clinical anatomy of the upper limb

Muhammmad Ramzan Ul Rehman Muhammmad Ramzan Ul Rehman

MUHAMMAD RAMZAN UL REHMAN MUHAMMAD RAMZAN UL REHMAN

Bone Injuries of The Upper Limb Bone Injuries of The Upper Limb


ClavicleClavicleIt is the most commonly fractured It is the most commonly fractured bone in the body.bone in the body.The fracture occurs due to falling on The fracture occurs due to falling on the shoulder or the outstretched hand.the shoulder or the outstretched hand.It is most commonly fractured at the It is most commonly fractured at the junction of the middle and outer thirds junction of the middle and outer thirds (weakest point).(weakest point).The lateral fragmentThe lateral fragment : : Depressed by the weight of the Depressed by the weight of the

armarm Pulled medially and forwards by Pulled medially and forwards by

the adductors of arm (especially the adductors of arm (especially pectoralis major).pectoralis major).

The medial fragmentThe medial fragment : : Pulled upward by the Pulled upward by the

sternomastoid.sternomastoid. Involvement of supraclavicular Involvement of supraclavicular

nerves can be the cause of nerves can be the cause of persistent pain over the side of the persistent pain over the side of the neck.neck.


HumerusHumerusFractures of the proximal end: Fractures of the proximal end: Humeral head fracture: Humeral head fracture:

may occur in anterior or posterior may occur in anterior or posterior dislocations of shoulderdislocations of shoulder

Greater tuberosity fracture:Greater tuberosity fracture: It is due to direct trauma, It is due to direct trauma,

dislocation of the shoulder joint or dislocation of the shoulder joint or due to violent contraction of due to violent contraction of supraspinatus muscle.supraspinatus muscle.

The bone fragment will have the The bone fragment will have the attachments of the rotator cuff attachments of the rotator cuff musclesmuscles

Severe tearing of the rotator cuff Severe tearing of the rotator cuff with the dislocation can result in with the dislocation can result in the greater tubercle remaining the greater tubercle remaining displaced posteriorly even after the displaced posteriorly even after the joint is reduced.joint is reduced.

Lesser tuberosity fractureLesser tuberosity fracture Surgical neck fractures: Surgical neck fractures: may result in may result in

injury to axillary nerveinjury to axillary nerveMuhammmad Ramzan Ul Rehman Muhammmad Ramzan Ul Rehman

HumerusHumerusFractures of the shaft:Fractures of the shaft: Are common Are common The displacement of the fragments The displacement of the fragments

depends on the relation of the site of depends on the relation of the site of fracture to the insertion of the deltoid. fracture to the insertion of the deltoid. musclemuscle

If the fracture line is proximalIf the fracture line is proximal toto the the deltoid insertiondeltoid insertion:: The The proximalproximal fragment is adducted by fragment is adducted by

the pectoralis major, latissimus dorsi the pectoralis major, latissimus dorsi and teres major. and teres major.

The The distal distal fragment is pulled proximally fragment is pulled proximally by deltoid, biceps & triceps.by deltoid, biceps & triceps.

If the fracture line is distalIf the fracture line is distal toto the the deltoid insertiondeltoid insertion:: The The proximalproximal fragment is abducted by fragment is abducted by

deltoid.deltoid. The The distaldistal fragment is pulled proximally fragment is pulled proximally

by the biceps & triceps.by the biceps & triceps. The The radial nerve radial nerve can be injured. can be injured.


HumerusHumerus

Fractures of the Fractures of the lower lower end:end: Supracondylar fracture:Supracondylar fracture:

Common in childrenCommon in children May injure median May injure median

nerve and brachial nerve and brachial artery artery

Medial epicondyle Medial epicondyle fracture:fracture: May injure the ulnar May injure the ulnar

nervenerve


RadiusRadiusFracture of the distal end Fracture of the distal end (Colle’s fracture):(Colle’s fracture):It is due to a fall on the outstretched It is due to a fall on the outstretched hand in patients hand in patients over (50) yearsover (50) years..The distal fragment of the radius is The distal fragment of the radius is pulled pulled posteriorly and superiorlyposteriorly and superiorlyThe distal articular surface is The distal articular surface is directed posteriorly.directed posteriorly.The posterior displacement The posterior displacement produces a posterior bump.produces a posterior bump.The deformity is referred to as, The deformity is referred to as, ‘dinner-fork deformity’ ‘dinner-fork deformity’ because the because the forearm and wrist resemble the forearm and wrist resemble the shape of a dinner fork.shape of a dinner fork.

