BONES OF UPPER LIMB

1. UPPER LIMB INJURIES

a. Variations of Clavicle
More curved in manual workers
Sites of muscular attachment more marked
b. Fracture of Clavicle
more common among children
indirect force from an outstretched hand during fall
falling directly on a shoulder
weakest part: junction of medial and lateral thirds
Sternocleidomastoid elevates the medial fragment
of bone
Trapezius unable to hold the lateral fragment
shoulder drops
Coracoclavicular ligament prevents dislocation of
AC joint
Lateral fragment pulled medially by adductor
muscles (e.g. pectoralis major)
Greenstick fracture- one side broken, the other bent
c. Ossification of Clavicle
First bone to ossify (intramembranous ossification)
Cartilaginous phase (endochondral ossification)
Failure of fusion of ossification center: between
lateral and medial thirds of clavicle usually a
congenital defect and bilateral
2. Fracture of Scapula
- Pedestrian vehicle accident
- Also presents with fractured ribs
3. Fracture of Humerus
Most common fracture: fracture of surgical neck
a. Impacted Fracture- one fragment driven into the
spongy bone
Minor fall on the hand, force transmitted up the
forearm of extended limb
b. Avulsion fracture of greater tubercle-small part of
tubercle is avulsed away; common among elderly
Young people: fall on hand when arm is abducted
o Subscapularis pull the limb into medial rotation
c. Transverse fracture of the shaft of humerus- direct
blow to the arm
Proximal fragment carried laterally by deltoids
d. Spiral fracture of the humeral shaft- indirect injury
from a fall on the outstretched hand
e. Intercondylar fracture of the humerus- severe fall on
flexed elbow
Olecranon of ulna driven like a wedge between
medial and lateral epicondyle separate one or both
parts from humerus
f. Parts of humerus in direct contact with nerves:
Surgical neck- axillary nerve
Radial groove- radial nerve
Distal end of humerus- median nerve
Medial epicondyle- ulnar nerve
4. Fractures of Radius and Ulna
a. Fracture of distal end of radius- adults
Colles fracture- complete transverse fracture of distal
radius
o Most common fracture in radius

o Distal fragment displaced dorsally and often

comminuted
o From forced extension of the hand
o Ulnar styloid process avulsed
o Dinner fork deformity- posterior angulation of
forearm
b. Epiphyseal plate injury
Common in older children
Frequent fall forces transmitted from hand to the
radius and ulna
Malalignment of epiphyseal plate disturbed radial
growth
5. Fracture of scaphoid
Most commonly fractured carpal bone
Fall on arm when hand is abducted fracture at
narrow part of scaphoid
Pain during dorsiflexion and abduction of hand
Misdiagnosis: severely sprained wrist
Poor blood supply
o Healing: 3 months
o Avascular necrosis of the proximal fragment of
scaphoid
o Degenerative joint disease of the wrist
o Arthrodesis- surgical fusion of carpals
6. Fracture of Hamate
Non-union of fractured bony parts
May lead to damage of ulnar nerve and/or ulnar
artery decreased grip strength
7. Fracture of metacarpals
Metacarpals closely bound together hence isolated
fractures tend to be stable
Severe crushing injuries of the hand- multiple
metacarpal fractures
Boxers fracture- fracture of 5th metacarpal
o Punches with closed and abducted fist
o Head rotates to the distal end of shaft flexion
deformity
8. Fracture of phalanges
Crushing injury of distal phalanges
Fracture of distal phalanx- comminuted with painful
hematoma
Fracture of proximal and middle phalanges- crushing/
hyperextensions
Close to flexor tendons

PECTORAL, SCAPULAR, DELTOID

1 Absence of Pectoral Muscle

Poland Syndrome
Pectoralis major and minor absent
Breast hypoplasia and 2-4 rib segment absent
No disability usually occurs
2 Paralysis of Serratus Anterior
Due to injury of long thoracic nerve superficial
aspect of serratus anterior vulnerable in knife fight
Bullet in thorax: common source of injury
Medial border of scapula moves laterally and
posteriorly away from thoracic wallwinged scapula

Upper limb may not be abducted above the

horizontal position
Unable to rotate the glenoid cavity superiorly
Triangle of Auscultation
Superior horizontal border of latissimus dorsi
Medial border of scapula
Inferolateral border of trapezius
Examination of posterior segment of lungs with
stethoscope
Exposed when arms are folded across the chest
-

