CLINICALLY ORIENTED ANATOMY BLUE BOXES 14 INTEGUMENTARY SYSTEM Cyanotic not enough blood flow with oxygen to the

he skin. Bluish hue Erythema looks abnormally red. Caused by injury, exposure to head, infection, inflammation, or allergic reaction Jaundice yellow due to bilirubin from the liver Scarring due to keloids during healing Stretch marks growth too quickly causing the collagen fibers to stretch Burn Classifications 1. 1st degree superficially limited to epidermis. Symptoms: erythema, pain, edema, and desquamation (peeling) 2. 2nd degree partial thickness burn of epidermis and dermis. Blistering or loss of skin and nerve ending damage. Will heal win weeks/months with scarring 3. 3rd degree full thickness burn through (an may include) muscle. Edema and numbness because sensory nerves are destroyed. Require grafts. Eschar (dead material) is removed and grafted over with harvested skin from a non-burned (auto graft) location. Major burn includes 3rd degree burn over 10% of body or anywhere on the hands, feet, or perineum. 2nd degree of 25% surface area. When burn covers 70% of the body rate of mortality increases 50% Rule of nines: Head 9% Upper limbs together 18% Trunk total 36% Both lower limbs 36% Perineum 1% 23 BONES Accessory bones forms when additional ossification occurs and forms apparent extra bones. It is actually part of the main bone but separated common in feet. Heterotropic bones form in soft tissues where bones usually arent present. Example horse riding causes strain, which causes hemorrhage that causes calcification of blood which leads to ossification. Atrophy occurs in unused bones (eg. Paralyzed limb) Hypertrophy can occur to support extra weight over a long time Reduction of fracture broken ends of bones come back to normal position Fibroblasts (CT) 0 proliferate and secrete collagen to form a collar of callus around a fracture. The callus then calcifies as it heals and is then reabsorbed. Greenstick fracture incomplete break Osteoporosis atrophy of bone tissue. Decrease quantity of bone. Can be seen with bone scanning Because the sternum is so close to the skin a sternal puncture can easily be made with a wide bore needle for a sample of red bone marrow Bone age determined by radiographs (negative images on x-ray films) Age can be discerned by: 1. Calcification in diaphysis/epiphyses 2. Disappearance of epiphyseal plate (which is a dark line on a film)

Thickened trabeculae indicate times of stopped growth. Without knowledge of the disappearance of the epiphyseal plate it can be mistaken for a fracture Avascular necrosis loss of blood flow to the bone Osteochondroses clinical disorders in children where necrosis occurs at the epiphyses. 28 JOINTS Clavaria skull cap Fontanelles in newborns where sutures are between cranial bones. The anterior fontanelle is the most prominent Osteoarthritis degenerative joint disease with stiffness, discomfort and pain Septicemia blood poisoning. Can occur after the infection of a joint. 35 SKELETAL MUSCLES Absence of muscle tone without tone small things may occur. For example the lips keep teeth from moving and without tone the teeth will move forward. Example an unconscious patient may dislocate a joint as they are being moved. Also, in paralysis, overall resting position of the body may be changed Muscle soreness caused by eccentric contraction (why walking downstairs hurts more than up because it is not caused by concentric contractions). Excessive lengthening happens to hamstrings often because they reach their maximum length before the hip is fully flexed Growth and Regeneration Satellite cells make new muscle fibers because they cannot divide. Represent a potential source of myoblasts precursor to muscle cells Hypertrophy lengthens and increases myofibrisl Electromyography electrical stimulation to test muscle action 37 CARDIAC AND SMOOTH MUSCLE Compensatory hypertrophy myocardium increases size of fibers to meet increased demands. . Same happens to smooth muscle. For example the uterine wall during pregnancy increases in size and number (hyperplasia). Myocardial infarct fibrous scar tissue of myocardial necrosis 42 CARDIOVASCULAR SYSTEM Arteriosclerosis: Ischemia and Infarction Arteriosclerosis hardening of the arteries, thickening, and loss of elasticity Atherosclerosis build up of fat (cholesterol) in the lumen Atheromatous plaque calcium deposit in inside wall of the arteries These can cause thrombosis (clotting) intravascularly or an embolus (occlusion of a vessel). Consequences of atherosclerosis include: ischemia (decreased blood supply to an organ) and infarction (local death from decreased delivery of oxygen from blood) Significant to the heart (MI), brain (stroke), and distal limbs (gangrene). Varicose veins Swollen twisted veins (often in legs). Have incomplete valves. Incompetent fascia degenerated so musculovenous pump is ineffective