Smith’s fractureSmith’s fracture is a reversed is a reversed Cole’s as the distal segment is Cole’s as the distal segment is displaced displaced anteriorlyanteriorly


Fracture of the Scaphoid BoneFracture of the Scaphoid BoneCommon in Common in young adultsyoung adultsFracture line passes through the Fracture line passes through the narrowest narrowest part of the bonepart of the boneThe blood supply to scaphoid may come from The blood supply to scaphoid may come from its distal end and the only way the proximal its distal end and the only way the proximal pole can receive any blood supply and pole can receive any blood supply and nutrients is through the rest of the bone. Thus nutrients is through the rest of the bone. Thus a fracture of the scaphoid in the proximal pole a fracture of the scaphoid in the proximal pole or waist, deprives the proximal fragment of its or waist, deprives the proximal fragment of its arterial supply, and this fragment undergoes arterial supply, and this fragment undergoes avascular necrosisavascular necrosis. . If the fragments will not unite properly, there If the fragments will not unite properly, there will be permanent pain and weakness at the will be permanent pain and weakness at the wristwristDeep tenderness in the Deep tenderness in the anatomical snuff boxanatomical snuff box after a fall on an outstretched hand in a young after a fall on an outstretched hand in a young adult is an indication of adult is an indication of fracture of scaphoid fracture of scaphoid bone bone


Sternoclavicular JointSternoclavicular Joint

Occasionally dislocated Occasionally dislocated because of strong ligaments because of strong ligaments aroundaround Anterior dislocation: Anterior dislocation:

medial end of clavicle medial end of clavicle pulled forward and upwardpulled forward and upward

Posterior dislocation: Posterior dislocation: medial end of clavicle medial end of clavicle pulled backward, which pulled backward, which may press trachea, may press trachea, esophagus & great esophagus & great vessels in the root of the vessels in the root of the neckneck

Anterior dislocation


Acromioclavicular JointAcromioclavicular JointThe stability of the The stability of the acromioclavicular joint depends acromioclavicular joint depends on the strong on the strong coracoclavicular coracoclavicular ligamentligamentThe joint may get injured by a The joint may get injured by a severe blow such as a hard fall severe blow such as a hard fall on the shoulder.on the shoulder.The acromian thrusts beneath The acromian thrusts beneath the lateral end of the clavicle the lateral end of the clavicle tearing the coracoclavicular tearing the coracoclavicular ligament. This condition is ligament. This condition is called called shoulder separation, shoulder separation, asas the shoulder separates (falls the shoulder separates (falls away) from the clavicle because away) from the clavicle because of the weight of the upper limb.of the weight of the upper limb.The displaced lateral end of The displaced lateral end of clavicle is easily palpableclavicle is easily palpable


Shoulder JointShoulder JointIt is the It is the most commonly most commonly dislocated large jointdislocated large joint..Dislocations happen when a Dislocations happen when a force overcomes the strength of force overcomes the strength of the rotator cuff muscles and the the rotator cuff muscles and the ligaments of the shoulder. ligaments of the shoulder. Nearly all dislocations are Nearly all dislocations are anterior inferior dislocationsanterior inferior dislocations, , meaning that the humerus slips meaning that the humerus slips out of the front of the glenoid.out of the front of the glenoid.Only three percent of Only three percent of dislocations are dislocations are posterior posterior dislocationsdislocations, or out the back, or out the back..


AnteriorAnterior inferiorinferior dislocation dislocation Sudden violence applied to the Sudden violence applied to the

humerus when the joint is fully humerus when the joint is fully abducted. The humeral head abducted. The humeral head moves downward onto the moves downward onto the inferior weak part of the capsule inferior weak part of the capsule which tears.which tears.

The The humeral head comes to lie humeral head comes to lie inferior to the glenoid fossainferior to the glenoid fossa

The acromion acts as a fulcrum The acromion acts as a fulcrum and the head of the humerus is and the head of the humerus is pulled upward and forwards by pulled upward and forwards by the strong flexors and adductorsthe strong flexors and adductors..

Posterior displacementPosterior displacement It is due to direct violence to the It is due to direct violence to the

front of the joint.front of the joint. The shoulder loses its rounded The shoulder loses its rounded

appearance as the greater appearance as the greater tuberosity is no more bulging tuberosity is no more bulging laterally.laterally.

The The axillary nerveaxillary nerve can be can be damageddamaged..


