16-clinical anatomy of the upper limb

7/29/2019 16-Clinical Anatomy of the Upper Limb

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ClavicleIt is the most commonly fractured bonein the body.

The fracture occurs due to falling onthe shoulder or the outstretched hand.

It is most commonly fractured at thejunction of the middle and outer thirds(weakest point).

The lateral fragment :

Depressed by the weight of thearm

Pulled medially and forwards bythe adductors of arm (especiallypectoralis major).

The medial fragment :

Pulled upward by thesternomastoid.

Involvement of supraclavicularnerves can be the cause ofpersistent pain over the side of theneck.


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HumerusFractures of the proximal end:

Humeral head fracture: may occur in anterior or posterior

dislocations of shoulder

Greater tuberosity fracture:

It is due to direct trauma,dislocation of the shoulder joint or

due to violent contraction ofsupraspinatus muscle.

The bone fragment will have theattachments of the rotator cuffmuscles

Severe tearing of the rotator cuff

with the dislocation can result in thegreater tubercle remainingdisplaced posteriorly even after the

joint is reduced.

Lesser tuberosity fracture

Surgical neck fractures: may result in

injury to axillary nerve


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HumerusFractures of the shaft:

Are common

The displacement of the fragmentsdepends on the relation of the site offracture to the insertion of the deltoid.muscle

If the fracture line is proximaltothedeltoid insertion:

The proximal fragment is adducted bythe pectoralis major, latissimus dorsiand teres major.

The distal fragment is pulled proximallyby deltoid, biceps & triceps.

If the fracture line is distaltothe deltoid

insertion: The proximal fragment is abducted by

deltoid.

The distal fragment is pulled proximallyby the biceps & triceps.

The radial nerve can be injured.


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Humerus

Fractures of the lowerend:

Supracondylar fracture:

Common in children

May injure mediannerve and brachial

artery

Medial epicondyle

fracture: May injure the ulnar

nerve


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RadiusFracture of the distal end(Colles fracture):

It is due to a fall on the outstretchedhand in patients over (50) years.

The distal fragment of the radius ispulled posteriorly and superiorly

The distal articular surface is

directed posteriorly.The posterior displacementproduces a posterior bump.

The deformity is referred to as,dinner-fork deformity because theforearm and wrist resemble the

shape of a dinner fork.

Smiths fractureis a reversedColes as the distal segment isdisplaced anteriorly


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Fracture of the Scaphoid BoneCommon in young adults

Fracture line passes through the narrowestpart of the bone

The blood supply to scaphoid may come fromits distal end and the only way the proximalpole can receive any blood supply andnutrients is through the rest of the bone. Thus

a fracture of the scaphoid in the proximal poleor waist, deprives the proximal fragment of itsarterial supply, and this fragment undergoesavascular necrosis.

If the fragments will not unite properly, therewill be permanent pain and weakness at thewrist

Deep tenderness in the anatomical snuff boxafter a fall on an outstretched hand in a youngadult is an indication offracture of scaphoidbone


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Sternoclavicular Joint

Occasionally dislocatedbecause of strong ligamentsaround

Anterior dislocation:medial end of clavicle

pulled forward and upward Posterior dislocation:

medial end of claviclepulled backward, whichmay press trachea,

esophagus & greatvessels in the root of theneck

Anterior

dislocation


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Acromioclavicular Joint

The stability of the

acromioclavicular joint dependson the strong coracoclavicularligament

The joint may get injured by asevere blow such as a hard fall

on the shoulder.The acromian thrusts beneaththe lateral end of the clavicletearing the coracoclavicularligament. This condition iscalled shoulder separation, asthe shoulder separates (fallsaway) from the clavicle becauseof the weight of the upper limb.

The displaced lateral end ofclavicle is easily palpable


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Shoulder Joint

It is the most commonly

dislocated large joint.Dislocations happen when aforce overcomes the strength ofthe rotator cuff muscles and theligaments of the shoulder.

Nearly all dislocations areanterior inferior dislocations,meaning that the humerus slipsout of the front of the glenoid.

Only three percent ofdislocations are posteriordislocations, or out the back.


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Anteriorinferiordislocation Sudden violence applied to the

humerus when the joint is fullyabducted. The humeral head

moves downward onto theinferior weak part of the capsulewhich tears.

The humeral head comes to lieinferior to the glenoid fossa

The acromion acts as a fulcrum

and the head of the humerus ispulled upward and forwards bythe strong flexors and adductors.

Posterior displacement It is due to direct violence to the

front of the joint.

The shoulder loses its roundedappearance as the greatertuberosity is no more bulginglaterally.

The axillary nerve can bedamaged.


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Elbow JointDislocations are common and

most are posterior. Are morecommon in children, due to a

fall on outstretched hand. The

distal end ofhumerus is

pushed anteriorly through

weak part of the capsule

Pulled Elbow: occurs in

children, when the child is

lifted by the upper limb. The

radial head is pulled out of the

annular ligament


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Rotator Cuff TendinitisResults due to excessiveoverhead activity of the upper

limb.It is a common cause ofpain inthe shoulder region

Normally during abduction of theshoulder joint, friction between

the supraspinatus tendon andthe acromion is minimized by thesubacromial bursa.

