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BLUE CLINICAL BOXES
Compression of axillary a
Aneurysm of axillary a
Injuries to axillary v
Enlargement of axillary
lymph nodes
Description
-compression of the third part of this artery against the humerus may be necessary when profuse bleeding occurs
-if needing compression at a more proximal site, can be compressed at its origin (as the subclavian a crosses the 1st
rib) by exerting downward pressure in the angle btwn clavicle & inferior attachment of the SCM muscle
-first part may enlarge & compress trunks of brachial plexus, causing pain & anesthesia in areas of the skin supplied by
affected nerves
-may occur in baseball pitches & football QBs b/c of their rapid & forceful arm movements
-wound in proximal part is particularly dangerous d/t profuse bleeding & risk of air entering it & producing air emboli
in the blood
-humeral group of nodes usually 1st involved
-lymphangitis: characterized by development of warm, red, tender streaks in skin of limb
-infections in the pectoral region & breast can also cause enlargement
-in metastatic cancer of apical group, nodes often adhere to vein which may necessitate excision of part of the vessel
-may obstruct cephalic vein superior to pectoralis minor
Dissection of axillary lymph -2 nerves are at risk during dissection: long thoracic & thoracodorsal nerves
nodes
-if nodes are obviously malignant, nerves will have to be sacrificed to increase chance of complete resection of
malignant cells
Variations of brachial
-variations are common
plexus
-small contributions may be made by the anterior rami of C4 or T2
-when superior most root of the plexus is C4 & inferior most root is C8, called prefixed brachial plexus
-postfixed brachial plexus when superior root is C6 & inferior root T2
*inferior trunk may be compressed by 1st rib  causing neuro sx of UE
-variations can occur in formation of trunks, divisions, & cords; origin and/or combination of branches; & in
relationship to axillary a & scalene muscles
Brachial plexus injuries
-trunk divisions or cord formations may be absent in one or other parts of the plexus; however, the makeup of the
terminal branches is unchanged
-injuries affect movements & cutaneous sensations in the UE
-disease, stretching, & wounds in lateral cervical region of the neck may produce injuries
-injuries to superior parts:
*usually from excessive increase in angle btwn shoulder & neck
*stretches or ruptures superior parts of the brachial plexus or avulses (tears) roots from spinal cord
*injuries apparent by characteristic position of the limb, in which limb hangs by side n medial roation
*can also occur in neonate when excessive stretching of neck occurs during delivery
*paralysis of muscles of shoulder & arm supplied by C5 & C6: deltoid, biceps, & brachialis
*clinical appearance-adducted shoulder, medially rotated arm, & extended elbow. Lateral aspect of forearm loss of
sensation
*may produce muscle spasms & severe disability in hikers who carry a backpack for a long period of time- motor &
sensory deficits in the distribution of musculocutaneous & radial nervers
-acute brachial plexus neuritis: disorder of unknown cause characterized by sudden onset of pain (usually around
shoulder)
*night pain  muscle weakness  muscular atrophy
*inflammation of plexus
*usually from superior trunk of brachial plexus
-compression of cords:
*may result from hyperabduction of arm
*impinged or compressed btwn coracoid process of scapula & pectoralis minor tendon
*neurological sxs & weakness of hands
*compression of axillary a & v causes ischemia of UE & distension of superficial veins
*hyperabduction syndrome may result from compression of axillary vessels & nerves
-injuries to inferior parts:
*LESS COMMON
*may occur when UE is suddenly pulled superiorly
Brachial plexus block
*C8 & T1
*may avulse roots of spinal nerves from spinal cord
*short muscles of hand are affected & claw hand results
-injection of an anesthetic solution into or immediately surrounding the sheath interrupts conduction of impulses of
PN and produces anesthesia of structures supplied by branches of cords of plexus
