shoulder
1. Glenohumeral Joint: A spheroidal (ball & socket) joint that is the principal articulation of the shoulder
Inferior Glenohumeral ligament
A major anterior stabilizer of the glenohumeral joint, especially with the arm abducted
Middle Glenohumeral ligament
Prevents anterior instability when the shoulder is externally rotated and abducted 45 degrees
Superior Glenohumeral ligament
Works with the coracohumeral ligament to prevent inferior instability in the adducted arm
Labrum
Is a fibrocartilagenous thickening surrounding the glenoid that deepens the glenoid cavity.
It prevents abnormal motion and serves to anchor the inferior glenohumeral ligament complex

Shoulder
2. Sternoclavicular Joint:
Gliding joint with disc
anchors shoulder girdle to chest wall (sternum to clavicle)
3. Acromioclavicular joint:
Gliding joint with incomplete disc.
Attaches acromion and clavicle
4. Scapulothoracic joint:
Medial border of scapula articulates with posterior aspect of ribs 2-7
The ratio of glenohumeral to scapulothoracic motion during shoulder abduction is 2:1

Shoulder
5. Supporting structures (from superficial to deep layers)
A. deltoid, pectoralis major
B. clavicopectoral fascia, conjoined tendon, pectoralis minor
C. subdeltoid bursa, rotator cuff muscles
D. glenohumeral capsule, coracohumeral ligament

Finding Significance
Muscle wasting Chronic rotator cuff tear, nerve injury
“ Popeye” muscle Proximal rupture of long head of biceps
Scapular winging Serratus anterior (long thoracic nerve) injury
Superior prominence Acromioclavicular
(piano key sign) separation/ clavical fracture
Anterior prominence Glenohumeral dislocation, sternoclavicular injury
Systemic hyperlaxity Multidirectional instability

Exam Technique Significance
Impingement sign passive forward flexion pain = >90 degrees impingement syndrome
Impingement Test same after subacromial relief of pain=
lidocaine impingement syndrome
Hawkins Test passive forward flex to pain= impingement synd (Dump out can) 90 & internal rotation
Apprehension Test Abduction to 90 & + appreh test= ant.
external rotation shoulder instability
Sulcus sign downward traction sulcus below on arm acromion=inferior laxity

Exam Technique Significance
Crossed Chest, Passive forward flex pain= AC pathology
Adduction test to 90 & adduction
Acromioclavicular same after AC lido inj relief of pain= AC path
Injection
Yergason test resisted supination pain= bicipital tendonitis
Lift off sign arm behind back lifted inability to accomplish
posteriorly = subscapularis tear
Wrights test extension, abduction, loss of pulse,
external rotation of arm, reproduction of symp
neck rotated away = thoracic outlet synd

Anterior Glenohumeral Dislocation “Shoulder dislocation”
Mechanism of injury:
From external rotation or abduction force on humerus
From a direct posterior blow to proximal humerus
From a posterolateral blow on the shoulder
Exam:
Space underneath acromion where humeral head should lie
Palpable anterior mass representing humeral head in anterior axilla
Tx:
Closed reduction
Immobilization in internal rotation

Types of closed reduction
Stimson maneuver:
Pt prone on table with weight on arm
Mitch maneuver:
Pt supine, steady downward traction applied at elbow, combined with slow gradual external rotation and abduction of limb
Hippocratic maneuver:
Pt supine, examiner places sole of foot in axilla (shoe removed), grabs pt’s wrist with both hands and applies steady longitudinal traction
Traction/ countertraction:
Sheet method 2 people opposing
Scapular manipulation
Stimson maneuver with medial manipulation of tip of scapula

Anterior Glenohumeral Dislocation
2 lesions with recurrent dislocations:
Bankhart Lesion:
Anterior capsular injury assoc with a tear of the glenoid labrum off the anterior glenoid rim
Hill-Sachs Lesion:
Compression fracture of the articular surface of the humeral head posterolaterlaterally that is created by the sharp edge of the anterior glenoid as the humeral head dislocates over it