45 LYMPHOID SYSTEM Spread of cancer Cancer invades by contiguity (growing into adjacent tissue) or metastasis (desemenation of tumor cells to other sites). Metastasis occurs: 1. Direct seeding of serious membranes of body cavities 2. Lymphogenous spread 3. Hematogenous spread Lymphogenous spread of cancer is most common for carcinomas (skin). They travel vial the lymph and move to lymph nodes, which become secondary cancer sides. Must understand lymph node drainage: 1. Know what nodes are likely to be affected when a tumor is in a certain location 2. Be able to determine likely primary site when enlarged node (cancerous) is detected Hematogenous spread is common for sarcomas (connective tissue) Metastasis occurs by venous routes. Lymphangitis and lymphaditis are secondary inflammations of the vessels and nodes respectively. May occur after injury or infection. Lymphedema lymph doesnt drain from an area of the body and causes swelling 53 DAMAGE TO THE CNS Injured axons to not recover in most circumstances. They try but are blocked by astrocyte proliferation at the injury site. As a result disability ensues Rhizotomy Posterior and anterior roots are the only sites where motor and sensory fibers are segregated. Only here can a surgeon selectively section either for relief of intractable pain or spastic paralysis (rhizotomy) Degeneration and Ischemia of Nerves If axons are damaged but the cell body is not, they may regenerate. Chance of survival is best when they have been compressed. Parasthesia asleep pins and needles. Least likely to regenerate if they have been severed Anterograde degeneration degeneration of axons detached from cell bodies Compression of vasa vervorum compromising a nerves blood supply Transient paresthesia used at the dentist for numbing. 104 BREASTS Changes in breasts During menstrual periods and pregnancy the lactiferous ducts branch Colostrum premilk fluid secreted within the last trimester of pregnancy and at the beginning of nursing. Rich in protein, immune agents, and a growth factor affecting the infants intestines. Breast quadrants

For the anatomical location and description of tumors/cysts, the surface is divided into four quadrants perpendicularly through the nipple with use of oclock to reference. Carcinoma of the breast Malignant tumors, usually adenocarcinomas (glandular cancer) arising from the epithelial cells of the lactiferous ducts in the mammary gland lobules. Interference with the lymphatic drainage by cancer may cause lymphedema, which in turn may result in deviation of the nipple and a thickened, leather-like appearance of the skin. Dimpled pores give it an orange-peel appearance (peau dorange). Larger dimples result from cancerous invasion of the glandular tissue and fibrosis (fibrous degeneration), which puts traction on the suspensory ligaments. Subareolar breast cancer may cause retraction of the nipple by a similar mechanism involving the lactiferous ducts Usually spreads via lymphogenic metastasis to the lymph nodes of the breast, supraclavicular lymph nodes, or the abdomen. Most common site are the axillary lymph nodes. The posterior intercostal veins drain into the azygosl hemi-azygos system of veins alongside the bodies of the vertebrae and communicate with the internal vertebral venous plexus surrounding the spinal cord. Cancer can also spread via these venous routes to the brain. May also spread via contiguity (invasion of adjacent tissue) into the retromammary space and into the pectoral fascia. Mammography Radiographic examination of the breasts will indicate a large jagged density in the mammogram Surgical incisions Made in the inferior breast quadrants when possible because they are less vascular. Simple mastectomy breast is removed down to the retromammary space Radical mastectomy extensive and involves removal of pectoral muscles, fat, fascia, and lymph nodes of the axilla and pectoral region. Polymastia, Polythelia, and Amastia Polymastia supernumerary breasts. Usually consist of only a rudimentary nipple and areola, which may be mistaken for a mole (nevus) until they change pigmentation with normal nipples during pregnancy. Sometimes glandular tissue may be present. Polythelia accessory nipples May occur superior or inferior to the normal pair, sometimes developing in the axillary fossa. Amastia no breast development Breast cancer in men 1.5% of breast cancer occurs to men. Usually not detected until extensive metastases have occurred. Gynecomastia Temporary enlargement of the breasts in a male at puberty is normal. But after puberty it is rare and called gynecomastia. May be age or drug related. May also

result from an imbalance between estrogenic and androgenic hormones or from a change in metabolism of sex hormones by the liver. Thus finding this should be regarded as a symptom. Approximately 40% of postpubertal males with Klinefelter syndrome (XXY trisomy) have this. 456 VERTEBRAE Vertebral Body Osteoporosis Common metabolic bone disease often detected during routine x-rays. Osteoporosis results from a net demineralization of the bones caused by a disruption of the normal balance of calcium deposition and resorption. Most affected areas are the neck of the femur, the vertebrae, and the hand. Dininishing of spongy (trabecular) bone of vertebral bodies. Later stages may reveal vertebral collapse (compression fractures) and increased thoracic kyphosis (curvature of the back) Laminectomy Surgical excision of one or more spinous processes. Also removal of the vertebral arch by transecting the pedicles. Performed to relieve pressure on the spinal or nerve roots caused by a tumor, herniated intervertebral disc, or bony hypertrophy. Dislocation of Cervical Vertebrae Due to the horizontally oriented articular facets, they are less tightly interlocked than other vertebrae. Can be dislocated with less force than required to cause a fracture. Fracture and Dislocation of Atlas The atlas is connected by relatively thin anterior and posterior arches and a transverse ligament. If a rupture of the transverse ligament occurs it is called a Jefferson or burst fracture. It does not necessarily result in spinal cord injury if the ligament isnt ruptured. Fracture and Dislocation of the Axis Fractures of the vertebral arch of the axis are one of the most common injuries of the cervical vertebrae. Usually the fracture occurs in the column formed by the superior and inferior articular processes of the axis (par interarticularis). A fracture in this location is called a traumatic spondylolysis usually occurs as a result of hyperextension of the head ON the neck. Used to happen via hanging and thus is called the hangmans fracture. If an anterior dislocation occurs it is likely to cause serious damage to the spinal cord resulting in quadriplegia. Lumbar spinal stenosis Describes a stenotic (narrow) vertebral foramen in one or more lumbar vertebrae. May cause compression of one or more spinal roots. Surgical treatment is a decompressive laminectomy. Can tell a spinal stenosis on MRI because the bulging is at the level of the bone and not the IV disc. Cervical ribs Anomaly. Extra rib supernumerary rib or a fibrous connection extending from its tip to the first thoracic rib may elevate and place pressure on structures that emerge from the superior thoracic aperture specifically the subclavian artery. May cause thoracic outlet syndrome. Caudal Epidural Anesthesia

