Clinical Notes On The Upper Limb PDF

ON THE UPPER LIMB Prof. Dr. Mohammed Sh. Al –Edanni Orthopedic surgeon Fractures and Dislocation Fractures. Loss of continuinty of the bone with loss of function Dislocation. Comple loss of contact between two articular surface of the joint Sublaxation. Partial loss of contact...

ON THE UPPER LIMB Prof. Dr. Mohammed Sh. Al –Edanni Orthopedic surgeon Fractures and Dislocation Fractures. Loss of continuinty of the bone with loss of function Dislocation. Comple loss of contact between two articular surface of the joint Sublaxation. Partial loss of contact between two articular surface of the joint Mammary gland The shoulder The shoulder is uniquely adapted to allow freedom of movement and maximum reach for the hand. Five ‘articulations’ are involved: the gleno-humeral joint the pseudojoint between the humerus and the coracoacromial arch the sternoclavicular joint the acromioclavicular joint the scapulothoracic articulation. Rotator cuff The rotator cuff is a sheet of conjoint tendons closely applied over the top of the shoulder capsule and inserting into the greater tuberosity of the humerus. It is made up of subscapularis in front, supraspinatus above and infraspinatus and teres minor behind. The ‘rotator’ muscles have an stabilizing the head of the humerus by pulling it firmly into the glenoid whenever the deltoid lifts the arm forwards or sideways.  IMPINGEMENT SYNDROME, SUPRASPINATUS TENDINITIS Is a painful disorder arise from repetitive compression or rubbing of the tendons (mainly supraspinatus) under the coracoacromial arch. Normally, when the arm is abducted, the conjoint tendon slides under the coracoacromial arch. As abduction approaches 90 degrees, there is a natural tendency to externally rotate the arm, thus allowing the rotator cuff to occupy the widest part of the subacromial space. If the arm is held persistently in abduction and then moved to and fro in internal and external rotation (as in cleaning a window, painting a wall or polishing a flat surface) the rotator cuff may be compressed and irritated as it comes in contact with anterior edge of the acromion process and the taut coracoacromial ligament. This attitude (abduction, slight flexion and internal rotation) has been called the ‘impingement position’.. The Biceps Tendinitis The long head of biceps is subject to tenosynovitis because of its anatomy in the bicipital groove. usually with rotator cuff impingement; Tenderness is sharply localized to the bicipital groove. Two maneuvers that often cause pain are: (1) resisted flexion with the elbow straight and the forearm supinated (Speed’s test); (2) resisted supination of the forearm with the elbow bent (Yergason’s test). Biceps rupture Biceps brachii rupture TENNIS ELBOW (LATERAL EPICONDALITIS) Pain and tenderness over the lateral epicondyle of the elbow (or, more accurately, the bony insertion of the common extensor tendon) is a common complaint among tennis players – due to forceful repetitive wrist extension GOLFER’S ELBOW (MEDIAL EPICONDYLITIS) This is similar to tennis elbow but about three times less common. In this case it is the pronator origin that is affected.. Pain and tenderness over the medial epicondyle of the elbow {common flexor origion} DE QUERVAIN’S DISEASE reactive thickening of the sheath around the extensor pollicis brevis and abductor pollicis longus tendons within the first extensor compartment. Tenderness is most acute at the very tip of the radial styloid. The pathognomonic sign is elicited by Finkelstein’s test. The examiner places the patient’s thumb across the palm in full flexion and then, holding the patient’s hand firmly, turns the wrist sharply into adduction.---- positive test this is acutely painful Ossification of the elbow bones CRITOE 1-3-5-7-9-11 years capitellum: 1 year radial head: 3 years internal epicondyle: 5 years trochlea: 7 years olecranon: 9 years external epicondyle: 11 years  Ossification of the wrist bones The ossific centre for the distal radius epiphysis appears at age 2 and fuses at age 16–18. The other bones develop ossification centers in clockwise order (looking at the right hand from behind, fully pronated i.e. face down). Capitate (1 month), Hamate (1 year); Triquetrum (2 years); Lunate (4 years); Scaphoid (4–6 years); Trapezium (4–6 years); Trapezoid (4–6 years); Pisiform (8–10 years).  