Review of the Upper Limb-II.Joints, muscles and their functions.

Frequent injuries and their consequences.

Dr. Magdolna KovácsDept. of AnatomyMay 2006.

Wrist drop (deep branch is damaged)

Radial nerve injuryExtensors of the elbow and/or wrist are paralysed

Elbow in felexion and wrist drop(the main nerve is dameged on the arm)

Clow handExtension at the metacarpo- phalangeal,Flexion at the interphalangeal joints due to

Interosseus and lumbrical paralysis

Insensitivity of the ulnar side of the palm(one and a half fingers)

Ulnar nerve injury(All interosseus & ulnar lumbricals)

Wasting of the thenar musclesNo opposition of thumb

Monkey hand

Median nerve injury in the carpal region

Carpal Tunnel Syndrome is the #1 Repetitive Motion Injury

It is a condition where the median nerve being pressed at the wrist, causingpain in the wrist and numbness in the thumb and the first 2 and ½ fingers.

Carpal Tunnel Syndrome

When the opponens pollicis muscle contracts it pulls the thumbtowards the palm. This movement causes the flexor retinaculumto press down onto the median nerve. If either the thumb muscle, or the flexor muscles, are tight, this movement will cause your thumb and fingers to go numb.

Causes: 1./ Anatomical cause + 2./ Repetitive hand motion

1./ Nine flexor tendons pass through the small carpal tunnel, along with themedian nerve.

2./ Repetitive wrist or hand motions, cancause swelling in the carpal tunnel.

working at a computer terminal,playing a musical instrument, sports, knitting

Mechanism:When the flexor muscles, or the thumb muscles, are in spasm they put excessive pressure, or pull, on the carpal tunnel and put pressure on the median nerve.

Any pressure exerted onto this area will squeezethe median nerve causing pain, and numbness to the hand and wrist.

Symptoms of the Carpal Tunnel Syndrome

Splints are used to keep the wrist and hand in neutral position

Anti-inflammatory medications are commonly used to reduce inflammation and decrease pain.

Conservative Treatment

SURGERY1. Endoscopic surgery or2. Open tunnel surgery

Open tunnel surgery:Here, the transverse ligament is split openwhich relieves pressure on the median nerve from an overcrowded carpal tunnel.

Both surgeries are performed to relieve pressure on the median nerve in the carpal tunnel. Endo is a refinement of the Open Tunnel technique. Since Endo is not as invasive[smaller incision] as Open Tunnel is, then recovery time is shorter for Endo (2-4 weeks for Endo) than for Open Tunnel (4-6 weeks or more).

A small scalpel is inserted under the skin through the carpal tunnel to cut the roof of the tunnel [transverse ligament] from the inside out.

Endoscopic surgery

Elective hand surgery has a very low risk of infection.

However, when infections do occur following surgery in the moving parts of the hand, the problem can be catastrophic, because the slippery synovial tissues which cover the inner moving surfacesboth allow infection to grow and allow it to spread easily to other parts of the hand.

Complication: Deep infection following open carpal tunnel release

She was treated with repeated radical debridement and intravenous antibiotics.Her infection was cured, but she was left with stiffness of the small finger.

Handlebar palsy(overuse injury)

Ulnar nerve neuropathy, known to cyclists, is caused by compression of the ulnar nerve.

The pressure placed on the ulnar nerve results in numbness and tingling in the ring and little fingers or hand weakness

It can be accompanied by carpal tunnel syndrome (holding the handlebar in top position)

grips

In Dupuytren's contracture, scar-like tissuein the palm pulls fingers into an abnormal position. The surgeon may make zig-zag

incisions across this band of tissue, creating small skin flaps.

Dupuytren's contracture

After surgery of removing the scar tissuethe repositioned flaps expand like an accordion,allowing freer finger motion

Anesthesia before surgery on fingers(Oberst ‘s anesthesia)

Needle is inserted at a point on the dorsolateral aspect of the base of the finger, both sides of the finger

The transthecal digital block is placed by using the flexor tendon sheath for local anesthetic infusion.

Transthecal digital block

Anesthesia to the entire digit with a single injectionFor more extensive operation on the finger.

Axillary arteryand anastomoses

Anastomosis betweenAxillary and Subclavian artery By

Suprascapular and Cicumflex scapular arteries

Quadrangular space (hiatus)Axillary n., Post. circumflex humeral a.

Triangular spaceCircumflex scapular a.

Axillary hiatus

Radial collateral

Middle

Collateral circulation of elbow

ulnar n.ulnar n.

radial n.radial n.

Collateral ulnar sup. a.& ulnar n.

Deep brachial a.& radial n.

Pulse arteries on the upper limb

Radial a.

Brachial a. (in cubital fossa, medial to biceps tendon)

Ulnar a.Radial a.

Superficial palmar archDeep palmar arch

Princeps pollicis a.Common digitalpalmar aa.

Proper digital palmar aa.

Palmar metacarpal aa.

Dorsal and volar metacarpal arteries communicate with commom digital palmar arteries at the root of the fingers

Dorsal carpalbranch

Dorsalmetacarpal aa.

Proper digital palmar a.

Dorsal digital a.

Blood supply of the hand

Anatomical snuff-box(Foveola radialis)(Fossa tabatieri)