Elbow JointElbow JointDislocationsDislocations are common and are common and most are posterior. Are more most are posterior. Are more common in children, due to a common in children, due to a fall on outstretched hand. The fall on outstretched hand. The distal end of distal end of humerus is humerus is pushed anteriorlypushed anteriorly through through weak part of the capsule weak part of the capsule

Pulled ElbowPulled Elbow: occurs in : occurs in children, when the child is children, when the child is lifted by the upper limb. The lifted by the upper limb. The radial head is pulled out of the radial head is pulled out of the annular ligamentannular ligament


Rotator Cuff Tendinitis Rotator Cuff Tendinitis Results due to Results due to excessive excessive overhead activityoverhead activity of the upper of the upper limb.limb.It is a common cause of It is a common cause of pain in pain in the shoulder region the shoulder region Normally during abduction of the Normally during abduction of the shoulder joint, friction between shoulder joint, friction between the supraspinatus tendon and the supraspinatus tendon and the acromion is minimized by the the acromion is minimized by the subacromial bursasubacromial bursa. . Degenerative changes in the Degenerative changes in the bursa are followed by bursa are followed by degenerative changes in the degenerative changes in the tendon of supraspinatus that tendon of supraspinatus that may extend to the tendons of the may extend to the tendons of the other rotator cuff other rotator cuff There is a There is a spastic pain in the spastic pain in the middle range of abduction.middle range of abduction.


Rupture of the Supraspinatus TendonRupture of the Supraspinatus Tendon

In advanced cases of In advanced cases of tendinitis, the necrotic tendinitis, the necrotic supraspinatus tendon supraspinatus tendon may become calcified may become calcified and ruptureand rupture

The patient is The patient is unable to unable to initiate abductioninitiate abduction of the of the armarm


Tennis ElbowTennis ElbowCaused by partial tear or Caused by partial tear or degeneration of the origin of degeneration of the origin of superficial extensor musclessuperficial extensor muscles attached to the lateral attached to the lateral epicondyleepicondyle

It results due to excessive It results due to excessive use of these muscles as in use of these muscles as in tennis, violinists and tennis, violinists and housewives.housewives.

Results in pain and Results in pain and tenderness over the tenderness over the lateral lateral epicondyleepicondyle that radiates to that radiates to the lateral side of the the lateral side of the forearm forearm


Golfer’s Elbow (Medial Epicondylitis)Golfer’s Elbow (Medial Epicondylitis)

Caused by partial tear or Caused by partial tear or degeneration of the origin degeneration of the origin of of superficial flexor superficial flexor musclesmuscles attached to the attached to the medial epicondylemedial epicondyle

It results due to excessive It results due to excessive use of these muscles as in use of these muscles as in playing golfplaying golf

Results in pain and Results in pain and tenderness over the tenderness over the medial medial epicondyleepicondyle that radiates to that radiates to the medial side of the the medial side of the forearm forearm


Biceps Brachii & Osteoarthritis of the Biceps Brachii & Osteoarthritis of the Shoulder JointShoulder Joint

Advanced osteoarthritic Advanced osteoarthritic changes in the shoulder joint changes in the shoulder joint can cause can cause erosion of the erosion of the tendon of the long head of tendon of the long head of bicepsbiceps by osteophytic by osteophytic changes.changes.

The tendon may be reptured.The tendon may be reptured.


Volkmann’s Ischaemic ContraVolkmann’s Ischaemic Contracturecture

It is the It is the contractures of the muscles of the forearmcontractures of the muscles of the forearm that follows that follows fractures of the distal end of the humerus or fractures of the radius fractures of the distal end of the humerus or fractures of the radius and ulna.and ulna.Spasm of a localized segment of the Spasm of a localized segment of the brachial arterybrachial artery reduces the reduces the blood flow to the flexors and extensor muscles so that they under blood flow to the flexors and extensor muscles so that they under go ischemic necrosis.go ischemic necrosis.The The flexor musclesflexor muscles are mostly affected are mostly affectedThe muscles are The muscles are replaced by fibrous tissuereplaced by fibrous tissue, which contract and , which contract and result in the deformityresult in the deformity


3 types of deformity exists:3 types of deformity exists: The long flexorsThe long flexors of the carpals of the carpals

and fingers are more contracted and fingers are more contracted than extensors. The wrist joint than extensors. The wrist joint is flexed and the fingers are is flexed and the fingers are extended.extended.

The long extensorsThe long extensors of the of the fingers are greatly contracting fingers are greatly contracting The wrist and metacarpo-The wrist and metacarpo-phalngeal joints are extended. phalngeal joints are extended. The interphalngeal joints are The interphalngeal joints are flexed.flexed.

Both the flexor and extensor Both the flexor and extensor are contracted:are contracted:

The wrist joint and the The wrist joint and the interphalangeal joints are interphalangeal joints are flexed. The metacarpo-flexed. The metacarpo-phalangeal joints are extended.phalangeal joints are extended.