Glenoid Labrum Injury
From repeated anterior subluxation of the shoulder
From anterior instability during acceleration phase of throwing secondary to long head of biceps pulling on anterior labrum
From repetitive bench pressing and overhead pressing
From fall on outstretched arm

Glenoid Labrum Injury
Patient c/o pain that interrupts smooth functioning of shoulder during performance of specific activity
Exam:
Pain on forced external rotation @ 90 degrees abduction
“ pop” or “click” on forced external rotation
Weakness of rotator cuff muscles
CT scan or MRI with contrast may allow early detection
Tx:
Physical therapy
Arthroscopic repair

Rotator Cuff
The rotator cuff connects the humerus to the scapula.
The rotator cuff is formed by the tendons of four muscles:
the supraspinatus,
infraspinatus,
teres minor, and
subscapularis.

Bursitis

Bursitis
Bursitis is defined as inflammation of a bursa.
Bursae are closed, round, flattened sacs that are lined by synovium and separate bare areas of bone from overlapping muscles (deep bursae) or skin and tendons (superficial bursae).
They occur at areas of friction or possible impingement.
Bursae function to reduce friction and allow a greater range of movement when muscle contracts.
They may or may not communicate with the adjacent joint space. Symptoms of bursitis include inflammation, localized tenderness, warmth, edema, erythema of the skin (if superficial), and loss of function
When inflamed, the synovial cells increase in thickness and may show villous hyperplasia.
Bursal lining eventually may be replaced by granulation tissue prior to fibrous tissue formation.
The bursa becomes filled with fluid, which is often rich in fibrin. Hemorrhage sometimes occurs.
Patients often complain of a dull shoulder ache.
The most common symptom of subacromial bursitis is tenderness over the greater trochanter (and beneath the deltoid muscle) that disappears when the arm is abducted.

Clavicle fracture
Most common bone fractured
The weakest part being the junction of the middle and lateral thirds
Class A (middle third fractures) (80%):
Treat with sling immobilization.
Some prefer using a figure-eight clavicular splint, especially for displaced fractures.
Class B (distal third fractures) (15%):
Treat type I (nondisplaced) and type III (articular surface) fractures with sling immobilization.
Immobilize type II (displaced) fractures in a sling and swathe.
These may require orthopedic surgical fixation.
Class C (proximal third) (5%):
Treat nondisplaced fractures with sling immobilization.
Displaced injuries may require orthopedic referral for surgical reduction.
Neonatal fractures generally heal spontaneously in several weeks without special treatment.

Normal----- 
 ----- Normal
FRACTURE ---- 

Acromio-clavicular (AC) separation (separated shoulder)
Mechanism of injury- fall onto point of shoulder
If there has been significant disruption (or a fracture to the clavicle itself), the area will appear swollen and deformed compared with the other side.
The patient will avoid movement, do to pain.
Gently have the patient move their arm across their chest while you palpate in the AC region.
This will cause pain specifically at the AC joint if there is separation.
Tenderness is felt at the junction, or the site of the AC (acromioclavicular) joint .

Paralysis of the Serratus Anterior
Results from injury to the long thoracic nerve causing a “Winging of the Scapula”

ITALY
TREVI FOUNTAIN ROMA
FONTANA DI TREVI

Brachial Plexus Injuries
Disease, stretching, and wounds in the posterior triangle of the neck
Injuries to the brachial plexus result in paralysis and anesthesia.
Superior trunk injuries (C5-6): “Waiter’s tip ” position (Erb-Duchenne palsy)
Fall (motorcycle), newborn forced delivery (stretched neck), heavy backpacks
Inferior injuries (C8-T1 ): “Claw hand” (Klumpke paralysis)
Arm jerked superiorly, grabbing tree branch while falling, pulling on baby’s upper ext during childbirth.

