Some Clinical Aspects of the Soft Tissues of the Superior Extremity
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Describe and explain the anatomical aspects of the common clinical conditions of the superior extremity. Guided by, Dr. Nahid Farhana Amin, Associate Professor, Dept. of Anatomy, BSMMU.
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Some Clinical Aspects of the Soft Tissues of the Superior Extremity
- 1. Some Clinical Aspects of the Soft Tissues of the Superior Extremity Dr. Rayhan Shahrear, MS Resident Phase A, Year 2, Block 5 Dept. of Anatomy, BSMMU Guided by: Dr. Nahid Farhana Amin Associate Professor Dept. of Anatomy, BSMMU
- 2. Objective Audience will be able to describe and explain the anatomical aspects of the common clinical conditions of the superior extremity 2
- 3. 3
- 4. AXILLARY ARTERY ANEURISM Excessive localized enlargement of an artery 4
- 5. Axillary Artery Aneurism (contd.) 5
- 6. Axillary Artery Aneurism (contd.) 6
- 7. Axillary Artery Aneurism (contd.) 7
- 8. Axillary Artery Aneurism (contd.) 8
- 9. ENLARGEMENT OF AXILLARY LYMPH NODES 9
- 10. Enlargement of Axillary Lymph Nodes (contd.) 10
- 11. INJURY TO THE AXILLARY NERVE 11
- 12. Injury to the Axillary Nerve (contd.) 12
- 13. WINGING OF THE SCAPULA 13
- 14. Winging of the Scapula (contd.) 14
- 15. IMPINGEMENT SYNDROME Rotator cuff lesions 15
- 19. Bicipital Tendon Rupture (contd.) 19
- 20. Bicipital Tendon Rupture (contd.) 20
- 21. Bicipital Tendon Rupture (contd.) 21
- 22. Bicipital Tendon Rupture (contd.) 22
- 23. Bicipital Tendon Rupture (contd.) 23
- 25. Volkmann’s Ischaemic Contracture (contd.) 25
- 26. Volkmann’s Ischaemic Contracture (contd.) 26
- 28. De Quervain Syndrome (contd.) 28
- 29. De Quervain Syndrome (contd.) 29
- 30. De Quervain Syndrome (contd.) 30
- 36. GAMEKEEPER'S THUMB Insufficiency of the ulnar collateral ligament of thumb 36
- 37. Gamekeeper's Thumb (contd.) 37
- 38. Gamekeeper's Thumb (contd.) 38
- 39. Gamekeeper's Thumb (contd.) 39
- 40. GOLFER'S ELBOW Tendinosis of the medial epicondyle of the elbow 40
- 41. Golfer's Elbow (contd.) 41
- 42. Golfer's Elbow (contd.) 42
- 43. TENNIS ELBOW 43
- 44. Tennis Elbow (contd.) 44
- 45. Tennis Elbow (contd.) 45
- 46. GUYON'S CANAL SYNDROME Ulnar nerve palsy 46
- 47. Guyon's Canal Syndrome (contd.) 47
- 48. Guyon's Canal Syndrome (contd.) 48
- 49. Guyon's Canal Syndrome (contd.) Location Symptoms Associations Zone 1 Proximal (prior to ulnar nerve bifurcation) Mixed motor & sensory Ganglia & hook of hamate fractures Zone 2 Surrounding deep motor branch ulnar nerve Motor only Ganglia & hook of hamate fractures Zone 3 Surrounding superficial sensory branch of ulnar nerve Sensory only Ulnar artery pathology 49
- 50. MALLET FINGER 50
- 51. Mallet Finger (contd.) 51
- 52. Mallet Finger (contd.) 52
- 53. Mallet Finger (contd.) 53
- 54. PREISER'S DISEASE Avascular necrosis of scaphoid 54
- 55. Preiser's Disease (contd.) 55
- 56. Preiser's Disease (contd.) 56
- 57. Preiser's Disease (contd.) 57
- 58. Preiser's Disease (contd.) 58
- 59. Preiser's Disease (contd.) 59
- 60. Preiser's Disease (contd.) 60
- 62. Trigger Finger (contd.) 62
- 63. TENOSYNOVITIS 63
- 66. Median Nerve Palsy (contd.) 66
- 67. Median Nerve Palsy (contd.) 67