Dupuytren’s ContractureDupuytren’s ContractureIt is a localized thickening and It is a localized thickening and contracture of the contracture of the palmar palmar aponeurosis.aponeurosis.It commonly starts near the root of It commonly starts near the root of the the ring finger ring finger pulling it to the palm pulling it to the palm and and flexing it at the metacarpo-flexing it at the metacarpo-phalngeal jointphalngeal joint. Later the . Later the little finger little finger is involved.is involved.In long standing cases prolonged In long standing cases prolonged pulling of the fibrous sheaths of pulling of the fibrous sheaths of these two fingers would these two fingers would flex their flex their proximal interphalangeal jointsproximal interphalangeal jointsTheir distal interphalangeal joints Their distal interphalangeal joints are not involved and they actually are not involved and they actually become extendedbecome extendedDupuytren's disease is familial, and Dupuytren's disease is familial, and may be associated with cigarette may be associated with cigarette smoking, vascular disease, epilepsy, smoking, vascular disease, epilepsy, and diabetes.and diabetes.


Compartment syndromes of the forearmCompartment syndromes of the forearm

The The deep facial sheathdeep facial sheath, the , the interosseous membraneinterosseous membrane & & the fibrous the fibrous intermuscular intermuscular septaeseptae divide the forearm into divide the forearm into compartments, that contain compartments, that contain muscles, vessels and nerves muscles, vessels and nerves

There is very little room within There is very little room within each compartment, and any each compartment, and any edema will cause edema will cause secondary secondary vascular compression.vascular compression.

The veins are affected first The veins are affected first and later the arteriesand later the arteries


Tenosynovitis & Infection of the Fascial Tenosynovitis & Infection of the Fascial Spaces of PalmSpaces of Palm

May get infected and May get infected and distended with pus, after distended with pus, after penetrating wounds of the penetrating wounds of the palmpalm


Pulp-Space Infection (Felon)Pulp-Space Infection (Felon)This is the This is the commonest hand commonest hand infection.infection. Pus more often gathers in Pus more often gathers in the finger tips than anywhere else in the finger tips than anywhere else in the hand.the hand.It is more common in the It is more common in the thumb and thumb and index fingers.index fingers.Bacteria enter the space through Bacteria enter the space through needles or nails.needles or nails.Accumulation of inflammatory Accumulation of inflammatory exudate within the small exudate within the small compartments of the pulp would compartments of the pulp would rapidly increase its pressure. There rapidly increase its pressure. There is little room for swelling, so that is little room for swelling, so that infection causes a infection causes a throbbing painthrobbing pain early. early. If infection is not decompressed, it If infection is not decompressed, it can extend into the terminal can extend into the terminal phalanx.phalanx.


Pus from the pulp can track: Pus from the pulp can track: through to the skin outside through to the skin outside through the periosteum, through the periosteum,

causing causing osteomyelitis of the osteomyelitis of the distal phalanxdistal phalanx..

Since the blood supply of the Since the blood supply of the diaphysis of the phalanx passes diaphysis of the phalanx passes through the pulp space (in through the pulp space (in children), the infection would children), the infection would result in result in necrosis of the necrosis of the diaphysis.diaphysis. Its epiphysis is Its epiphysis is supplied by a separate artery, so supplied by a separate artery, so this usually survives the this usually survives the infection. infection. The synovial sheaths of the The synovial sheaths of the affected fingers can be involved affected fingers can be involved because of their close because of their close relationships to the proximal part relationships to the proximal part of the pulp space.of the pulp space.


VenipuncturVenipunctureeThe The superficial veinssuperficial veins of the upper limb of the upper limb are used for venipuncture, transfusion are used for venipuncture, transfusion and cardiac cathetrization.and cardiac cathetrization.When a patient is in shock, the When a patient is in shock, the superficial veins are not always visible. It superficial veins are not always visible. It is very important to know their course is very important to know their course and the relations to important landmarks. and the relations to important landmarks. The cephalic vein:The cephalic vein: At the wristAt the wrist, it passes , it passes posterior to the posterior to the

styloid process of the radius. styloid process of the radius. In the In the cubital fossa it is separated it is separated

from the brachial artery by the from the brachial artery by the bicipital aponeurosisbicipital aponeurosis which protects which protects the artery from irritating drugs.the artery from irritating drugs.

In the In the deltopectoral groovedeltopectoral groove, it , it communicates with the external communicates with the external jugular vein by a small vein that jugular vein by a small vein that passes in front of the clavicle. passes in front of the clavicle. Fracture of the clavicle can tear this Fracture of the clavicle can tear this communicating vein and causes a communicating vein and causes a large hematoma.large hematoma. Muhammmad Ramzan Ul Rehman Muhammmad Ramzan Ul Rehman

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clinical anatomy of the upper limb

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