-sensation blocked in all deep structures of the UE & skin distal to middle of the arm
Bicipital myotatic reflex
-can be anesthetized using a number of approaches including interscalene, supraclavicular, & axillary approach or
block
-biceps reflex routinely tested
-positive response confirms integrity of the musculocutaneous nerve & the C5 and C6 spinal cord segments
Biceps tendinitis
-excessive, diminished, or prolonged (hung) responses may indicate central or peripheral NS disease or metabolic
disorders (e.g., thyroid disease)
-wear & tear of movement w/in synovial sheath causes shoulder pain
-inflammation of tendon (usually result of repetitive microtrauma, is common in sports involving throwing
Dislocation of tendon of
long head of biceps brachii
-tight, narrow, and/or rough intertubercular sulcus may irritate & inflame tendon, producing tenderness & crepitus
(crackling sound)
-tendon of long head can be partially or completely dislocated
-injury may occur in young persons during traumatic separation of proximal epiphysis of humerus
Rupture of tendon of long
head of biceps brachii
-injury also occurs in older persons w/a hx of biceps tendinitis
*usually sensation of popping or catching is felt during arm rotation
-usually results from wear & tear of an inflamed tendon as it moves back & forth in intertubercular sulcus of humerus
-usually in individuals >35yo
-typically tendon torn from attachment to supraglenoid tubercle of scapula
*commonly dramatic & assoc. w/snap or pop
-detached muscle belly forms ball near center of distal part of anterior aspect of arm
-rupture may result from forceful flexion of arm against excessive resistance
*more often result of prolonged tendinitis that weakens it
Interruption of blood flow
to brachial artery
-repetitive overhead motions that tear the weakened tendon in the intertubercular sulcus
-best place to compress brachial artery is medial to humerus near middle of arm
-may be clamped distal to origin of deep a. of arm w/o producing tissue damage
-occlusion or laceration creates a surgical emergency b/c paralysis of muscles results from ischemia of elbow &
forearm w/in a few hours
*can tolerate up to 6 hrs
*after this, fibrous scar tissue replaces necrotic tissue & causes involved muscles to shorten permanently, producing
a flexion deformity, the ischemic compartment syndrome
Fracture of humeral shaft
-flexion of fingers & sometimes wrist results in loss of hand power as a result of irreversible necrosis of forearm flexor
muscles
-midhumeral fracture may injure radial nerve in radial groove in humeral shaft
*fracture is not likely to paralyze triceps b/c of high origin of nerves to two of its 3 heads
-distal fracture is called supra-epicondylar fracture
*distal bone fragment may be displaced anteriorly or posteriorly
*actions of brachialis & triceps pull distal fragment over proximal fragment, shortening limb
Injury to
musculocutaneous nerve
Injury to radial nerve in
arm
-any nerves or branches of brachial vessels related to humerus may be injured by displaced bone fragment
-injury of nerve in axilla usually inflicted by a weapon such as a knife
*results in paralysis of coracobrachialis, biceps, & brachialis
*weak flexion at shoulder joint
*weakened flexion of elbow joint & supination of forearm, not completely lost (supplied by radial nerve)
-loss of sensation to lateral surface of forearm supplied by lateral antebrachial cutaneous nerve (continuation of
musculocutaneous nerve)
-injury superiorly to origin of its branches to triceps brachii results in paralysis of triceps, brachioradialis, supinator, &
extensor muscles of wrist & fingers
-loss of sensation in areas supplied by this nerve also occurs
-when injured in radial groove, triceps not completely paralyzed but only weakened b/c only medial head affected
*muscles in posterior compartment of forearm that are supplied by distal braches of the nerve are paralyzed
Venipuncture in cubital
fossa
-clinical sign: wrist-drop (inability to extend wrist & fingers at the metacarpophalangeal joints)
*relaxed wrist assumes partly flexed position (d/t unopposed tonus of flexor muscles & gravity)
-common site for sampling & transfusion of blood & IV injections