- 68. Median Nerve Palsy (contd.) 68
- 69. Median Nerve Palsy (contd.) 69
- 70. CARPAL TUNNEL SYNDROME Pressure on the median nerve 70
- 71. Carpal Tunnel Syndrome (contd.) 71
- 72. Carpal Tunnel Syndrome 72
- 73. Carpal Tunnel Syndrome (contd.) 73
- 74. Carpal Tunnel Syndrome (contd.) 74
- 75. Carpal Tunnel Syndrome (contd.) 75
- 76. ANTERIOR INTEROSSEOUS NERVE ENTRAPMENT SYNDROME Damage to the anterior interosseous nerve 76
- 77. Anterior Interosseous Nerve Entrapment Syndrome (contd.) 77
- 78. ULNAR NERVE INJURY Claw hand 78
- 79. MCP PIP DIP Ulnar Nerve Injury (contd.) 79
- 80. Ulnar Nerve Injury (contd.) 80 IO L EDL FDP FDS
- 81. Ulnar Nerve Injury (contd.) 81 Flexor Digitorum Superficialis
- 82. Ulnar Nerve Injury (contd.) 82 Flexor Digitorum Profundus
- 83. Ulnar Nerve Injury (contd.) 83 Extensor Pollicis Longus
- 84. Ulnar Nerve Injury (contd.) 84 Interossei
- 85. Ulnar Nerve Injury (contd.) 85 Lumbrical
- 86. Ulnar Nerve Injury (contd.) 86
- 87. Ulnar Nerve Injury (contd.) 87
- 88. Ulnar Paradox 88
- 89. Ulnar Paradox (contd.) 89
- 91. ERB’S PALSY Injury of the upper trunk of the brachial plexus 91
- 92. Erb’s Palsy (contd.) 92
- 93. Erb’s Palsy (contd.) 93
- 94. Erb’s Palsy (contd.) 94
- 95. Erb’s Palsy (contd.) 95
- 96. Erb’s Palsy (contd.) 96
- 97. KLUMPKE'S PARALYSIS Partial palsy of the lower roots of the brachial plexus 97
- 98. Klumpke's Paralysis (contd.) 98
- 99. Klumpke's Paralysis (contd.) 99
- 100. Klumpke's Paralysis (contd.) 100
- 102. Radial Nerve Palsy (contd.) 102
- 103. Radial Nerve Palsy (contd.) 103
- 104. Radial Nerve Palsy (contd.) 104
- 105. Radial Nerve Palsy (contd.) 105
- 106. Radial Nerve Palsy (contd.) 106
- 107. Radial Nerve Palsy (contd.) 107
- 108. Radial Nerve Palsy (contd.) 108
- 109. Reference Books • McMinn and Abraham’s Clinical Atlas of Human Anatomy • Moore’s Clinically Oriented Anatomy • Snell’s Clinical Anatomy by Regions • Datta’s Essentials of Human Anatomy 109
- 110. Web References • teachmeanatomy.info • wikipedia.org • clinicalgate.com • balourdas.com • jscr.oxfordjournals.org • worldscientific.com • orthosports.info 110
- 111. Softwares 111
Editor's Notes
- Aneurysms can affect any of the arteries of the human body, but the subclavian-axillary segment is an uncommon site for this type of condition.
- True aneurysms that involve the subclavian artery have atherosclerotic etiology. When these aneurysms emerge in the more distal segments of this artery or in the axillary artery, they may be associated with thoracic outlet syndrome. Aneurysms in this territory can also be posttraumatic; infectious; associated with coarctation of the aorta; congenital; or related to Marfan syndrome and cystic necrosis of the tunica media
- An aneurysm is dilation of a blood vessel to more than twice its original size. Although rare, axillary artery aneurysms can occur as a result of atherosclerosis, thoracic outlet syndrome, or trauma. The dilated portion of the axillary artery can compress the brachial plexus, producing neurological symptoms such as paresthesia and muscle weakness. The definitive treatment of an axillary artery aneurysm is surgical, and involves removing the aneurysm and reconstructing the vessel wall using a graft.