The sacral hiatus is closed by the sacrococcygeal ligament, which is pierced by the filum terminale (CT extending from the tip of the spinal cord to the coccyx). Deep to the ligament lies fatty CT. In caudal analgesia anesthetic is injected into this. Sensation is lost inferior to the epidural block. Used during childbirth. Injury of the coccyx Can occur via trauma. Sometimes surgical removal of the fractured bone may be required to relieve pain. Sometimes after trauma coccygodynia is a syndrome that occurs without pain relief treatment. Abnormal fusion of vertebrae In 5% of people the L5 is partly or completely incorporated into the sacrum hemisacralization. In others, S1 is separated from the sacrum and fused with L5 lumbarization of the S1 vertebra. Effect of Aging on Vertebrae During older age, there is an overall decrease in bone density and strength. Particularly in the vertebral body. Consequently, the articular surfaces bow inward so the vertebrae become concave and the IV discs become convex. As a result, osteophytes (bony spurs) develop around the margins of the vertebral body. Anomalies of Vertebrae Spina bifida occulta neural arches of L5 and/or S1 fail to develop normally and fuse posterior to the vertebral canal. Spina bifida cystica vertebral arches may fail to develop completely. Associated with herniation of the meninges and/or the spinal cord. Neurological symptoms are usually present in severe cases of meningomyelocele (paralysis of limbs or bowel control). Severe forms result from neural tube defects, such as defective closure of the neural tube during early embryonic development. 474 VERTEBRAL COLUMN Aging of Intervertebral Discs The nuclei of the discs dehydrate and lose elastin with age. The discs become stiffer and the nuclei almost seem to disappear. Margins of adjacent vertebral bodies may approach more closely. However, it has been shown that the IV discs increase in size with age. Herniation (protrusion) of nucleus pulposus Well recognized cause of lower back and limb pain. In young persons the discs are usually so strong that the vertebrae will typically fracture before the disc will rupture. However, with violent hyperflexion is possible to rupture an IV disc. Flexion of the column produces compression anteriorly and tension posteriorly. This will push the nucleus posteriorly to the thinnest part of the annulus fibrosis. If this has degenerated, the nucleus may herniated into the canal and compress the spinal cord. ACUTE pain for a herniated disc results from pressure on the longitudinal ligaments and periphery of the annulus fibrosus. Referred pain occurs from compression of the spinal nerve due to the herniation resulting in chronic pain. Siatica pain in the lower back and hip radiating the back of the thigh into the leg is often caused by a herniated lumbar disc onto the sciatic nerve.

Discs may be damaged by violent rotation (eg. During a golf swing) or flexing of the vertebral column. Forcible hyperflexion of the cervical region may rupture the IV disc posteriorly without fracturing the vertebral body. In this case the nerve that is exiting at that level will be damaged rather than the one below it. Fracture of the Dens of Axis These make up 40% of fractures of the axis. Most common fractures occur at its base. Often wont reunite because the transverse ligament of the atlas becomes interposed between fragments. The dens will no longer have a blood supply (avascular necrosis). Rupture of Transverse Ligament of Atlas Atlantoaxial subluxation incomplete dislocation of the median atlanto-axial joint. Aka. C1 will slide anteriorly. Steeles Rule of thirds Approximately one third of the atlas ring is occupied by the ends, one third by the spinal cord, and the remaining third by the fluid filled space and tissues around the cord. Rupture of Alar Ligaments They are weaker than the transverse ligament of the atlas. Thus, it is easier to tear one or both of them. Results in increase range of movement to the contralateral side. Fractures and Dislocations of Vertebrae Sudden forceful flexion can cause a compression fracture car accident or blow to the back of the head Hyperextension injury of the neck head butting or illegal face blocking. Severe hyperextension of the neck whiplash. Occurs during a rear-end collision. Anterior longitudinal ligament may be stretched or torn. Can also cause cervical spondylolysis or hangmans fracture. Hyperflexion injury may occur as the head rebounds from a hyperextension. CV may lock because of dislocation of vertebral arches. Most commonly non cervical vertebrae to be fractured are the T11 and T12 Spondylolysis fracture of the column of bones connecting the superior and inferior articular processes (pars interarticularis). Spondylolisthesis dislocation between adjacent vertebrae. Injury and disease of Zygapophysial Joints (articular facets of vertebrae) When these are injured or develop osteophytes (osteoarthritis). This causes pain along the distribution patters of the dermatomes (subcutaneous area) and spasm in the muscles derived from the associated myotomes (all muscles or parts of muscles receiving innervation from one spinal nerve). Denervation of lumbar zygapophysial joints is a procedure used for treatment of back pain caused by disease of these joints. The nerves are either sections or destroyed by percutaneous rhizolysis. Back pain Second most common reason people visit their doctor (after the common cold). Five categories of structures receive innervation in the back and can be sources of pain 1. fibroskeletal structures periosteum, ligaments, and annuli fibrosi of IV discs 2. Meninges coverings of the spinal cord (rarely a factor)

