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Case based learning joints of upper limb
1. CASE BASED LEARNING
JOINTS OF UPPER LIMB
BY
DR. ABDUL WAHEED ANSARI
CHAIRPERSON & PROFESSOR OF ANATOMY,
RAKCOMS. RAKMHSU.
12/18/2014 1
2. Learning our comes are as follows:-
• Identify the elements forming shoulder joint,
demonstrate movements at the shoulder joint, muscles
involved in the movements and applied aspects of
shoulder joint.
• Learn the gross anatomy of elbow joint and muscles
involved in the movements at elbow joint.
• Gross features of wrist joint and muscles producing
these movements.
• Features of small joints of the fingers and muscles
responsible for the movements of fingers.
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3. A case of dislocation of shoulder joint
• The goalkeeper in a soccer match
fell on his outstretched left arm.
• He felt an immediate pain in the
shoulder region and was unable to
move his arm.
• At the hospital the arm was
abducted and the deltoid muscle
looked flat or hollow.
• The injured arm looked "too long",
and there was intense pain on
attempting to move the arm.
• A plain radiograph of the region
showed that the humeral head was
lying below the glenoid labrum and
that there was no fracture of the
humerus.
• The diagnosis was an anterior
dislocation of the shoulder.
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4. Elements of
shoulder joint
• The shoulder joint is glenohumeral
joint.
• It is a synovial joint of ball and
socket variety.
• The skeletal elements of the joint
are the head of humerus and the
glenoid cavity of the scapula.
• The ligaments of the shoulder
joints are:-
capsular ligament,
coracohumeral ligament,
coracoacromial ligament,
transverse humeral ligament,
and
glenohumeral ligament.
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5. Movements at the shoulder joint
• It is a freely mobile joint.
• The following movements
occur at the joint:-
• Abduction
• Adduction
• Flexion
• Extension
• Lateral rotation
• Medial rotation and
• Circumduction
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11. Applied anatomy of shoulder joint
• Dislocation of shoulder joint. Anterior dislocation is
very common.
• Rotator cuff muscles injuries and inflammation –
Frozen shoulder. The supraspinatus, infraspinatus,
teres minor and subscapularis constitute the rotator
cuff muscles.
• Osteoarthritis, septic arthritis.
• Winged scapula-paralysis of serratus anterior.
• Deltoid paralysis
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12. This 45 year old man presented following a fall from a
ladder. He has suffered an injury to his right arm.
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13. The anatomy of elbow joint
• The elbow is a hinge joint
and consists of the humero-
ulnar, humero-radial and
proximal radio-ulnar
articulations.
• The radial head articulates
with the humeral capitellum
whilst the trochlear notch of
the ulna articulates with the
humeral trochlea.
• Posteriorly the ulna forms
the olecranon, which
contacts the olecranon fossa
of the humerus at full elbow
extension.
• The elbow joint allows 0° -
140° of flexion.
• Movement at the proximal
and distal radio-ulnar joints
combine to produce 75° of
pronation and 80° of
supination.
• When fully extended the
elbow joint forms a valgus
angle, this is commonly
referred to as the carrying
angle and is generally greater
in women.
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14. Bony landmarks of the elbow palpable on
examination are the:
• Medial and lateral humeral
epicondyles.
• Olecranon process and
proximal ulnar shaft.
• Head of radius.
• Imaging studies in AP and
lateral views showing
elbow joints elements.
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16. Movements at elbow joint
• Elbow flexion results from
the actions of the biceps
brachii, brachialis,
brachioradialis and
pronator teres muscles,
which cross the joint
anteriorly.
• The triceps tendon inserts
into the olecranon process
posteriorly and together
with the anconeus muscle
is responsible for elbow
extension.
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17. Neurovascular bundles around the
elbow joint
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• The ulnar nerve passes just
behind the medial epicondyle.
• The radial nerve passes anterior
to the lateral epicondyle.
• Median nerve and brachial artery
pass in front of the elbow.
• Median nerve, ulnar nerve and
brachial artery are at risk of
injury in elbow dislocation &
supracondylar fracture of
humerus.