- Risk of ischemic complications secondary to thromboembolic phenomena in upper extremities and in the carotid-vertebral territory, due to the possibility of retrograde embolization. Furthermore, peripheral neurological symptoms such as chest pain, caused by compression of the brachial plexus, dysphagia and rupture are also possible elements in the clinical presentation, depending on the location and diameter of the aneurysm
- Enlargement of these lymph nodes can have a number of either infectious or malignant causes: Infection of the upper limb, resulting in lymphangitis (inflammation of lymphatic vessels, with tender, enlarged lymph nodes). The humeral group of lymph nodes is usually affected first, and red, warm and tender streaks are visible in the skin of the upper limb. Infections of the pectoral region and breast. Metastasis of breast cancers.
- The axillary nerve is most commonly damaged by trauma to the shoulder or proximal humerus – such as a fracture of the humerus surgical neck. Motor functions: Paralysis of the deltoid and teres minor muscles. This renders the patient unable to abduct the affected limb. Sensory functions: The upper lateral cutaneous nerve of arm will be non functional, resulting in loss of sensation over the regimental badge area. Characteristic clinical signs: In long standing cases, the paralysed deltoid muscle rapidly atrophies, and the greater tuberosity can be palpated in that area.
- If damage to the long thoracic nerve occurs, the serratus anterior muscle will become paralyzed. When pushing with the affected limb, the scapula is no longer held against the rib cage, and protrudes out of the back. It is said to have a ‘winged’ appearance. The long thoracic nerve can become damaged by trauma to the shoulder, repetitive movements involving the shoulder or by structures becoming inflamed and pressing on the nerve.
- 16
- A rotator cuff tear: Usually follows trauma in young people. It is usually atraumatic in elderly people and caused by attrition from bony spurs on the undersurface of the acromion or intrinsic degeneration of the cuff, possibly. Partial tears may be difficult to differentiate from rotator cuff tendinopathy on examination. The drop arm test (see 'Examination', below) may be used to detect a massive tear. Calcific tendonitis: Crystalline calcium phosphate is deposited in the rotator cuff tendon. The cause is not known. It is more common in women (70% of cases) and affects people aged 30-60. It is a self-limiting condition as the calcium will eventually resorb but may take many years.
- Torn tendons begin by fraying. As the damage progresses, the tendon can completely tear, sometimes when lifting a heavy object.
- The long head of the biceps tendon is more likely to be injured. This is because it is vulnerable as it travels through the shoulder joint to its attachment point in the socket. Tearing of the biceps tendon, it can also damage other parts of the shoulder, such as the rotator cuff tendons.
- Many tears are the result of a wearing down and fraying of the tendon that occurs slowly over time. This naturally occurs as we age. It can be worsened by overuse - repeating the same shoulder motions again and again. Overuse can cause a range of shoulder problems, including tendinitis, shoulder impingement, and rotator cuff injuries. Having any of these conditions puts more stress on the biceps tendon, making it more likely to weaken or tear.
- Symptoms Sudden, sharp pain in the upper arm Sometimes an audible pop or snap Cramping of the biceps muscle with strenuous use of the arm Bruising from the middle of the upper arm down toward the elbow Pain or tenderness at the shoulder and the elbow Weakness in the shoulder and the elbow Difficulty turning the arm palm up or palm down Because a torn tendon can no longer keep the biceps muscle tight, a bulge in the upper arm above the elbow ("Popeye Muscle") may appear, with a dent closer to the shoulder.
- De Quervain syndrome; also known as BlackBerry thumb, texting thumb, gamer's thumb, washerwoman's sprain, radial styloid tenosynovitis, de Quervain disease, de Quervain's tenosynovitis, de Quervain's stenosing tenosynovitis, mother's wrist, or mommy thumb), is a tenosynovitis of the sheath or tunnel that surrounds two tendons that control movement of the thumb.