3. Synovial joints capsules of the zygapophysial joints 4. Muscles intrinsic muscles of the back 5. Nervous tissue spinal nerves or nerve roots exiting the IV foramina First two are innervated by meningeal branches, next two are innervated by posterior rami. Localized lower back pain is generally muscular, joint, or fibroskeletal pain. Zygapophysial joint pain is generally associated with aging or disease. Abnormal curvatures of the vertebral column Excessive thoracic kyphosis known as humpback is characterized by an abnormal increase in the thoracic curvature. This can result from erosion (due to osteoporosis) of the anterior part of vertebrae. Dowagers Hump a colloquial name for excessive thoracic kyphosis in older women from osteoporosis. Excessive lumbar lordosis anterior tilting of the pelvis with increased extension of the lumbar vertebrae causing an abnormal increase in the lumbar kyphosis. This is an extension deformity associated with weakened trunk musculature. Can be caused by pregnancy or obesity. Scoliosis abnormal lateral curvature that is accompanied by rotation of the vertebrae. The ribs protrude on the ide of convexity. Can be caused by deformities such as only half of a vertebra to develop. Most are idiopathic. Can also be caused by asymmetrical weakness of the intrinsic back muscles (myopathic scoliosis) or a difference in length of the lower limbs with a compensatory pelvic tilt may lead to functional scoliosis. 683 BONES OF UPPER LIMB Variations of clavicle Varies in more in shape than most other long bones. Occasionally it is pierced by a branch of the supraclavicular nerve. Becomes thicker with manual work. Fracture of Clavicle Often caused in children by an indirect force transmitted from an outstretched hand through the bones of the forearm and arm to the shoulder during a fall. The weakest part is the junction of its middle and lateral thirds. The shoulder will drop because the trapezius cannot hold up the weight of the upper limb. Ossification of Clavicle It is the first long bone to ossify via intramembranous ossification. The ends later go through a cartilaginous phase, which is followed by a secondary ossification at the sternal end that fuses with the shaft when you are older. Fracture of Scapula Usually the result of severe trauma. Most fractures involve the protruding subcutaneous acromion. Fractures of the Humerus Most injuries are fractures of the surgical neck. Humeral fractures often result in one fragment being driven into the spongy bone of the other fragment (impacted fracture)

Avulsion fracture of the greater tubercle of the humerus is seen in older people where a small part of the tubercle is torn away. Usually results from a fall on the acromion. Transverse fracture of the shaft of the humerus results from a direct blow to the arm. Spiral fracture of the humeral shaft indirect injury resulting from a fall on the outstretched hand Intercondylar fracture of the humerus results from a severe fall on the flexed elbow. The olecranon of the ulna is driven like a wedge between the medial and lateral parts of the condyle. The following are in direct contact with indicated nerves 1. surgical neck axillary nerve 2. radial groove radial nerve 3. distal end of humerus median nerve 4. medial epicondyle ulnar nerve Fractures of Radius and Ulna Fracture of both is usually the result of severe injury. Direct injury usually produces transverse fractures at the same level usually in the middle third of the bones. Fracture of the distal end of the radius common in the elderly and more often in women. A complete transverse fracture of the distal end is called a Colles fracture and it is the most common fracture of the forearm. The distal fragment is displaced dorsally and is often comminuted (broken into pieces). FOUSH Often the ulnar styloid process is avulsed (broken off). Often referred to as a dinner fork deformity because a posterior angulation occurs in the forearm just proximal to the wrist. Fracture of Scaphoid Most frequently fractured carpal bone. Often results from a fall on the palm when the hand is abducted. Pain occurs primarily on the lateral side of the wriest (especially during dorsiflexion and abduction of the hand). Often this is MISDIAGNOSED as a severely sprained wrist. Will show later and may take at least 3 months to heal. Avascular necrosis of the proximal fragment of the scaphoid may occur and produce degenerative joint disease of the wrist. In some cases, it is necessary to fuse the carpals surgically via arthrodesis. Fracture of the hamate Because the ulnar nerve is so close, it may be injured by the fracture causing decreased grip strength. Artery may also be damaged. Fracture of metacarpals Fractures usually heal rapidly. Severe crushing injuries may produce multiple fractures resulting in instability. Boxers fracture fracture of the 5th metacarpal that occurs when you punch wrong. Flexion deformity Fracture of Phalanges Crushing injuries are common. Extremely painful. Fracture of a distal phalanx is usually comminuted and a painful hematoma (local collection of blood) soon develops. Bone fragments must be carefully realigned to restore normal function.