Bicipital Tendonitis
Pain localized to proximal humerus and shoulder joint, with resistive supination of the forearm aggravating symptoms
+ Yergason test (resisted supination) for unstable long head of biceps in bicipital groove
Tx:
Physical therapy
Activity modification
NSAID’s

Shoulder Fractures
Proximal Humerus Fractures:
Neer classificaton:
Non-displaced fractures:
are displaced less than 1cm or angulated <45 degrees, regardless of the fracture pattern or # of fragments
Displaced fractures:
2 part fx’s are fractured either through the anatomical neck, surgical neck, greater tuberosity or lesser tuberosity
3 part fx’s are fx’s of the surgical neck with fractures of either the greater tuberosity or lesser tuberosity
4 part fx’s are fxs of the anatomic neck & fractures of the greater and lesser tuberosities

Humeral Fractures
Neurovascular status must be evaluated with fractures
The humerus is in direct contact with nerves that can be injured due to a fracture.
Surgical neck : axillary nerve (C5-6, deltoid atrophy) (also from improper crutch use “waiter’s tip”)
Radial groove: radial nerve
Distal end of humerus : median nerve
Medial epicondyle: ulnar nerve

Proximal Humerus Fracture
The vascularity is at risk with anatomical neck fractures
Most common mechanism of injury= FOOSH
Signs & symptoms:
Pain, swelling, tenderness
Tx:
For nondisplaced fx’s= sling, begin ROM exercises
2 part/3 part fx’s= closed reduction, sling, possible ORIF
Absolute indication for hemi-arthroplasty: 4 part fx’s, non-reducible 3 part fx’s
FOOSH = Fall On Outstretched Hand

Midshaft Humerus Fractures
Signs & Symptoms:
Arm pain, swelling, deformity
The arm is shortened with gross motion & crepitus on gentle manipulation
XR:
AP/lat c shoulder & elbow
Tx:
Coaptation splint
Carefully molded plaster slab placed around medial & lateral aspects of arm, extending from axilla around elbow & over deltoid & acromion x 2 wks
Change to Sarmiento brace @ 2 wks
May require ORIF with plate/screw or intramedullary nailing

Midshaft humerus fx

Distal Humerus Fracture
Supracondylar fx’s of the Humerus:
Characterized by dissociation b/t diaphysis & condyles of distal humerus, frequently extended distally & involves articular surface
Caused by FOOSH or direct blow
PE:
+ deformity, instability, crepitus
XR:
AP/lat/obliq
Management:
Initial: alignment, immobilization, ice, long arm splint
Definitive: ORIF, early motion
(Other fx’s: transcondylar, medial condyle, lateral condyle)

MONTMARTRE
PARIS
FRANCE

Radial Head Fracture
MOI:
Fall forward with elbow extended, forearm pronated
Pain localized to radial head
XR:
AP/lat/obliq
TX:
Types I, II, & III without mechanical block are treated with a sling and AROM x 3 wks
After 3 wks d/c sling & begin aggressive PT
Fx’s with elbow instability or mechanical block are treated operatively with either reduction & fixation of head, excision of head, or ligament repair

Olecranon Fractures
Pain @ elbow with h/o trauma
XR:
AP/lat/obliq
Management
Initial: sling for comfort
Definitive:
non-displaced fx’s can be managed with posterior splint @ 90 degrees flexion x 2 wks
Other fx’s are managed with ORIF or percutaneous pinning & early motion post-operatively

Nursemaid’s Elbow
Subluxation of the radial head from the Annular ligament
MC from sudden jerking of child’s hand while in pronation

Elbow Fractures
Monteggia Fracture
Usually a fx of the mid or proximal ulna with anterior dislocation of the radial head
MOI:
Forceful pronation or direct blow to dorsum of ulna
H&P:
Pain & h/o trauma, may have obvious deformity
XR:
AP/lat/obliq
TX:
Hematoma block, reduction, long arm cast or splint
May require ORIF

Galeazzi Fracture/dislocation
An injury pattern involving a radial shaft fracture with associated dislocation of the distal radioulnar joint (DRUJ), which disrupts the forearm axis joint.
"fracture of necessity" refers to the adult Galeazzi fracture not being amenable to treatment by closed means, necessitating surgical stabilization.