-median cubital vein usually selected
*runs diagonally from cephalic vein of forearm to basilic vein of arm
*crosses bicipital aponeurosis
*also site for introduction of cardiac catheters to secure blood samples from great vessels & chambers of heart
*also used for coronary angiography
Variation of veins in cubital -in about 20% of people, median antebrachial vein divides into a median basilic vein which joins the basilic vein of the
fossa
arm & a median cephalic vein that oins the cephalic vein of the arm
*in this case, a clear M formation is produced by cubital veins
*these are good for drawing blood but not for injecting an irritating drug b/c of the danger of injecting it into the
brachial artery
Elbow tendinitis or lateral
epicondylitis
-in obese people, considerable amount of fatty tissue may overlie the vein
-from repetitive use of superficial extensor muscles of forearm
-pain felt over lateral epicondyle- radiates down posterior surface of forearm
Mallet or baseball finger
-repeated forceful flexion & extension of wrist strain the attachment of common extensor tendon, producing
inflammation of the periosteum of lateral epicondyle
-sudden severe tension on a long extensor tendon may avulse part of its attachment to phalanx
-deformity results from distal interphalangeal joint suddenly being forced into extreme flexion
Fracture of olecranon
-person cannot extend DIP joint
*deformity bears some resemblance to a mallet
-“fractured elbow”- COMMON b/c olecranon is subcutaneous & protrusive
-injury is a fall on elbow combined w/sudden powerful contraction of triceps brachii
-fractured olecranon is pulled away by active & tonic contraction of triceps is usually required
Synovial cyst of wrist
-healing occurs slowly and often a cast must be worn for an extended period of time
-non-tender cystic swelling appears on hand
*most commonly on dorsum of wrist
*distal attachment of ECRB tendon to base of 3rd metacarpal another common site
-usually size of small grape but can be as large as a plum
-contains clear mucinous fluid; cause of cyst unknown
-flexion of wrist makes cyst enlarge & painful (clinically called “ganglion”)
-close to & often communicate w/synovial sheaths on dorsum of wrist
High division of brachial a
Superficial ulnar a
-common flexor synovial sheath on anterior aspect of wrist can enlarge enough to produce compression of median
nerve by narrowing carpal tunnel
-sometimes brachial a divides at a more proximal level than usual
-ulnar & radial a begin in superior or middle part of the arm & median nerve passes btwn them
-about 3% of people, ulnar a descends superficial to flexor muscles
-pulsations of a superficial ulnar a can be felt & may be visible
Variations in origin of
radial n
Median nerve injury
**if aberrant ulnar a is mistaken for a vein, may be damaged & produce bleeding
-depending on drug, could be fatal
-origin may be more proximal than usual: it may be a branch of axillary a or the brachial a
-sometimes superficial to deep fascia instead of deep to it
*when superficial vessel is pulsating near wrist, probably superficial radial a
*aberrant vessel is vulnerable to laceration
-When the median nerve is severed in the elbow region, flexion of the proximal interphalangeal joints of the 1st–3rd
digits is lost and flexion of the 4th and 5th digits is weakened
*Flexion of the distal interphalangeal joints of the 2nd and 3rd digits is also lost
*Flexion of the distal interphalangeal joints of the 4th and 5th digits is not affected because the medial part of the
FDP, which produces these movements, is supplied by the ulnar nerve
*ability to flex the metacarpophalangeal joints of the 2nd and 3rd digits is affected b/c digital branches of the median
nerve supply the 1st and 2nd lumbricals
-when the person attempts to make a fist, the 2nd and 3rd fingers remain partially extended (“hand of benediction”)
-Thenar muscle function (function of the muscles at the base of the thumb) is also lost, as in carpal tunnel syndrome
-When the anterior interosseous nerve is injured, the thenar muscles are unaffected, but paresis (partial paralysis) of
the flexor digitorum profundus and flexor pollicis longus occurs.