709 PECTORAL, SCAPULAR, AND DELTIOD REGIONS Absence of Pectoral Muscles Uncommon, however, no disability when it occurs. Axillary fold is missing. The nipple is more inferior than usual. Poland Syndrome when both pectoralis muscles are missing. Breast hypoplasia. Paralysis of Serratus Anterior Injury to the long thoracic nerve may cause paralysis of the serratus anterior. The medial border of the scapula moves laterally and posteriorly away from the thoracic wall, creating a winged scapula. Lack of abduction above the horizontal position because the muscle is unable to rotate the glenoid cavity superiorly. Triangle of Ausculatation Between the trapezius, latissimus dorsi, and the scapula. Good place to put a stethoscope. Injury of Spinal Accessory Nerve (Cranial Nerve 11) Innervates the trapezius. The clinical manifestation of this palsy is a marked ipsilateral weakness when shoulders are elevated. Injury of the Thoracodorsal Nerve Innervates the latissimus dorsi. Vulnerable during axillary surgery and during mastectomies. Unable to raise the trunk with the upper limbs (aka cant climb). Injury to Dorsal Scapular Nerve Innervates the rhomboids and wont allow retraction of scapula or depression of glenoid cavity. Will cause the scapula to list further from the midline. Injury to Axillary Nerve The deltoid will atrophy. Usually injured during a fracture near the surgical neck of the humerus or during dislocation. Additionally, a loss of sensation may occur over the lateral side of the proximal part of the arm the area supplied by the superior lateral cutaneous nerve of the arm (the cutaneous branch of the axillary nerve). Fracture-Dislocation of Proximal Humeral Epiphysis Direct injury of the shoulder may produce this fracture because the joint capsule of the glenohumeral joint is stronger than the epiphysial plate. Occurs in children before the plate disappears. Rotator cuff injuries Degenerative tendonitis of the rotator cuff is common in older people. Rotator cuff muscles are the Supraspinatus, Infraspinatus, Teres Minor, and the Subscapularis. 726 AXILLA Arterial Anastomoses (connection between structures) Around Scapula Collateral circulation circulation in an area with several different pathways for blood to reach it. Important when ligation (surgical procedure tying off part of the artery) of a lacerated subclavian or axillary artery is necessary. Vascular stenosis may result from an atherosclerotic lesion that causes reduced blood flow. In any case, the direction of blood flow in the subscapular artery is reversed enabling blood to reach the rest of the axillary artery. Typically slow occlusion of the axillary artery often enables sufficient collateral circulation to develop and prevent ischemia. Sudden occlusion does not allow adequate blood supply.

Surgical ligation of the axillary artery between origins of the subscapular artery and the profunda brachii artery will cut off the blood supply to the arm because collateral circulation is inadequate. Aka as long as its cut off above the subscapular artery, it should be alright. Compression of Axillary Artery Compression may be necessary when profuse bleeding occurs. If it is more proximal, compress its origin. Aneurysm of Axillary Artery An enlargement (aneurysm) may occur at the first part of the axillary artery and compress the trunks of the brachial plexus, causing pain and anesthesia (loss of sensation). May occur in pitchers and football quarterbacks because of their rapid and forceful arm movements Injury to Axillary Vein Wounds in the axilla often involve the vein because its so large and exposed. Dangerous to be wounded because of bleeding and it risks air entering it an producing air emboli. Role of Axillary Vein in Subclavian Vein Puncture Clinically significant that the vein lies anterior and inferior to the axillary artery. Based on location it is important for a catheter. Enlargement of Axillary Lymph Vessels Can be caused by an infection (called lymphangitis which is inflammation). The humeral group of nodes is usually the first to be involved. Characterized by the development of warm, red, tender streaks in the skin of the limb. In metastatic cancer of the apical group, the nodes often adhere to the axillary vein and obstruct the cephalic vein superior to the pectoralis minor. Dissection of Axillary Lymph Nodes Excision and pathologic analysis of the nodes are often necessary for staging and determining the appropriate treatment of cancer. Because the nodes are in a specific order in which they receive lymph, it is necessary to remove them in that order to determine how far the cancer has developed. Once removed, lymphedema may occur in the subcutaneous tissue. During the node dissection the long thoracic nerve and thoracodorsal nerve are at risk for injury. Variations of Brachial Plexus Variations are common. Sometimes contributions may be made by C4 or T2. Prefixed brachial plexus when the superior most root is C4 and the most inferior is C8. Postfixed brachial plexus superior most root is C6 and most inferior is T2. The inferior trunk of the plexus may be compressed by the first rib, producing neurovascular symptoms in the upper limb. The median nerve may have two medial roots instead of 1. This results from the fibers of the medial cord of the brachial plexus dividing into three branches instead of two. Regardless, the components of the nerve are the same. Brachial plexus injuries

Affect movements and sensation in the upper limb (paralysis and anesthesia). Complete paralysis no movement is detectable. Incomplete paralysis not all muscles are paralyzed and thus the person can move but with weak movements. Injuries to superior parts of the brachial plexus (C5 and C6) usually result from an excessive increase in the angle between the neck and the shoulder. The limb will hang by the side in medial rotation, with an adducted shoulder, and extended elbow. The deltoid, biceps, and brachialis are paralyzed. An injury may produce muscle spasms and severe disability in hikers who carry heavy backpacks for long periods. Acute brachial plexus neuritis (brachial plexus neuropathy) is a neurologic disorder that is characterized by the sudden onset of severe pain followed by atrophy. The nerve fibers involved are usually from the superior trunk of the brachial plexus Compression of cords of the brachial plexus may result from prolonged hyperabduction of the arm during performance of manual tasks over the head (eg painting a ceiling). The cords are compressed and pain radiates, numbness, paresthesia (tingling), erythema (redness of the skin), and weakness of the hands. Injuries to inferior parts of the brachial plexus (Klumpke paralysis) are less common. May occur when the limb is suddenly pulled superiorly (for example when a person grasps something to break a fall). This may avulse (tear) the roots affecting the short muscles of the hand causing claw hand. Brachial Plexus Block Injection into/around the axillary sheath. Sensation is blocked in all deep structures of the upper limb and the sin distal to the middle of the arm. Enables the surgeons to operate without using a general anesthetic. 741 ARM AND CUBITAL FOSSA Bicipital Myotatic Reflex Biceps reflex is one of several deep tendon reflexes that are tested during a physical. Normal response is an involuntary contraction of the biceps. Biceps tendinitis Usually the result of repetitive microtrauma and is common in sports involving throwing. A tight, narrow, and/or rough bicipital groove may irritate and inflame the tendon producing crepitus (a crackling sound) Dislocation of Tendon of Long Head of Biceps Brachii May occur during traumatic separation of the proximal epiphysis. Also occurs in older persons with a history of tendinitis. Rupture of the Long head of the Biceps Brachii Results from wear and tear of an inflamed tendon (or from forceful flexion against resistance). Occurs usually over the age of 35. Associated with a snap or a pop and the muscle belly forms a ball near the center of the distal part of the anterior aspect of the arm. Interruption of Blood Flow in Brachial Artery Hemostasis stopping bleeding through manual control. The best place to compress the brachial artery is medial to the humerus near the middle of the arm because there is collateral circulation due to the deep artery of the arm. If sudden complete occlusion occurs it becomes a surgical emergency because paralysis results within a

