Upper Limb Injury And Clinical Correlates

Front 1

Median Nerve Injury Above the Elbow

Back 1

Common mechanism of injury:

-Supracondylar Fracture

Motor deficit: (flexion or pronation)

-Loss of pronation of forearm

-Weakness in flexion of the hand at the wrist

-loss of flexion of radial half of digits and thumb

-loss of abduction and opposition of thumb.

Sensory deficit:

Loss of sensation in lateral three 1⁄2 digits including their nail beds, and thenar area.

Other Signs:

Ape hand deformity

Benediction sign

Front 2

Ape Hand Deformity

Back 2

Median nerve injury above the elbow or at the wrist:

When hand is at rest it demonstrates hyperextension of index finger, thumb, and adducted thumb

Front 3

Benediction Sign

Back 3

Median nerve injury above the elbow or at the wrist

Loss of flexion of radial half of digits

Front 4

Median Nerve Entrapment at the Elbow

Back 4

Pronator Teres Syndrome:

a compression neuropathy of the median nerve at the elbow.

Symptoms:

-tenderness over the proximal median nerve, which is aggravated by resisted pronation of the forearm.

-Impairment of the pincer movement.

-Sensory changes in the first three fingers as well as in the palm

Front 5

Median Nerve Injury at the Wrist

Back 5

Common mechanism:

Wrist laceration

Motor deficit:

Weakness in flexion of radial half of digits and thumb

loss of abduction and opposition of thumb.

Sensory deficit:

-Loss of sensation in lateral 3 1⁄2 digits including their nail beds, and the thenar area.

Other Signs:

Ape hand deformity

Benediction sign

Front 6

Median Nerve Injury Within The Wrist (Carpal Tunnel Syndrome)

Back 6

Common mechanism:

An injury by compression in the carpal tunnel

Motor deficits:

-Weakness in flexion of radial half of digits and thumb,

-weakness in abduction and opposition of thumb.

Sensory deficit:

Numbness and tingling in lateral 3 1⁄2 digits including their nail beds but excluding the thenar eminence which is supplied by the palmar cutaneous branch of Median Nerve

Other Signs:

No deformities as opposed to complete median nerve palsy.

Front 7

Muscular Median Interosseous Nerve Test

Back 7

Ask patient to make OK sign.

in a Positive test thenar muscles function normally, but FDP and FPL are weakened.

This results in a triangle with index finger and thumb not a round OK sign

Front 8

Ulnar Nerve Injury At The Elbow

Back 8

Common mechanisms of injury:

-Cubital tunnel syndrome

-Fracture of themedial epicondyle

Motor deficit:

-Weakness in flexion of the hand at the wrist

-Loss of flexion of ulnar half of digits, or the 4th and 5th digits

-Loss of ability to cross the digits of the hand.

Sensory deficit:

Loss of sensation or paresthesiae in ulnar half of the palm and dorsum of hand,

Loss of sensation in medial 1½ digits on both palmar and dorsal aspects of the hand

***Note: Motor deficit is absent or very minor in cubital tunnel syndrome as the ulnar nerve is compressed rather than transected.)·

Other Signs:

-Claw hand deformity when the hand is at rest, due to hyperextension of the 4th and 5th digits at the metacarpophalangeal joints, and flexion at the interphalangeal joints.·

Front 9

Claw Hand Deformity

Back 9

Results from injury to the Ulnar Nerve

-hyperextension of the 4th and 5th digits at the metacarpophalangeal joints

-flexion at the interphalangeal joints

Front 10

Ulnar Nerve Injury at the Wrist

Back 10

Common mechanisms:

-Penetrating wounds

-Guyon canal cyst

Motor deficit:

-Loss of flexion of ulnar half of digits / 4-5th digits

-Loss of ability to cross the digits of the hand.