- Also known as Dupuytren's disease, or by the slang term "Viking disease“ Flexion contracture of the hand, in which the fingers bend towards the palm and cannot be fully extended (straightened). It is an inherited proliferative connective tissue disorder that involves the hand's palmar fascia.
- The earliest sign of a contracture is a triangular “puckering” of the skin of the palm as it passes over the flexor tendon just before the flexor crease of the finger, at the metacarpophalangeal (MCP) joint. Generally, the cords or contractures are painless, but, rarely, tenosynovitis can occur and produce pain. The most common finger to be affected is the ring finger; the thumb and index finger are much less often affected. The disease begins in the palm and moves towards the fingers, with the metacarpophalangeal (MCP) joints affected before the proximal interphalangeal (PIP) joints
- In Dupuytren's contracture, the palmar fascia within the hand becomes abnormally thick, which can cause the fingers to curl and can impair finger function. The main function of the palmar fascia is to increase grip strength; thus, over time, Dupuytren's contracture decreases patients' ability to hold objects. Patients may rarely report pain, aching and itching with the contractions. Normally, the palmar fascia consists of collagen type I, but in Dupuytren sufferers, the collagen changes to collagen type III, which is significantly thicker than collagen type I.
- Symptoms of gamekeeper's thumb are instability of the MCP joint of the thumb, accompanied by pain and weakness of the pinch grasp. The severity of the symptoms are related to the extent of the initial tear of the UCL (in the case of Skier's thumb), or how long the injury has been allowed to progress (in the case of gamekeeper's thumb). Characteristic signs include pain, swelling, and ecchymosis around the thenar eminence, and especially over the MCP joint of the thumb. Physical examination demonstrates instability of the MCP joint of the thumb. The patient will often manifest a weakened ability to grasp objects or perform such tasks as tying shoes and tearing a piece of paper. Other complaints include intense pain experienced upon catching the thumb on an object, such as when reaching into a pants pocket.
- The anterior forearm contains several muscles that are involved with flexing the digits of the hand, and flexing and pronating the wrist. The tendons of these muscles come together in a common tendinous sheath, which originates from the medial epicondyle of the humerus at the elbow joint. In response to minor injury, or sometimes for no obvious reason at all, this point of insertion becomes inflamed. The pain is normally caused due to stress on the tendon as a result of the large amount of grip exerted by the digits and torsion of the wrist which is caused by the use and action of the cluster of muscles on the condyle of the ulna.
- Ulnar tunnel syndrome, also known as Guyon's canal syndrome or Handlebar palsy, is caused by entrapment of the ulnar nerve in the Guyon canal as it passes through the wrist. Symptoms usually begin with a feeling of pins and needles in the ring and little fingers before progressing to a loss of sensation and/or impaired motor function of the intrinsic muscles of the hand which are innervated by the ulnar nerve. Ulnar tunnel syndrome is commonly seen in regular cyclists due to prolonged pressure of the Guyon's canal against bicycle handlebars.
- Mallet finger refers to a condition in which the end joint of a finger bends but will not straighten by itself. The tendon which pulls on the end bone to straighten the finger pulls one way, and the force on the end of the fingertip pulls the other way, and something comes apart in between. Often, the tendon tears away from its attachment to the bone. Sometimes, the tendon comes off with a piece of bone attached.
- In the anatomical snuffbox, the scaphoid and the radius articulate to form part of the wrist joint. In the event of a blow to the wrist (e.g. falling on an outstretched hand), the scaphoid takes most of the force. If localised pain is reported in the anatomical snuffbox, a fracture of the scaphoid is the most likely cause.
- Generally, these abnormalities of bone perfusion are mainly due to trauma, prolonged use of corticosteroids, chemotherapy, systemic disease or scaphoid hypoplasia.