few hours and last up to 6 without blood flow. After this amount of time, fibrous scar tissue replaces necrotic tissue and the muscles will shorten permanently producing a flexion deformity (Volkmann contracture). Fracture of Humeral Shaft Midhumeral fracture may injure the radial nerve but not likely to paralyze the triceps due to high origin of the nerves to two of the three heads. Fracture of the distal part of the humerus (supra-epicondylar fracture) will shorten the limb. Injury to Musculocutaneus nerve Typically inflicted by a weapon. Results in paralysis of the coracobrachialis, biceps, and brachialis. Weak flexion may occur at the shoulder as well as the elbow and weakening in supination of the forearm. Loss of sensation may occur on the lateral surface of the forearm supplied by the lateral antebrachial cutaneus nerve (continuation of the musculocutaneus nerve). Injury to Radial Nerve in Arm Injury to the nerve superior to the origin of its branches to the triceps results in paralysis of the triceps, brachioradialis, supinator, and extensor muscles of the wrist and fingers. Loss of sensation in areas of skin supplied by this nerve also occurs. If it is injured in the radial groove the triceps is usually not completely paralyzed. Clinical sign is wrist drop inability to extend the wrist and fingers at metacarpophalangeal joints. Venipuncture in cubital fossa Common site for sampling and transfusion of blood and IV injections. During the days of bloodletting, the bicipital aponeurosis was known as the grace Deux tendon (grace of god) by the grace of which arterial hemorrhage was usually avoided. Median cubital vein is also a site for the introduction of cardiac catheters. These veins (median cubital, cephalic, and basilic) may also be used for coronary angiography. Variation of veins in cubital fossa In 20% of people a median antebrachial vein divides into a median basilic vein, which joins the basilic vein of the arm and a median cephalic vein that joins the cephalic vein of the arm. Thus a clear M formation is produced by the cubital veins. These always cross superficially to the brachial artery with the bicipital aponeurosis in the middle. 766 FOREARM Elbow Tendinitis or Lateral Epicondylitis Condition that may follow repetitive use of the superficial extensor muscles of the forearm. Can feel pain with something as simple as lifting a glass. Lateral epicondylitis is caused by repeated forceful flexion and extension of the attachment of the common extensor tendon. Mallet or Baseball finger Sudden sever tension on a long extensor tendon may avulse part of its attachment to the phalanx. Hyperflexion of the distal interphalangeal joint due to jamming. Cannot extend distal interphalangeal joint. Fracture of the Olecranon

Common because the olecranon is protrusive. Mechanism of injury is a fall on the elbow combines with sudden powerful contraction of the triceps. Considered an avulsion fracture of the ulna with the olecranon split off. Pinning is usually required. Synovial Cyst of the wrist Sometimes cystic swelling appears most commonly on the dorsum of the wrist. Contains clear mucinous fluid and may result from mucoid degeneration. Flexion typically makes the cyst enlarge. Clinically this type of swelling is called a ganglion (even though anatomically that is a collection of nerve cell bodies). The distal attachment of the extensor carpi radialis brevis tendon to the base of the third metacarpal is another common site. Swelling of the synovial sheath is enough to produce compression of the median nerve by narrowing the carpal tunnel. High Division of Brachial Artery Sometimes it divides at a more proximal level than usual. Thus, ulnar and radial arteries begin in the superior part of the arm. Superficial Ulnar Artery In 3% of people the ulnar artery descends superficial to the flexor muscles. Must be kept in mind because it should not be mistaken for a vein to collect blood. Measuring Pulse Rate Most common place is where the radial artery lies on the anterior surface of the distal end of the radius, lateral to the tendon of the flexor carpi radialis. An aberrant radial artery on one side may make the pulse difficult to palpate so the other wrist should be used. Variations in Origin of the Radial Artery May be more proximal than usual or may be a branch of the axillary or brachial artery. Median Nerve Injury When it is severed in the elbow region, flexion of the proximal interphalangeal joints of the thumb, index, and middle finger is lost and the flexion of the ring and pinky is weakened. Flexion of the distal interphalangeal joints of the 2nd and 3rd digits is also lost. Thus, when a person attempts to make a fist the 2nd and 3rd fingers remain partially extended (hand of benediction). When the anterior interosseus nerve is injured, paresis (partial paralysis) of the flexor digitorm profundus and flexor pollicis longus occurs. The okay sign becomes a pinch posture. Pronator Syndrome A nerve entrapment syndrome caused by compression of the median nerve near the elbow. May be compressed between the heads of the pronator teres as a result of trauma/hypertrophy/fibrous bands. Initially seen with pain in the proximal aspect of the anterior forearm and hypesthesia (decreased sensation) of palm. Communications between Median and Ulnar Nerves Important because even with a complete lesion of the median nerve some muscles may not be paralyzed. Injury of Ulnar Nerve at Elbow and in Forearm Injuries occur in 4 places 1. posterior to the medial epicondyle - Occurs most commonly where the nerve passes posterior to the medial epicondyle (and the medial