Sensory deficit:

Loss of sensation or paresthesiae in ulnar half of the palm, and the medial 1½ digits on the palmar aspect of the hand

Other Signs:

Claw hand deformity

Note 1:

Claw hand deformity is more prominent with injury at the wrist as opposed to a lesion higher up in the arm because the ulnar half of flexor digitorum profundus is not affected.

Note 2:

The dorsal sensory aspect of the hand is unaffected as the posterior cutaneous branch of the ulnar nerve is given off higher up in the forearm and does not reach the wrist.

Front 11

Injury of the Radial Nerve at the Axilla

Back 11

Common mechanisms of injury:

-Saturday night palsy

-crutch palsy

Motor deficit:

-Loss of extension of forearm

-Weakness of supination

-Loss of extension of hand and fingers.

Sensory deficit:

Loss of sensation in lateral arm, posterior forearm, the radial half of dorsum of hand, and dorsal aspect of radial 3 1⁄2 digits, excluding their nail beds.

Other Signs:

-Presence of wrist drop, due to inability to extend the hand and fingers.

Front 12

Injury of the Radial Nerve at Mid-Arm

Back 12

Common mechanism ofinjury:

-Mid-shaft humeral fracture

Motor deficit:

-Weakness ofsupination

-Loss of extension of hand and fingers.

Sensory deficit:

Loss of sensation in posterior forearm, the radial half of dorsum of hand, and dorsal aspect of radial3 1⁄2 digits, excluding their nail beds.

Other Signs:

-Presence of wrist drop, due to inability to extend the hand and fingers.

Front 13

Injury of the Radial Nerve Below the Elbow

Back 13

Common mechanism ofinjury:

-Neck of radius fracture

-Elbow dislocation or fracture

-Tight cast

-Rheumatoid nodules

-Injections due to tennis elbow

Motor deficit:

-Weakness in extension of hand and loss of extension of fingers.

Sensory deficit:

None, as sensation is supplied by the superficial radial nerve

Other Signs:

-Presence of fingerdrop.

-Presence of partial wrist drop

-extensor carpi radialis and brachioradialis are working

Front 14

Injury of the Radial Nerve within the Distal Forearm

Back 14

Common mechanism ofinjury:

Wartenberg's syndrome due to entrapment beneath the tendinous insertion of brachioradialis by tight jewellery and watch bands

Motor deficit:

-None

Sensory deficit:

Numbness and tingling in radial half of dorsum of hand, and dorsal aspect ofradial 3 1⁄2 digits,excluding their nail beds.

Note:

In Wartenberg's syndrome,there is significant radial wrist pain, and numbness of thumb

Front 15

Injury of the Axillary Nerve

Back 15

Mechanism:

-Compression of axilla with a crutch

-Fracture of surgical neck of humerus

-Anterior-inferior dislocation of the shoulder jt

Motor:

-Paralysis of the teres minor and deltoid, resulting in loss of abduction of arm

-Weak flexion, extension, and rotation of shoulder.

Sensory:

Loss of sensation in the skin over a small part of the lateral upper arm

Other Signs:

-Flat shoulder deformity.

Front 16

Injury of the Long Thoracic Nerve

Back 16

Winged Scapula or Winging

shoulder blade, or shoulder bone, protrudes from a person’s back in an abnormal position.

It is a rare condition with the potential to lead to limited functional activity in the upper extremity to which it is adjacent.

It can affect a person’s ability to lift, pull, and push weighty objects.

Front 17

What Structures go through the Carpal Tunnel

Back 17

4 Tendons of Flexor Digitorum Profundus

4 Tendons of Flexor Digitorum Superficialis

1Tendon of Flexor Pollicis Longus

Median Nerve

Front 18

Radical Mastectomy

Back 18

Often Injured:

1) Long thoracic nerve

2) Lower subscapular nerve

3) Thoracodorsal nerve

Front 19

Muscular Radial Nerve Test

Back 19

Hook 'em Horns Sign

Extension of the index and small fingers and thumb

Front 20

Two Joint Muscles

Back 20

A muscle that crosses two joints is more susceptible to injury and may become involed in disease processes more readily

Front 21

Compartment Syndrome

Back 21

Compression of the forearm related to severe internal bleeding which can crush soft tissue in the antebrachial fascial.