Galeazzi (Reverse Monteggia)

SAN CARLOS DE BARILOCHE
ARGENTINA

Lateral Epicondylitis (Tennis Elbow)
Pain at lateral humeral epicondyle, reproduced by extending the wrist against resistance
Seen in patients who perform repetitive wrist extension (Tennis)
Tx:
NSAID’s, Restriction band, Physical therapy, lighter racquet, correction of backhand stroke

Medial Epicondylitis (Pitcher’s Elbow, Golfer’s)
Pain at medial humeral epicondyle
Seen in patients who golf, or perform throwing sports, such as baseball, football, javelin
Tx:
NSAID’s, Physical therapy

Movements at the wrist
Radial deviation (abduction)
Ulnar deviation (adduction)
Flexion
Extension
Supination
Pronation
Combination of all of the above

Distal Forearm Fractures
1. Extension fractures:
Colles Fracture
Extra-articular fx with dorsal displacement of distal radius
MC fx of the wrist
Usually 2° to FOOSH
Exam:
Silver fork deformity , swelling, decreased ROM secondary to pain
XR:
AP/true lateral/obliq- radius will be shortened

Colles fx

Distal Forearm Fractures (cont)
2. Non-displaced Distal Radius Fx’s
Require short arm cast (SAC) in neutral, ice, elevation, NSAIDS, analgesia
3. Other common fx’s:
Smith’s fx
Reverse Colles fx
Fracture of the distal radius with palmar displacement of the distal fragment.
Die Punch Fx
Intra-articular distal radius fx with impaction of the dorsal aspect of the lunate fossa
Barton’s Fx
Displaced intra-articular lip fx of the distal radius
May be assoc with carpal subluxation
May be dorsal or volar configuration
Extends into radio-carpal joint

Non-displaced distal radius fx

Smith’s fx

Die Punch Fx

Barton’s Fx

ROSETTE OF NOTRE DOME
PARIS
FRANCE

Scaphoid Fractures
MC fx’d carpal bone
There is no direct blood supply to the proximal portion of the scaphoid
Therefore, scaphoid fx’s have a tendency to develop delayed union or avascular necrosis
Remember the more proximal the fx line is in the scaphoid injuries, the greater the likelyhood of avascular necrosis
Mechanism of injury
Forceful hyperextension of the wrist

Scaphoid Fractures
Exam:
+ snuffbox tenderness ,
radial deviation of wrist will probably elicit pain
XR:
Obtain AP/lat/obliq/scaphoid views
Plain x-ray may not demonstrate fx for up to 4 wks
If x-rays are still negative at 10-14 days & pt is symptomatic, obtain bone scan for definitive diagnosis
Tx:
Initially in ER:
Thumb spica (*always tx snuffbox tenderness, even if x-ray neg)
Definitive:
Long arm thumb spica cast x 4-8 wks.
If scaphoid is displaced, may require ORIF

A. Thumb B. Index C. Middle finger D. Ring finger E. Little finger
I-V. Metacarpal bones
1,4. Distal phalanx 2. Middle phalanx 3,5. Proximal phalanx 6. Sesamoid bones 7. Distal interphalangeal joint (DIP) 8. Proximal interphalangeal joint (PIP) 9. Metacarpophalangeal joint (V.) 10. Carpometacarpal joints
11. Trapezium 12. Trapezoid 13. Capitate 14. Hamate 15. Scaphoid 16. Lunate 17. Triquetrum 18. Pisiform
19. Radius 20. Ulna

Metacarpal Neck Fractures
Boxer’s fx : Most frequently occur at the 5 th metacarpal, as a result of a direct blow delivered to the hand or by the hand to a solid (animate or inanimate) object while the hand is held in a fist

Metacarpal Neck Fx’s (Boxer’s fx)
Fractures with angulation <15 degrees should be immobilized in an ulnar gutter splint encasing both the 4 th & 5 th fingers with the mcp joint flexed as close to 90 degrees as possible & wrist held in slight extension
Fx’s with angulation >15 degrees &/or with rotational deformity of the finger should be reduced & casted/splinted in the aforementioned position
Post reduction films should be obtained
Unstable fx’s or fx’s that are not reduced to an acceptable position may require percutaneous pinning