Pronator syndrome
-When the person attempts to make the “okay” sign, opposing the tip of the thumb and index finger in a circle, a
“pinch” posture of the hand results instead owing to the absence of flexion of the interphalangeal joint of the thumb
and distal interphalangeal joint of the index finger (anterior interosseous syndrome)
-nerve entrapment syndrome: caused by compression of median nerve near elbow
-compressed btwn heads of pronator teres as result of trauma, muscular hypertrophy, or fibrous bands
Communications btwn
median & ulnar nerves
Injury of ulnar nerve at
elbow & in forearm
Cubital tunnel syndrome
Injury of radial nerve in
forearm (superficial or
deep branches)
-clinically- 1st seen with pain & tenderness proximal aspect of anterior forearm & hypesthesia of palmar aspects of
radial 3 & half digits & adj palm
*symptoms often follow activities that involve repeated pronation
-occasionally communications can occur
*branches usually represented by slender nerves but communications are important clinically b/c even w/a complete
lesion of median nerve, some muscles may not be paralyzed
*may lead to an erroneous conclusion that median nerve has not been damaged
-ulnar nerve may be compressed in cubital tunnel formed by tendinous arch joining humeral & ulnar head of
attachment of FCU
-signs & sx same as ulnar nerve lesion in ulnar groove on posterior aspect of the medial epicondyle of humerus
-More than 27% of nerve lesions of the upper limb affect the ulnar nerve
-Ulnar nerve injuries usually occur in four places: (1) posterior to the medial epicondyle of the humerus, (2) in the
cubital tunnel formed by the tendinous arch connecting the humeral and ulnar heads of the FCU, (3) at the wrist, and
(4) in the hand. Ulnar nerve injury occurs most commonly where the nerve passes posterior to the medial epicondyle
of the humerus
-injury results when the medial part of the elbow hits a hard surface, fracturing the medial epicondyle (“funny bone”)
*Any lesion superior to the medial epicondyle will produce paresthesia of the median part of the dorsum of the hand
*Compression of the ulnar nerve at the elbow (cubital tunnel syndrome) is also common
-produces numbness and tingling (paresthesia) of the medial part of the palm and the medial one and a half fingers
*Pluck your ulnar nerve at the posterior aspect of your elbow with your index finger and you may feel tingling in
these fingers
-Severe compression may also produce elbow pain that radiates distally.
-Uncommonly, nerve is compressed as it passes through the ulnar canal
-Ulnar nerve injury can result in extensive motor and sensory loss to the hand
*injury to the nerve in the distal part of the forearm denervates most intrinsic hand muscles
*power of wrist adduction is impaired & when an attempt is made to flex the wrist joint, the hand is drawn to the
lateral side by the FCR (supplied by the median nerve) in the absence of the “balance” provided by the FCU
*After ulnar nerve injury, the person has difficulty making a fist b/c in absence of opposition, the
metacarpophalangeal joints become hyperextended, & he or she cannot flex the 4th and 5th digits at the distal
interphalangeal joints when trying to make a fist
*person cannot extend the interphalangeal joints when trying to straighten the fingers
Dupuytren contracture of
palmar fascia
-characteristic appearance of the hand, resulting from a distal lesion of the ulnar nerve, is known as claw hand (main
en griffe)
*deformity results from atrophy of the interosseous muscles of the hand supplied by the ulnar nerve
*claw is produced by the unopposed action of the extensors and FDP
-disease of the palmar fascia resulting in progressive shortening, thickening, & fibrosis of the palmar fascia &
aponeurosis
*fibrous degeneration of the longitudinal bands of the palmar aponeurosis on the medial side of the hand pulls the
4th and 5th fingers into partial flexion at the metacarpophalangeal and proximal interphalangeal joints
-contracture is frequently bilateral and is seen in some men > 50 years of age
*cause is unknown, but evidence points to a hereditary predisposition
-disease first manifests as painless nodular thickenings of the palmar aponeurosis that adhere to the skin
*Gradually, progressive contracture of the longitudinal bands produces raised ridges in the palmar skin that extend
from the proximal part of the hand to the base of the 4th and 5th fingers
Hand infections
-Treatment usually involves surgical excision of all fibrotic parts of the palmar fascia to free the fingers
-b/c palmar fascia is thick and strong, swellings resulting from hand infections usually appear on the dorsum of the
hand, where the fascia is thinner.
-potential fascial spaces of the palm are important because they may become infected
*fascial spaces determine the extent & direction of the spread of pus formed by these infections
*depending on the site of infection, pus will accumulate in the thenar, hypothenar, midpalmar, or adductor
compartments
Tenosynovitis
-antibiotic therapy has made infections that spread beyond one of these fascial compartments rare; however, an
untreated infection can spread proximally from the midpalmar space through the carpal tunnel into the forearm,
anterior to the pronator quadratus and its fascia
-injuries such as a puncture of a finger by a rusty nail can cause infection of the digital synovial sheaths
-When inflammation of the tendon & synovial sheath occurs (tenosynovitis), the digit swells & movement becomes
painful
*b/c the tendons of the 2nd, 3rd, & 4th fingers nearly always have separate synovial sheaths, the infection is usually
confined to the infected finger
*If infection is untreated the proximal ends of these sheaths may rupture, allowing the infection to spread to the
midpalmar space
*b/c the synovial sheath of the little finger is usually continuous with the common flexor sheath, tenosynovitis in this
finger may spread to the common flexor sheath & thus through the palm & carpal tunnel to the anterior forearm,
draining into the space between the pronator quadratus and the overlying flexor tendons (Parona space).
