Download - 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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