Boutonniere Deformity
Disruption of the central slip of the Extensor Digitorum Communis tendon from its insertion at the dorsal base of the middle phalanx that results in
a flexed PIP joint & hyperextended DIP joint
The deformity may not be present at the time of injury & usually develops over 10-21 days
Tx:
1. Splint PIP joint into full extension with passive & active flexion of DIP joint
2. Insert K-wire to PIP joint to hold extension,
3. continue passive & active flexion at DIP joint
4. direct tendon repair & splinting

Mallet Finger
Disruption of the extensor tendon over the distal phalanx with flexion at the DIP joint & extension or hyperextension at the PIP joint
Tx:
1. splint with hyperextension of the DIP joint, flexion of the PIP joint
2. Hold with K-wire
3. Direct tendon repair & splinting

Flexor Tenosynovitis
Infection of the digital synovial sheaths.
Usually confined to affected finger
Except in pinky and thumb , can spread to palm, and forearm
Diagnosis is made on four classic findings .
1. tenderness over flexor tendon sheath
2. symmetric swelling of the finger (sausage finger)
3. pain with passive extension
4. flexed posture of the involved digit at rest

Trigger finger
Trigger finger is a painful condition caused by a narrowing of the sheath that surrounds the finger tendon.
Inflammation due to overuse is usually the cause.
Tendons slide through a snug tunnel .
Irritation as the tendons slip into the tunnel can cause the opening of the tunnel to become smaller, or the tendon to thicken so that it can't easily pass through the tunnel.
As you try to straighten the finger, the tendon becomes momentarily stuck at the mouth of the tunnel then pops as the tendon slips past the tight area.
No X-rays or other testing are usually needed
Tx:
NSAID’s, splint, cortisol injection, surgical release

Game Keeper’s Thumb Skier’s Thumb
Injury to the ulnar collateral ligament of the MCP joint of the thumb
Destroys joint stability
Impairs ability to pinch
Evaluation:
Stress ulnar aspect of the MCP joint by forcing thumb into radial abduction
If there is <15 degrees of side to side difference (one thumb compared to the other) or an opening > 45 degrees at the ulnar aspect of the MCP joint, surgical repair is required
Closed tx with a thumb spica cast or splint with the thumb slightly adducted may allow for healing of an incomplete tear

Game Keeper’s Thumb (occupation, over period of time)
Skier’s Thumb
(sport, acutely)

De Quervain’s Tenosynovitis
The disease is an entrapment tendonitis of the tendons contained within the first dorsal compartment at the wrist, resulting in pain with thumb motion.
The most classic finding in de Quervain tenosynovitis is a positive Finkelstein test .
Perform the Finkelstein test by having the patient make a fist with the thumb inside the fingers.
The clinician then applies passive ulnar deviation of the wrist to reproduce the chief complaint of dorsolateral wrist pain.
Tx:
Splinting of the thumb and wrist relieves symptoms (although noncompliance rates are high)
NSAIDS
Corticosteroid injection
Surgical release

Positive
Finkelstein test .

Paronychia
A paronychia is a superficial infection of epithelium lateral to the nail plate .
The acute painful purulent infection is most frequently caused by staphylococci.
The patient's condition and discomfort are markedly improved by a simple drainage procedure

Felon
Felons are closed-space infections of the fingertip pulp .
Fingertip pulp is divided into numerous small compartments by vertical septa that stabilize the pad.
Infection occurring within these compartments can lead to abscess formation, edema, and rapid development of increased pressure in a closed space.
This increased pressure may compromise blood flow and lead to necrosis of the skin and pulp.

Herpetic Whitlow
Herpes simplex virus may cause an intense, painful skin infection.
The fingertip is sore and swollen but is not as firm as in a felon.
The appearance of tiny fluid-filled blebs (vesicles) on the fingers is diagnostic .
A herpetic whitlow is often mistaken for a felon.
The disorder eventually goes away on its own.
Surgery is not needed.