18. Posterior dislocation of elbow
• This injury is seen in both children and adults and is usually caused
by a fall onto the outstretched hand.
• It is more common in children than dislocation of the shoulder.
• Examination may reveal obvious deformity of the elbow.
• The triangular relationship of the epicondyles and olecranon will be
disrupted.
• It is important to check the distal neurovascular status of the limb
due to possible damage to the brachial artery or median and ulnar
nerves.
• The dislocation is most commonly in a posterior or posterolateral
direction and will be confirmed on x-ray, along with the presence of
any associated fractures.
• Associated epicondylar fractures and fractures of the lateral condyle
are known to occur in children.
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19. Supracondylar fracture
• Typically follow a fall onto
an outstretched hand.
• Children are more prone
to supracondylar fracture
than adults.
• 90% of these fractures
are caused by
hyperextension injury due
to ligament laxity.
• The force is transmitted
up through the ulna and
into the distal humerus.
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20. Complications of supracondylar fractures include:
• Cubitus varus (gun stock deformity)
• Malunion and stiffness
• Myositis ossificans
• Nerve injury (most commonly median nerve)
• Brachial artery (due to stretch and posterior displacement)
• Volkmann’s ischaemic contracture (due to compartment
swelling)
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21. Lateral epicondylosis / Tennis elbow
• This condition occurs as a
result of overuse of the
forearm extensor tendons.
• The patient may complain of
a diffuse ache located over
the lateral aspect of the
elbow.
• Examples include golfers,
baseball players, bowlers,
gardeners or landscapers,
house or office cleaners
(because of vacuuming,
sweeping, and scrubbing),
carpenters, mechanics, and
assembly-line workers.
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22. Medial epicondylosis / Golfers elbow
• This condition is seen less
commonly than lateral
epicondylosis and is similarly
an overuse injury, this time
of the forearm flexor
tendons, giving rise to pain
over the medial aspect of
the elbow.
• In 20% of cases there may
be associated ulnar nerve
symptoms, specifically
paraesthesia in an ulnar
nerve distribution.
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23. Wrist joint-Radiocarpal Joint
The radiocarpal joint consists
of four bones in total.
These involve:
• Radius
• Scaphoid
• Lunate
• Triquetrum
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24. Radiocarpal articulation
• The radius is the lateral bone of the forearm, the lower or
distal end meets the carpal bones of the hand.
• The Triquetrum, Lunate and the Scaphoid bone cluster
together to form the proximal row of the carpus or the
bunch of small eight bones located underneath the wrist.
• The lunate and scaphoid bones meet the radius bone
situated in the radiocarpal joint.
• The Triquetrum does so only once, when the hand is drawn
towards the body or bent in the way of the pinky finger.
• This joint within the carpal and the radial bones is known as
an ellipsoid or condyloid joint
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25. Movements at the wrist joint
• Extension:-The ulnar extensors and the radial extensors
aided by the extensors of thumb and fingers produce
extension.
• Abduction (radial deviation):-The Abductor Pollicis Longus
produce abduction.
• Adduction (ulnar deviation):-Two radial extensors and the
flexor carpi radialis act together to produce abduction when
the wrist moves from the midline.
• Flexion:-Flexion is primarily produced by flexor carpi
ulnaris and flexor carpi radialis assisted by abductor
pollicis longus, palmaris longus and the thumb and finger
flexors.
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27. Case of rheumatoid
arthritis (RA)
• Joint inflammation from RA
comes with pain, warmth, and
swelling.
• The inflammation is typically
symmetrical, occurring on both
sides of the body at the same
time (such as the wrists, knees,
or hands).
• Other symptoms of RA include
joint stiffness, particularly in the
morning or after periods of
inactivity; ongoing fatigue, and
low-grade fever.
• Affecting about 1% of the U.S.
population, RA usually strikes
between ages 30-60, but younger
and older people can also be
affected.
• RA occurs two to three times
more often in women than in
men. Other risk factors include
cigarette smoking and family
history.
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