Signs:

pink or reddish limb

pain to severe pain

loss of muscle or sensory

Notes:

-Can perminantly damage tissue

-May result in Volkmann's contracture

-Treatment involves cutting through the fasica to release the pressure. The wound is left open.

Front 22

Volkmann's contracture

Back 22

Damage to median and ulnar nerves as well as the flexor muscles in the anterior compartment results in a severe flexion deformity.

Front 23

Ulnar Positive

Back 23

Normally ulna is 2-4 mm shorter than the radius at the wrist.

Subsequent to distal radial fractures the radius may be shortened causing the ulna to be even or longer.

Results in prolonged ulner wrist pain from ulna on lunate

If untreate the lunate may become cystic and become necrosis (kienbock's disease)

Front 24

Scaphoid Fracture

Back 24

The most fractured carpal bone

Distal area is well supplied with blood.

Proximal area is not well supplied.

May not see a fracture on xray because no blood.

Symptoms:

-Aching, loss of strength

-Pain on palpation of the anatomical snuff box

-May become necrotic

Front 25

The First Carpometacarpal Joint

Back 25

Usually the first and sometimes only joint to be involved in osteoarthritis.

Front 26

Gamekeeper / Skiers Thumb

Back 26

Spraining of the first MP joint or avulsion of ulnar collateral ligament.

Thumb becomes unstable and is painful in opposition.

Front 27

Trigger Finger

Back 27

Inflmaation or repetitive stress to flexor tendon and first annualar pulley swell.

Tendon catches on the pulley swell and will not extend unless manually forced which is painful

Front 28

Useful Nerve Skin Testing Sites

Back 28

1) Pad of the index finger: Median Nerve

2) Pad of small finger: Ulnar Nerve

3) Thumb/index web space: Radial Nerve

4) Lateral Deltoid: Axillary Nerve

5) Lateral Forearm: Musculocutaneous nerve

Front 29

Dupuytren's Disease and Contracture

Back 29

Palmar fascia may become thickened as a result of diseased connective tissue.

Inherited condition causes nodules, thick cords to form longitudinally along fingers and trajectory of flexor tendons.

As cords shorten palm and fingers are drawn in resulting in permanent flexion of fingers.

Front 30

Muscle testing for the Ulnar Nerve

Back 30

Palmar Interosseous test:

-Test adduction by piece of paper between digits.

Dorsal Interosseous Test:

-Test Abduction by holding fingers together

Front 31

Intrinsic Plus Position

Back 31

Shows that the intrinsic muscles of the heand innervated by the median and ulnar nerves are working okay.

Wrist neutral

MCP joint flexed at 90 degrees

PIP and DIP joint extended

Note: Intrinsic Minus Means-innervation is weak or absent

Front 32

Wasting of intrinsic Muscles

Back 32

Best visualized at the first dorsal interossei muscle in the web space between index finger and thumb.

Front 33

Most Distal Muscle to Median Nerve

Back 33

Median Nerve:

-Opponens Pollicis

-Weak thumb opposition

Front 34

Most Distal Muscle to Ulnar Nerve

Back 34

Ulnar Nerve:

-First Dorsal Interosseous

-Abduction of the index finger

Front 35

Most Distal Muscle to Radial Nerve

Back 35

Radial Nerve:

-Extensor indicis

-Extensor of index finger at Metacarpal Phalangeal Joint (MCP)

Front 36

Most Distal Muscle to Musculocutaneous Nerve

Back 36

Musculocutaneous Nerve:

-Brachialis

-Forearm Flexion

Front 37

Most Distal Muscle to the Axillary Nerve

Back 37

Axillary Nerve:

-Deltoid

-Shoulder Abduction