*tenosynovitis in the thumb may spread via the continuous synovial sheath of the FPL (radial bursa).
-how far an infection spreads from the fingers depends on variations in their connections with the common flexor
sheath
*The tendons of the APL & EPB are in the same tendinous sheath on the dorsum of the wrist
*excessive friction of these tendons on their common sheath results in fibrous thickening of the sheath and stenosis
of the osseofibrous tunnel
*excessive friction is caused by repetitive forceful use of the hands during gripping and wringing (e.g., squeezing
water out of clothes).
*called Quervain tenovaginitis stenosans- causes pain in the wrist that radiates proximally to the forearm & distally
toward the thumb
*Local tenderness is felt over the common flexor sheath on the lateral side of the wrist
Laceration of palmar
arches
Ischemia of digits
-thickening of a fibrous digital sheath on the palmar aspect of the digit produces stenosis of the osseofibrous tunnel,
the result of repetitive forceful use of the fingers
*If tendons of the FDS & FDP enlarge proximal to the tunnel, person is unable to extend the finger
*When finger is extended passively, a snap is audible
*flexion produces another snap as the thickened tendon moves
*called digital tenovaginitis stenosans (trigger finger or snapping finger).
-Bleeding is usually profuse
*may not be sufficient to ligate only one forearm artery when the arches are lacerated, b/c these vessels usually have
numerous communications in the forearm and hand & thus bleed from both ends
-To obtain a bloodless surgical operating field for treating complicated hand injuries, it may be necessary to compress
the brachial artery & its branches proximal to the elbow (e.g., using a pneumatic tourniquet)
*prevents blood from reaching the ulnar & radial arteries through anastomoses around the elbow
-Intermittent bilateral attacks of ischemia of the digits, marked by cyanosis, paresthesia & pain characteristically
brought on by cold & emotional stimuli
-condition may result from an anatomical abnormality or an underlying disease.
-when the cause of the condition is idiopathic (unknown) or primary- called Raynaud syndrome
Lesions of median nerve
-arteries of the UE are innervated by sympathetic nerves
*Postsynaptic fibers from the sympathetic ganglia enter nerves that form the brachial plexus & distributed to the
digital arteries through branches arising from the plexus
*treating ischemia resulting from Raynaud syndrome- may be necessary to perform a cervico Dorsal presynaptic
sympathectomy (excision of a segment of a sympathetic nerve) to dilate the digital arteries
Carpal tunnel syndrome
-results from any lesion that significantly reduces size of the carpal tunnel or, more
commonly, increases the size of some of the nine structures or their coverings that pass
through it (e.g., inflammation of synovial sheaths)
-Fluid retention, infection, & excessive exercise of the fingers may cause swelling of the
tendons or their synovial sheaths
-median nerve is the most sensitive structure in the tunnel
*median nerve has two terminal sensory branches that supply the skin of the hand;
hence paresthesia (tingling), hypoesthesia (diminished sensation), or anesthesia
(absence of sensation) may occur in the lateral three & a half digits
*palmar cutaneous branch of the median nerve arises proximal to, & does not pass
through tunnel; thus sensation in the central palm remains unaffected
*nerve also has one terminal motor branch, the recurrent branch, which serves the
three thenar muscles
-progressive loss of coordination & strength of the thumb (owing to weakness of the
APB and opponens pollicis) may occur if the cause of compression is not alleviated
-unable to oppose their thumbs & have difficulty buttoning a shirt or blouse as well as
gripping things such as a comb
Trauma to median nerve
-as progresses, sensory changes radiate into the forearm & axilla
*Sx can be reproduced by compression of the median nerve with your finger at the
wrist for approximately 30 seconds
*to relieve both the compression & resulting sx partial or complete surgical division of
the flexor retinaculum, a procedure called carpal tunnel release, may be necessary
*incision for carpal tunnel release is made toward the medial side of the wrist & flexor
retinaculum to avoid possible injury to the recurrent branch of the median nerve
-Laceration of the wrist often causes median nerve injury b/c nerve relatively close to
surface
*In attempted suicides by wrist slashing, median nerve is commonly injured just
proximal to the flexor retinaculum
*results in paralysis of the thenar muscles and the first two lumbricals
*opposition of the thumb is not possible & fine control movements of the 2nd & 3rd
digits are impaired
*Sensation is also lost over the thumb & adj two & a half fingers
-most nerve injuries in UE affect opposition of the thumb
*injuries to nerves supplying intrinsic muscles of the hand, especially median nerve,
have the most severe effects on this complex movement
*If median nerve is severed in forearm or at the wrist thumb cannot be opposed; the
APL & adductor pollicis (supplied by the posterior interosseous and ulnar nerves,
respectively) may imitate opposition, although ineffective.