- The scaphoid has a unique blood supply, which runs distal to proximal. A fracture of the scaphoid can disrupt the blood supply to the proximal portion – this is an emergency. Failure to revascularize the scaphoid can lead to avascular necrosis, and future arthritis for the patient.
- Carpal X-rays showed bilateral scaphoid bone rarefaction, with marked sclerosis and severe degenerative signs. Patients present with insidious and progressive pain lasting months to years on the dorsoradial aspect of the wrist. Upon examination there may be inflammation, movement limitation and loss of strength; these symptoms mainly occur on the dominant side.
- The flexor tendon can become irritated as it slides through the tendon sheath tunnel. As it becomes more and more irritated, the tendon may thicken and nodules may form, making its passage through the tunnel more difficult. The tendon sheath may also thicken, causing the opening of the tunnel to become smaller. If you have trigger finger, the tendon becomes momentarily stuck at the mouth of the tendon sheath tunnel when you try to straighten your finger. You might feel a pop as the tendon slips through the tight area and your finger will suddenly shoot straight out. Trigger fingers are more common in women than men. They occur most frequently in people who are between the ages of 40 and 60 years of age. Trigger fingers are more common in people with certain medical problems, such as diabetes and rheumatoid arthritis. Trigger fingers may occur after activities that strain the hand.
- The median nerve receives fibers from roots C6, C7, C8, T1 and sometimes C5. It is formed in the axilla by a branch from the medial and lateral chords of the brachial plexus, which are on either side of the axillary artery and fuse together to create the nerve anterior to the artery. The median nerve is closely related to the brachial artery within the arm. The nerve enters the cubital fossa medial to the brachialis tendon and passes between the two heads of the pronator teres. It then gives off the anterior interosseus branch in the pronator teres.
- The nerve continues down the forearm between the flexor digitorum profundus and the flexor digitorum superficialis. The median nerve emerges to lie between the flexor digitorum superficialis and the flexor carpi ulnaris muscles which are just above the wrist. At this position, the nerve gives off the palmar cutaneous branch that supplies the skin of the central portion of the palm. The nerve continues through the carpal tunnel into the hand, lying in the carpal tunnel anterior and lateral to the tendons of the flexor digitorum superficialis. Once in the hand, the nerve splits into a muscular branch and palmar digital branches. The muscular branch supplies the thenar eminence while the palmar digital branch supplies sensation to the palmar aspect of the lateral 3 ½ digits and the lateral two lumbricals. Damaged at the Elbow Supracondylar fracture of the humerus. The flexors and pronators in the forearm are paralyzed, with the exception of the flexor carpi ulnaris and medial half of flexor digitorum profundus. The forearm constantly supinated, and flexion is weak (often accompanied by adduction, because of the pull of the flexor carpi ulnaris). Flexion at the thumb is also prevented, as both the longus and brevis muscles are paralyzed. The lateral two lumbrical muscles are paralyzed, and the patient will not be able to flex at the MCP joints or extend at IP joints of the index and middle fingers. Lack of sensation over the areas that the median nerve innervates. Damaged at the Wrist Lacerations just proximal to the flexor retinaculum. Thenar muscles paralyzed, as are the lateral two lumbricals. This affects opposition of the thumb and flexion of the index and middle fingers. Same as an injury at the elbow.
- Median nerve palsy is often caused by deep, penetrating injuries to the arm, forearm, or wrist. It may also occur from blunt force trauma or neuropathy. Median nerve palsy can be separated into 2 subsections—high and low median nerve palsy. High MNP involves lesions at the elbow and forearm areas. Low median nerve palsy results from lesions at the wrist. Compression at the different levels of the median nerve produce variable symptoms and/or syndromes. The areas are: Underneath Struthers' ligament Passing by the bicipital aponeurosis (also known as lacertus fibrosus) Between the two heads of the pronator teres Compression in the carpal tunnel causes carpal tunnel syndrome
- Lack of ability to abduct and oppose the thumb due to paralysis of the thenar muscles. This is called "ape-hand deformity". Sensory loss in the thumb, index finger, long finger, and the radial aspect of the ring finger Weakness in forearm pronation and wrist and finger flexion. Activities of daily living such as brushing teeth, tying shoes, making phone calls, turning door knobs and writing, may become difficult with a median nerve injury.