INFECTIONS CAUSED BY BITES
The most common cause is injury to the knuckles by the teeth from a punch to the mouth.
Animal bites are also common causes.
Wound contamination by a number of types of bacteria can result from human and animal bites.
All bite injuries are potentially dangerous and can cause significant infection.
The injured area should be cleaned surgically, with the wound left open.
Antibiotics should be given to prevent joint infection (septic arthritis), which can otherwise lead to permanent destruction of the knuckle joints.
Bacteria in human and animal bites are resistant to many antibiotics but are generally sensitive to
ampicillin and penicillin.
(in practice use: augmentin)

The Hand
Nerves:
Radial :
Provides sensation to dorsum of hand on radial side of third metacarpal & dorsal thmb, index, & middle fingers as far as the distal phalanges.
The first web space is the most ‘pure’ area to test radial nerve sensation.
Motor= test thumb extension- hitchiking
Ulnar :
Provides sensation to the ulnar side of hand (dorsal & palmar), ring & little fingers.
The volar tip of the little finger is the most ‘pure’ area to test ulnar nerve sensation
Motor= test opposition (little finger), finger adduction
Median :
Provides sensation to palm & palmar surface of thumb, index, middle, & half of ring finger; may supply dorsum of terminal phalanges of these fingers
The distal palmer aspect of the index finger is the most ‘pure’ area to test median nerve sensation
Motor= test opposition (thumb)

UE Arteries & Nerves
Crutch misuse
Thoracic Outlet Obstruction
Carpal Tunnel
Cubital Tunnel
Saturday Night Palsy

Thoracic Outlet Syndrome
Usually resulting from irritation of C8 and T1 innervated nerves,
may be caused by
a cervical rib,
a fiber spanning from a rudimentary cervical rib,
tendinous bands from the scalenus anterior to the medius muscles or
hypertrophic clavicle fracture callus
Neurologic, venous, or arterial symptoms
Tx:
Postural exercises
Surgical resection of cervical rib, first rib, or scalenotomy

Carpal Tunnel
The syndrome is characterized by pain, paresthesias, and weakness in the median nerve distribution of the hand.
Trauma vs. repetitive motion
Acute CTS can be thought of as a compartment syndrome of the carpal canal, and decompression should be performed as soon as possible
Tinel’s and Phalen’s tests , nerve conduction studies
Tx:
Steroid inj, splinting, NSAID’s, surgical release

Cubital Tunnel Syndrome
is the effect of pressure on the “funny bone” causing pain, paresthesia’s to the ulnar nerve distribution

Saturday Night Palsy
The patient has injured his upper arm, usually by sleeping with his arm over the back of a chair, and now presents holding the affected hand and wrist with his good hand, complaining of decreased or absent sensation on the radial and dorsal side of his hand and wrist, and of inability to extend his wrist, thumb and finger joints.
With the hand supinated (palm up) and the extensors aided by gravity, hand function may appear normal, but when the hand is pronated (palm down) the wrist and hand will drop.

Enlargement of the Lymph Nodes (Lymphadenopathy)
Infection (streaking)
Lymphangitis: inflammation of the lymph vessels.
Breast Ca (sentinel node)
Lymphedema

'Excellence is an art won by training and habituation. We do not act rightly because we have virtue or excellence, but rather we have those because we have acted rightly. We are what we repeatedly do. Excellence, then, is not an act but a habit.' Aristoteles
A journey of a thousand miles begins with a single step.
Lao Tsu
“ I find that the harder I work, the more luck I seem to have”.
Thomas Jefferson
Self conquest is the greatest of victories.
Plato
“ Imagination is everything. It is the preview of life’s coming
attractions.”
Albert Einstein
Nothing great was ever achieved without enthusiasm.
Ralph Waldo Emerson
“ If a man empties his purse into his head, no man can take it
away from him. An investment in knowledge always pays the best
interest” Benjamin Franklin

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Anatomy Lect 7 Ue

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Anatomy Lect 7 Ue Presentation Transcript