Compartment Syndrome A condition in which increased pressure within a limited space compromises the circulation and function of the tissues within that space. Etiology Compartment Size tight dressing; Bandage/Cast Compartment Content Bleeding; Fx, vas inj, bleeding disorders Compartment Syndrome Tissue Survival Muscle ◦ 3-4 hours - reversible changes ◦6 hours - variable damage ◦8 hours - irreversible changes Nerve ◦2 hours - looses nerve conduction ◦4 hours - neuropraxia ◦8 hours - irreversible changes Compartment Syndrome Diagnosis Pain out of proportion Palpably tense compartment Pain with passive stretch Paresthesia/hypoesthesia Paralysis Pulselessness/Pallor 6P  Clinical Evaluation ❑ “Pain and the aggravation of pain by passive stretching of the muscles are the most sensitive (and generally the only) clinical finding before the onset of ischemic dysfunction in the nerves and muscles.” ❑ Other features like pallor, pulselessness, paralysis, paraesthesia etc. appear very late and we should not wait for these things.  Medical Management ❖ Ensure patient is normotensive ,as hypotension reduces prefusion pressure and facilitates further tissue injury. ❖ Remove cicumferential bandages and cast (Total of 85-90% reduction by just taking off the plaster) ❖ Maintain the limb at level of the heart as elevation reduces the arterial inflow and the arterio-venous pressure gradient on which perfusion depends. ❖ Supplemental oxygen administration. Surgical Treatment Fasciotomy, Fasciotomy, Fasciotomy All compartments Tenosynovitis Bursal infection Usually due to spread of flexor tenosynovitis from thumb or small finger Brachial plexus  Branches from the roots 1. dorsal scapular n.--levator scapular & rhomboid ms. 2.long thoracic n.-- serratus anterior ms..  Branches from the trunk 1. suprascapular n. supraspinatus & infraspinatus ms.. 2. n. to subclavius subclavius ms Branches from the lateral cord 1.lateral pectoral n.--pectoralis major ms.. 2. musculocatenous n.-Coracobrachialis ,biceps & brachialis ms.. 3. lateral root of the median n. Branches from the medial cord 1.medial pectoral n. --pectoralis minor & major ms.. 2.medial cutaneous n. of the arm --skin on the medial side of the arm. 3. medial cataneous n. of the forearm-- skin on the medial side of the forearm. 4.medial root of the median n. 5.ulnar n. (C8,T1) ranches from the posterior cord 1.upper subscapular n.--upper part of the subscapularis 2.lower subscapular n.--lower part of the subscapularis ms.& the teres major ms.. 3.thoracodorsal n.--Latismus dorsi ms. 4.axillary n.--deltoid & teres minor ms.. 5. radial n. BIRTH INJURY 1.Erb-Duchenne palsy 2.Klumpke s paralysis  Erb-Duchenne palsy UPPR LESIONS Injury of C5 &C6 nerve roots Excessive lateral displacement of the head of the fetus with forcible depression of the shoulder Kks Waiter s tip position The limb hold in adduction internal rotation of the arm & extended elbow Muscles paralys are 1. supra & infraspinatus. 2.subclavian. 3. biceps brachii. Brachialis & coracobrachialis 4. deltoid & teres minor.  Klumpke s paralysis LOWER LESION Lesion of C8 & T1 Due to forceful cephalad pull on the child s arm during birth,& from dislocation of the shoulder joint. INJURY TO THE ULNAR & MEDIAN NERVE paralysis of the all internsic muscle of the hand resulting a true claw hand with loss of sensation along ulnar side of the arm, foraerm & hand (HYEREXTENSION OF THE MCP JOINTS & FLEXION OF THE IP JOINTS) AXILLARY NERVE Usually due to dislocation of the shoulder& in fracture of the neck of the humerus Paralysis of the deltoid muscle & loss of abduction of the arm RADIAL NERVE Radial nerve injury Kks deformity is wrist drop Lesion bet. Upper &middle third of humerus ---- the action of the triceps muscle lost Lesion in the middle third ----the brachioradialis muscle is spared. Lesion of the deep radial nerve below elbow --- typical wrist drop not occure because the ECRL& ECRB muscles are not paralysis & instead the hand held in radial deviation on attempt extension & unable to extend the fingers ext. digitorum is paralysis MEDIAN NERVE  Median nerve injury Usually in the cubital fossa by misplaced intravenous injections & at wrist. All lesion site result ----the patient unable to pick up a pin with thumb & index finger or can not do OK sign  Lesion at the wrist --- loss of the Median nerve injury thener eminence & 1st & 2nd Lesion in or above cubital lumbrical muscles. We can examin the APB muscle by ( pen touching fossa --- result in loss of test) power to flex the interphalangeal joints of the index finger ( Ochner s clasping test) Lesion of Anterior interosseus nerve ---- loss of power of FPL muscle ULNAR NERVE  Ulnar nerve injury Ulnar nerve injury result in (Ulnar Claw hand) Lesion at the elbow Lesion at the wrist----result in loss of FCU muscle loss of ADDUCTOR POLLICIS muscle ( Forment s sign) SENSORY LOSS THANK YOU