- Pressure can come from swelling or anything that makes the carpal tunnel smaller. Many things can cause this swelling, including: Illnesses such as hypothyroidism, rheumatoid arthritis, and diabetes. Making the same hand movements over and over, especially if the wrist is bent down (your hands lower than your wrists), or making the same wrist movements over and over. Pregnancy.
- Compression of the median nerve within the carpal tunnel can cause carpal tunnel syndrome (CTS). It is the most common mononeuropathy and can be caused by thickened ligaments and tendon sheaths. Its aetiology is, however, most often idiopathic. If left untreated, CTS can cause weakness and atrophy of the thenar muscles. The patients history will comment on numbness, tingling and pain in the distribution of the median nerve. The pain will usually radiate to the forearm. Symptoms are often associated with waking the patient from their sleep and being worse in the mornings.
- Tapping the nerve in the carpal tunnel to elicit pain in median nerve distribution (Tinel’s Sign) Holding the wrist in flexion for 60 seconds to elicit numbness/pain in median nerve distribution (Phalen’s maneuver) Treatment involves the use of a splint, holding the wrist in dorsiflexion overnight to relieve symptoms. If this is unsuccessful, corticosteroid injections into the carpal tunnel can be used. In severe case, surgical decompression of the carpal tunnel may be required.
- Carpal tunnel syndrome can cause tingling, numbness, weakness, or pain in the fingers or hand. Some people may have pain in their arm between their hand and their elbow. Symptoms most often occur in the thumb, index finger, middle finger, and half of the ring finger. If there are problems in other fingers but the little finger is fine, this may be a sign having carpal tunnel syndrome. First noticed symptoms is at night. Pain can be relief by shaking hand.
- It is a pure lesion of the anterior interosseous nerve. Weakens the long flexor muscle of the thumb (Flexor pollicis longus), the deep flexor muscles of the index and middle fingers (Flexor digitorum profundus I & II) & the pronator quadratus muscle If asked to make the "OK" sign, patients will make a triangle sign instead. This 'Pinch-Test' exposes the weakness of the Flexor pollicis longus muscle and the flexor digitorum profundus I leading to weakness of the flexion of the distal phalanges of the thumb and index finger. This results in impairment of the pincer movement and the patient will have difficulty picking up a small item, such as a coin, from a flat surface. There is little sensory deficit since the anterior interosseous nerve has no cutaneous branch.
- The ulnar claw is a deformity that is seen in long standing ulnar nerve damage at the wrist. It affects the little and ring fingers of the hand. These fingers are hyperextended at the metacarpophalangeal (MCP) joint, and flexed at both interphalangeal (IP) joints. To explain why this occurs, we need to consider the muscles that are affected by an ulnar nerve lesion at the wrist: Medial two lumbricals: Flexes at the MCP joints and extends at the IP joints of the little and ring fingers. Interossei: Abducts and adducts the fingers. Hypothenar muscles: Flexes, abducts, and opposes the little finger. Adductor pollicis: Adducts the thumb. In the ulnar claw, the important muscles to consider are the medial lumbricals. If these muscles are paralyzed, there is a loss of flexion at the MCP joints, and a loss of extension at the IP joints. This leads to an imbalance between the intrinsic and extrinsic muscles of the hand – producing the claw deformity: The MCP joints are hyperextended due to unopposed extension from the long extensor muscles in the posterior compartment of the forearm. The IP joints are flexed due to unopposed flexion from the long flexor muscles in the anterior compartment of the arm. The extensor muscles cannot extend at the IP joints as their energy is dissipated in hyperextending the MCP joints. The ulnar claw only occurs in the little and ring fingers, as the lateral two lumbricals are innervated by the median nerve.