Degenerative changes in thebursa are followed by

degenerative changes in thetendon of supraspinatus thatmay extend to the tendons of theother rotator cuff

There is a spastic pain in themiddle range of abduction.


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Rupture of the Supraspinatus Tendon

In advanced cases of

tendinitis, the necrotic

supraspinatus tendon

may become calcifiedand rupture

The patient is unable to

initiate abduction of thearm


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Tennis ElbowCaused by partial tear or

degeneration of the origin ofsuperficial extensor muscles

attached to the lateral

epicondyle

It results due to excessive

use of these muscles as in

tennis, violinists and

housewives.

Results in pain and

tenderness over the lateral

epicondyle that radiates to

the lateral side of the

forearm


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Golfers Elbow (Medial Epicondylitis)

Caused by partial tear or

degeneration of the originofsuperficial flexor

muscles attached to the

medial epicondyle

It results due to excessiveuse of these muscles as in

playing golf

Results in pain and

tenderness over the medialepicondyle that radiates to

the medial side of the

forearm


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Biceps Brachii & Osteoarthritis of the

Shoulder Joint

Advanced

osteoarthritic changes

in the shoulder joint

can cause erosion ofthe tendon of the long

head of biceps by

osteophytic changes.

The tendon may bereptured.


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Volkmanns Ischaemic Contracture

It is the contractures of the muscles of theforearm that follows fractures of the distal end ofthe humerus or fractures of the radius and ulna.

Spasm of a localized segment of the brachial

artery reduces the blood flow to the flexors andextensor muscles so that they under go ischemicnecrosis.

The flexor muscles are mostly affected

The muscles are replaced by fibrous tissue,which contract and result in the deformity


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3 types of deformity exists:

The long flexors of the carpalsand fingers are more contracted

than extensors. The wrist jointis flexed and the fingers areextended.

The long extensorsof thefingers are greatly contractingThe wrist and metacarpo-phalngeal joints are extended.The interphalngeal joints areflexed.

Both the flexor and extensorare contracted:

The wrist joint and theinterphalangeal joints areflexed. The metacarpo-phalangeal joints are extended.


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Dupuytrens ContractureIt is a localized thickening andcontracture of the palmaraponeurosis.It commonly starts near the root ofthe ring fingerpulling it to the palmand flexing it at the metacarpo-phalngeal joint. Later the little fingeris involved.

In long standing cases prolongedpulling of the fibrous sheaths ofthese two fingers would flex theirproximal interphalangeal joints

Their distal interphalangeal jointsare not involved and they actually

become extendedDupuytren's disease is familial, andmay be associated with cigarettesmoking, vascular disease, epilepsy,and diabetes.


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Compartment syndromes of the forearm

The deep facial sheath, theinterosseous membrane &

the fibrous intermuscular

septae divide the forearm into

compartments, that contain

muscles, vessels and nerves

There is very little room within

each compartment, and any

edema will cause secondary

vascular compression.

The veins are affected first

and later the arteries


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Tenosynovitis & Infection of the Fascial

Spaces of Palm

May get infected

and distended with

pus, after

penetratingwounds of the

palm


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Pulp-Space Infection (Felon)This is the commonest handinfection. Pus more often gathers inthe finger tips than anywhere else inthe hand.

It is more common in the thumb andindex fingers.

Bacteria enter the space throughneedles or nails.

Accumulation of inflammatoryexudate within the smallcompartments of the pulp wouldrapidly increase its pressure. There

is little room for swelling, so thatinfection causes a throbbing painearly.

If infection is not decompressed, itcan extend into the terminal

phalanx.


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Pus from the pulp can track:

through to the skin outside

through the periosteum,

causing osteomyelitis of thedistal phalanx.

Since the blood supply of thediaphysis of the phalanx passesthrough the pulp space (in

children), the infection wouldresult in necrosis of thediaphysis. Its epiphysis issupplied by a separate artery, sothis usually survives theinfection.

The synovial sheaths of theaffected fingers can be involvedbecause of their closerelationships to the proximal partof the pulp space.


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VenipunctureThe superficial veins of the upper limbare used for venipuncture, transfusion

and cardiac cathetrization.When a patient is in shock, thesuperficial veins are not always visible. Itis very important to know their courseand the relations to important landmarks.

The cephalic vein:

At the wrist, it passes posterior to thestyloid process of the radius.

In the cubital fossa it is separatedfrom the brachial artery by thebicipital aponeurosis which protectsthe artery from irritating drugs.

In the deltopectoral groove, itcommunicates with the external

jugular vein by a small vein thatpasses in front of the clavicle.Fracture of the clavicle can tear thiscommunicating vein and causes alarge hematoma.


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Thank U & Good Luck

16-clinical anatomy of the upper limb

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