epicondyle (funny bone) is fractured). Any lesion above this will produce paresthesia of the median part of the dorsum of the hand. 2. in the cubital tunnel 3. at the wrist 4. in the hand Ulnar nerve injury usually produces numbness and tingling in the medial part of the palm and the medial one and a half fingers. Can result in extensive motor and sensory loss to the hand. After an injury, the person has difficulty making a fist because the metacarpophalangeal joints become hyperextended. Distal lesion of the ulnar nerve causes a claw hand. It is produced by the unopposed action of the extensors and flexor digitorum profundus. Cubital Tunnel Syndrome Ulnar nerve may be compressed in the cubital tunnel formed by the tendinous arch joining the humeral and ulnar heads of attachment of the flexor carpi ulnaris. Injury of Radial Nerve in Forearm May occur when wounds of the posterior forearm are deep (penetrating). Severance of the deep ranch results in an inability to extend the thumb and metacarpophalangeal(MP) joints. Loss of sensation does not occur because the deep branch of the radial nerve is entirely muscular. When the superficial branch is severed, sensory loss is usually minimal. Commonly, a coin shaped area of anesthesia occurs distal to the bases of the 1st and 2nd metacarpals. Such a small area due to overlap from cutaneous branches of median and ulnar nerves. 789 HAND Dupuytren Contracture of Palmar Fascia Disease of the fascia resulting in progressive shortening, thickening, and fibrosis. Degeneration of the longitudinal bands pulls the 4th and 5th fingers into partial flexion at the MP and proximal interphalangeal joints. It is frequently bilateral and seen in some men greater than 50 yrs old. The cause is unknown (hereditary?). First manifests with painless nodular thickenings of the palmar aponeurosis that adhere to the skin. Treatment involves surgical excision of all fibrotic parts of the palmar fascia to free the fingers. Hand Infections Depending on the site of infection, pus will accumulate. Antibiotic therapy. Tenosynovities Infection of the digital synovial sheath can occur as a result of a puncture of a finger by a rusty nail. The digit swells and movement becomes painful. Infection is confined to one finger unless it goes untreated and the sheath may rupture allowing the infection to spread. However, with the little finger, it is likely to spread to the common flexor sheath because the sheaths are continuous. Quervain tenovaginitis stenosans excessive friction caused by wringing hands causes pain in the wrist that radiates proximally to the forearm and distally towards the thumb. Laceration of Palmar Arches When palmar arches are lacerated, bleeding is profuse. In order to block off bleeding should be tied off at the brachial artery proximal to the elbow.

Ischemia of Digits Raynaud syndrome idiopathic ischemia of the digits. When this occurs, it may be necessary to perform a cervicodorsal presynaptic sympathectomy (excision of a segment of a sympathetic nerve) to dilate the digital arteries. Lesions of the Median nerve Usually occur at the forearm and the wrist, most commonly at the carpal tunnel Carpal Tunnel Syndrome Results from any lesion that significantly reduces the size of the carpal tunnel or more commonly increases the size of the structures within the tunnel. Fluid retention, infection, and excessive exercise of the fingers may cause swelling of the tendons/synovial sheaths. The median nerve is the most sensitive and thus paresthesia (tingling), hypoesthesia (diminished sensation), or anesthesia (Absence of sensation) may occur in the lateral three and a half digits. Loss of coordination and strength may occur if it is not alleviated. As the condition progresses, sensory changes radiate into the forearm and axilla. To relieve the compression and symptoms, division of the flexor retinaculum (carpal tunnel release) may be necessary. Trauma to median nerve Because this nerve is close to the surface, laceration often causes injury. In attempted suicides, the median nerve is commonly injured proximal to the flexor retinaculum. Opposition of the thumb is impossible and fine control movements of the 2nd and 3rd digits are impaired as well as sensation loss. Most nerve injuries in the upper limb affect opposition of the thumb. Simian hand deformity in which thumb movements are limited to flexion and extension of the thumb in the plane of the palm. The recurrent branch of the median nerve to the thenar muscles may be severed and will paralyze the thenar muscles. Ulnar Canal Syndrome Compression of the ulnar nerve where it passes through the pisiform and the hook of hamate. Between these bones lies the Guyon tunnel (so UCS is also known as Guyon tunnel syndrome). This syndrome is manifested by hypoesthesia in the medial one and a half fingers and weakness of intrinsic muscles of the hand. Clawing of the 4th and 5th fingers may occur, but their ability to flex is unaffected. No radial deviation of the hand. Handlebar Neuropathy Nerve compression due to pressure on the hook of hamate (example - caused by people who ride long distances on bicycles with their hands in an extended position against the handlebar). Results in sensory loss on the medial side of the hand and weakness to intrinsic hand muscles. Radial Nerve Injury in Arm and Hand Disability Although it doesnt supply muscles in the hand, injury in the arm can cause hand disability. Characteristic handicap is the inability to extend the wrist because the radial nerve innervates the extensor muscles of the forearm and it can paralyze these. The hand is flexed at the wrist and lies flaccid. (wrist drop previously discussed). Dermatoglyphics