- The ulnar claw is a deformity produced by an ulnar nerve lesion at the wrist. We shall now look at what happens if the ulnar nerve is damaged more proximally – at the elbow. In a high ulnar nerve injury, some muscles in the anterior forearm are paralyzed (in addition to the hand muscles mentioned above): Medial half of flexor digitorum profundus: Flexes at the distal IP joints of the ring and little fingers. Flexor carpi ulnaris: Flexes and adducts the wrist. The ulnar claw will develop as before, but with one key difference. The flexor digitorum profundus is paralyzed, and there will not be any flexion at the distal IP joints of the ring and little fingers. Now the ulnar claw only consists of hyperextension at the MCP joints and flexion at the proximal IP joints. This produces a much less evident claw hand. This is known as the ‘ulnar paradox‘ – you would expect a more debilitating injury to produce a more pronounced deformity, but in fact the opposite occurs.
- The ulnar claw is a deformity produced by an ulnar nerve lesion at the wrist. We shall now look at what happens if the ulnar nerve is damaged more proximally – at the elbow. In a high ulnar nerve injury, some muscles in the anterior forearm are paralyzed (in addition to the hand muscles mentioned above): Medial half of flexor digitorum profundus: Flexes at the distal IP joints of the ring and little fingers. Flexor carpi ulnaris: Flexes and adducts the wrist. The ulnar claw will develop as before, but with one key difference. The flexor digitorum profundus is paralyzed, and there will not be any flexion at the distal IP joints of the ring and little fingers. Now the ulnar claw only consists of hyperextension at the MCP joints and flexion at the proximal IP joints. This produces a much less evident claw hand. This is known as the ‘ulnar paradox‘ – you would expect a more debilitating injury to produce a more pronounced deformity, but in fact the opposite occurs.
- The ulnar claw is a deformity produced by an ulnar nerve lesion at the wrist. We shall now look at what happens if the ulnar nerve is damaged more proximally – at the elbow. In a high ulnar nerve injury, some muscles in the anterior forearm are paralyzed (in addition to the hand muscles mentioned above): Medial half of flexor digitorum profundus: Flexes at the distal IP joints of the ring and little fingers. Flexor carpi ulnaris: Flexes and adducts the wrist. The ulnar claw will develop as before, but with one key difference. The flexor digitorum profundus is paralyzed, and there will not be any flexion at the distal IP joints of the ring and little fingers. Now the ulnar claw only consists of hyperextension at the MCP joints and flexion at the proximal IP joints. This produces a much less evident claw hand. This is known as the ‘ulnar paradox‘ – you would expect a more debilitating injury to produce a more pronounced deformity, but in fact the opposite occurs.
- The ulnar claw is a deformity produced by an ulnar nerve lesion at the wrist. We shall now look at what happens if the ulnar nerve is damaged more proximally – at the elbow. In a high ulnar nerve injury, some muscles in the anterior forearm are paralyzed (in addition to the hand muscles mentioned above): Medial half of flexor digitorum profundus: Flexes at the distal IP joints of the ring and little fingers. Flexor carpi ulnaris: Flexes and adducts the wrist. The ulnar claw will develop as before, but with one key difference. The flexor digitorum profundus is paralyzed, and there will not be any flexion at the distal IP joints of the ring and little fingers. Now the ulnar claw only consists of hyperextension at the MCP joints and flexion at the proximal IP joints. This produces a much less evident claw hand. This is known as the ‘ulnar paradox‘ – you would expect a more debilitating injury to produce a more pronounced deformity, but in fact the opposite occurs.
- The ulnar claw is a deformity produced by an ulnar nerve lesion at the wrist. We shall now look at what happens if the ulnar nerve is damaged more proximally – at the elbow. In a high ulnar nerve injury, some muscles in the anterior forearm are paralyzed (in addition to the hand muscles mentioned above): Medial half of flexor digitorum profundus: Flexes at the distal IP joints of the ring and little fingers. Flexor carpi ulnaris: Flexes and adducts the wrist. The ulnar claw will develop as before, but with one key difference. The flexor digitorum profundus is paralyzed, and there will not be any flexion at the distal IP joints of the ring and little fingers. Now the ulnar claw only consists of hyperextension at the MCP joints and flexion at the proximal IP joints. This produces a much less evident claw hand. This is known as the ‘ulnar paradox‘ – you would expect a more debilitating injury to produce a more pronounced deformity, but in fact the opposite occurs.