-median nerve injury resulting from a perforating wound in the elbow region results in
loss of flexion of the proximal & distal interphalangeal joints of the 2nd & 3rd digits
*ability to flex the metacarpophalangeal joints of these fingers is also affected b/c
digital branches of the median nerve supply the 1st & 2nd lumbricals
*Simian hand refers to a deformity in which thumb movements are limited to flexion
and extension of the thumb in the plane of the palm
*caused by the inability to oppose and by limited abduction of the thumb
Ulnar canal syndrome
Handlebar neuropathy
Radial nerve injury in arm
& hand disability
Dermatoglyphics
-recurrent branch of the median nerve to the thenar muscles lies subcutaneously & may
be severed by relatively minor lacerations of the thenar eminence.
*severance of nerve paralyzes thenar muscles & thumb loses much of its usefulness
-compression may occur at the wrist where it passes between the pisiform & the hook of hamate
*depression between these bones is converted by the pisohamate ligament into an osseofibrous tunnel, the ulnar
canal (Guyon tunnel)
-Ulnar canal syndrome (Guyon tunnel syndrome) is manifest by hypoesthesia in the medial one & a half fingers, &
weakness of the intrinsic muscles of the hand
*“Clawing” of the 4th and 5th fingers may occur, but—in contradistinction to proximal ulnar nerve injury—their
ability to flex is unaffected, and there is no radial deviation of the hand
-People who ride long distances on bicycles with their hands in an extended position against the hand grips put
pressure on the hooks of their hamates
*compression, which has been called handlebar neuropathy, results in sensory loss on the medial side of the hand, &
weakness of the intrinsic hand muscle
-injury in the arm can produce serious hand disability
*characteristic handicap is inability to extend the wrist resulting from paralysis of extensor muscles of the forearm,
all of which are innervated by the radial nerve
*hand is flexed at the wrist & lies flaccid (wristdrop)- fingers of relaxed hand also remain in the flexed position at the
metacarpophalangeal joints.
*interphalangeal joints can be extended weakly through the action of the intact lumbricals and interossei, which are
supplied by the median and ulnar nerves
-radial nerve has only a small area of exclusive cutaneous supply on the hand
*extent of anesthesia is minimal, even in serious radial nerve injuries, & usually confined to a small area on the
lateral part of the dorsum of the hand
-science of studying ridge patterns of the palm: valuable extension of the conventional PE of people w/certain
congenital anomalies & genetic diseases
-For example, people with trisomy 21 (Down syndrome) have dermatoglyphics that are highly characteristic
Palmar wounds & surgical
incisions
*often have a single transverse palmar crease (Simian crease); however, approximately 1% of the general population
has this crease with no other clinical features of the syndrome
-location of superficial & deep palmar arches should be kept in mind when examining wounds of the palm & when
making palmar incisions
**important to know that the superficial palmar arch is at the same level as the distal end of the common flexor
sheath
-incisions or wounds along the medial surface of the thenar eminence may injure the recurrent branch of the median
nerve to the thenar muscles