Science of studying ridge patterns of the palm. It is a valuable extension of the conventional physical exam of people with congenital anomalies and genetic diseases. For example, people with downs (trisomy 21), have highly characteristic dermatoglyphics. In addition, there is often a single transverse palmar crease. Palmar Wounds and Surgical Incisions Know where the palmar arches are. Also know that the superficial palmar arch is at the same level as the distal end of the common flexor sheath. 813 JOINTS OF THE UPPER LIMB Dislocation of the Sternoclavicular Joint Rare to occur. More likely to fracture the clavicle. Most occur in those <25 years of age bc the epiphysis doesnt close until 23-25 years of age. Ankylosis of Sternoclavicular Joint Ankylosis stiffening/fixation. When this occurs, part of the clavicle is removed and a pseudojoint is created to permit scapular movement Dislocation of the Acromioclavicular Joint Easily injured by a direct blow such as being checked in hockey or FOUSH. When the coracoclavicular ligament tears, the shoulder separates from the clavicle and falls bc of the weight of the upper limb. Calcific Supraspinatus Tendinitis Calcific scapulohumeral bursitis inflammation and calcification of the subacromial bursa. Deposit of calcium in the supraspinatus tendon is common leads to increased pressure that causes pain during abduction. Subacromial bursitis calcium deposit irritates the overlying subacromial bursa. Rotator Cuff Injuries Degenerative tendinitis of the rotator cuff repetitive movement causes impingement on the coraco-acromial arch. To test of it person asked to lower a fully abducted limb smoothly. After 90 degrees the limb will suddenly drop to the side. May also occur during a sudden strain of the muscles. It can rupture a previously degenerated rotator cuff. If the supraspinatus is no longer functional, a person cannot initiate abduction of the upper limb except if it makes 15 degrees of passive abduction, the person can use the deltoid to abduct the rest of the way. Dislocation of the Glenohumeral joint Commonly dislocated due to instability typically downward. Anterior dislocation of the glenohumeral joint caused by excessive extention and lateral rotation of the humerus. Inferior dislocation of the glenohumeral joint often occurs after an avulsion fracture of the greater tubercle of the humerus Axillary Nerve Injury During dislocation, the subglenoid displacement of the head of the humerus into the quadrangular space damages the axillary nerve. Indicated by paralysis of the deltoid and loss of sensation in a small area covering the deltoid. Glenoid Labrum tears

Commonly occurs in athletes who throw a baseball or football and in those who have shoulder instability and subluxation. A tear usually occurs over the anterosuperior part of the labrum. Painful accompanied by popping/snapping. Adhesive Capsulitis of Glenohumeral joint Adhesive capsulitis frozen shoulder with difficult abduction. Seen in older age with a significant decrease in shoulder movement. Strain is placed on the AC joint and may be painful during other movements.(eg. Elevation) Bursitis of the elbow Subcutaneous olecrenon bursitis occurs after wrestling. Inflammation of the bursa of the olecrenon. Known as dart throwers elbow and miners elbow. Subtendinous olecranon bursitis less common. Caused by excessive friction between the triceps tendon and olecranon. Pain is most severe during flexion of the forearm. Bicipitalradial bursitis pain when forearm is pronated bc this action compresses the bicipitoradial bursa against radial tuberosity. Avulsion of Medial epicondyle Traction injury of the ulnar nerve is a frequent complication bc it passes posterior to the medial epicondyle before entering the forearm. Ulnar Collateral Ligament Reconstruction Known as the Tommy John Procedure involves an autologous transplant of a long tendon from the contralateral forearm or leg. Dislocation of the Elbow Joint Posterior dilocation may occur when children fall on their hands with their elbows flexted. The ulnar collateral ligament is often torn and the head of the radius/coronoid process/olecranon process may fracture. Subluxation and dislocation of radial head Subluxation incomplete dislocation. Caused by sudden upward pulling of the forearm while it is pronated. The sudden pulling tears the distal attachment of the anular ligaments where it is loosely attached ot the neck of the radius causing the radius to move distally. Pain comes from the pinched anular ligaments. Wrist fractures and Dislocations Colles fracture distal end of radius Anterior dislocation of the lunate results from FOUSH. Pushed out of place and may compress the median nerve and lead to carpal tunnel syndrome or avascular necrosis of the bone. Bull Riders thumb Sprain of the radial collateral ligament and avulsion fracture of the lateral part of the proximal phalanx of the thumb. Skiers Thumb Rupture of collateral ligament of the 1st MP joint. Caused by hyperabduction of the MP joint. In severe cases, the head of the metacarpal has an avulsion fracture.

Medially to laterally within the cubital fossa Median Nerve, Brachial Artery, Biceps tendon