- The hand of benediction occurs as a result of median nerve damage at the elbow. In contrast to the ulnar claw, which is produced spontaneously, the hand of benediction is only apparent if the patient is asked to make a fist. To explain how the hand of benediction is produced, we need to consider the muscles affected if the median nerve is lesioned at the elbow: Long flexors in the anterior compartment of the arm (except the medial half of the flexor digitorum profundus and the flexor carpi ulnaris). Lateral two lumbricals: Flexes at the MCP joints and extends at the IP joints of the index and middle fingers. If the patient is asked to make a fist, they will be able to flex the little and ring fingers. This action is performed by the medial half of the flexor digitorum profundus and the medial two lumbricals. The patient will not be able to flex the index and middle fingers. Thus, the patient displays a claw shape, where the little and ring fingers and flexed, the index and middle fingers extended.
- Erb's palsy or Erb–Duchenne palsy is a paralysis of the arm caused by injury to the upper group of the arm's main nerves, specifically the severing of the upper trunk C5–C6 nerves. These form part of the brachial plexus, comprising the ventral rami of spinal nerves C5–C8 and thoracic nerve T1. These injuries arise most commonly, but not exclusively, from shoulder dystocia during a difficult birth.
- The signs of Erb's Palsy include loss of sensation in the arm and paralysis and atrophy of the deltoid, biceps, and brachialis muscles. "The position of the limb, under such conditions, is characteristic: the arm hangs by the side and is rotated medially; the forearm is extended and pronated. The arm cannot be raised from the side; all power of flexion of the elbow is lost, as is also supination of the forearm". The resulting biceps damage is the main cause of this classic physical position commonly called "waiter's tip."
- A lower brachial plexus injury results from excessive abduction of the arm (e.g. person catching a branch as they fall from a tree). It has a much lower incidence than Erb’s palsy. Nerves derived from the T1 root – ulna and median nerves. All the small muscles of the hand (the flexors muscles in the forearm are supplied by the ulna and median nerves, but are innervated by different roots). Loss of sensation along medial side of arm. The metacarpophalangeal joints are hyperextended, and the interphalangeal joints are flexed. This gives the hand a clawed appearance. Involving the muscles of the forearm and hand, resulting from a brachial plexus injury in which the eighth cervical (C8) and first thoracic (T1) nerves are injured either before or after they have joined to form the lower trunk. The subsequent paralysis affects, principally, the intrinsic muscles of the hand (notably the interossei, thenar and hypothenar muscles) and the flexors of the wrist and fingers (notably flexor carpi ulnaris and ulnar half of the flexor digitorum profundus). Forearm pronators and wrist flexors may be involved, as may dilators of the iris and elevators of the eyelid (both of which may be seen in the case of associated Horner's syndrome). The classic presentation of Klumpke's palsy is the “claw hand” where the forearm is supinated and the wrist and fingers are flexed. If Horner syndrome is present, there is miosis (constriction of the pupils) in the affected eye.
- Symptoms include intrinsic minus hand deformity, paralysis of intrinsic hand muscles, and C8/T1 Dermatome distribution numbness. Involvement of T1 may result in Horner's syndrome, with ptosis, and miosis. Weakness or lack of ability to use specific muscles of the shoulder or arm.
- In the Axilla Dislocation of humerus at the glenohumeral joint or fractures of proximal humerus. Can also happen via excessive pressure on the axilla, e.g. a badly fitting crutch. Triceps brachii and muscles in posterior compartment are paralyzed. The patient is unable to extend the forearm, wrist and fingers. Unopposed flexion of wrist occurs, known as wrist drop. All four cutaneous branches of the radial nerve are affected. There will be a loss of sensation over the lateral and posterior upper arm, posterior forearm, and dorsal surface of the lateral three and a half digits.