3 Injury of Spinal accessory nerve

Spinal accessory nerve palsy- ipsilateral weakness when
shoulders are elevated against resistance
4 Injury of Thoracodorsal Nerve
Surgery in inferior part of axilla puts the
thoracodorsal nerve at risk of injury
Vulnerable during mastectomy and surgery of
scapular lymph nodes
Anteroposterior muscular sling: latissimus dorsi and
inferior part of pectoralis major
a. Paralysis of latissimus dorsi- unable to raise trunk,
cannot use axillary crutch (shoulder pushed
posteriorly)
5 Injury to dorsal scapular nerve
Dorsal scapular nerve- nerve to rhomboids
Scapula located farther from the midline
6 Injury to axillary nerve
Injury to surgical neck of humerus
Dislocation of glenohumeral joint
Compression from incorrect use of crutches
a. Deltoid atrophy
b. Loss of sensation to the lateral side of proximal part
of arm: supplied by superior lateral cutaneous nerve
of arm- cutaneous branch of axillary nerve
7 Fracture- Dislocation of Proximal Humeral Epiphysis
Direct blow/ injury of the shoulder of child/ adolescent
Joint capsule of glenohumeral joint is stronger than
epiphyseal plate
Shaft of humerus markedly displaced humeral head
retains its normal relationship with glenoid cavity
8 Rotator cuff injuries
Results to instability of glenohumeral joint
Most commonly ruptured: Supraspinatus
Degenerative tendonitis of rotator cuf

FOREARM INJURIES
1
-

2
-

Elbow Tendinitis/ Lateral Epicondylitis

Tennis elbow
Repetitive use of superficial extensor muscles of forearm
Pain at the lateral epicondyle region
o Pain when opening a door or lift a glass
o Forceful flexion and extension of wrist: strain
attachment of common extensor tendon
inflammation of periosteum of lateral epicondyle
Mallet/ Baseball Finger
Sudden severe tension on long extensor tendon
avulsion of attachment to phalanx
Hyperflexion of DIP joint

Tear away attachment of tendon to the base of

distal phalanx
o Cannot extend the DIP joint
3 Fracture of Olecranon
Fractured elbow
fall on elbow combined with sudden powerful contraction
of triceps brachii
fractured olecranon pulled away by active and tonic
contraction of triceps
4 Synovial Cyst of Wrist
Cystic swelling on the dorsum of wrist
o Usu size of a small grape to plum size
ganglion swelling
common site: distal attachment of extensor carpi radialis
brevis to base of 3rd metacarpal
enough to produce compression of median nerve (carpal
tunnel syndrome
o pain and paresthesia, clumsiness of finger
movements
5 High Division of Brachial Artery
Brachial artery divides more proximally than usual
Ulnar and radial arteries begin in the superior/middle
part of arm and median nerve passes between them
Musculocutaneous and median nerve commonly
communicates
6 Superficial Ulnar Artery
3% of time: ulnar artery descend superficial to flexor
muscles
pulsation of ulnar artery can be felt
Measuring Pulse Rate
common site: radial artery anterior surface of distal end
of radius, lateral to tendon of Flexor carpi radialis
other site aberrant radial artery
radial nerve can also be pulsed at anatomical snuff box
o

7
8
-

Variations in Origin of Radial Artery

More proximal radial artery
Becomes superficial to fascia rather than deep
Makes the radial artery vulnerable to laceration
Median Nerve Injury
Elbow region: flexion of PIP of 1st to 3rd digits is lost, 4th
and 5th digits weakened, flexion of 2nd and 3rd PIP is lost
Thenar muscle function lost
Injury of anterior interroseous nerve: thenar muscle
unaffected, partial paralysis of flexor digitorum profundus
and flexor pollicis longus
o Thumb opposition: Abnormal Pinch sign/ okay
sign
Causes of injury
9 Pronator Syndrome
Nerve entrapment syndrome
Compression of median nerve near the elbow
between heads of pronator teres
o Pain and tenderness in proximal aspect of
anterior forearm
o Hypesthesia (decreased sensation) of 3 digits
and adjacent palm
10 Injury of Ulnar Nerve at Elbow and Forearm
Places:

Posterior to medial epicondyle of humerus- most

common
o Cubital tunnel formed by tendinous arch
conneting humeral and ulnar heads of Flexor
carpi ulnaris
o Wrist
o Hand
a. Medial epicondyle- elbow hits a hard surface,
fracturing the medial epicondyle (funny bone)
o Paresthesia of the medial part of the parl
and medial 1 of fingers
b. Compression as it passes through the ulnar canal
Results to extensive motor and sensory loss to the hand
o Denervation of intrinsic hand muscles
o Power of wrist adduction impaired
o Hand is drawn to the lateral side by Flexor carpi
radialis in the absence of balance provided by
flexor carpi ulnaris
o Difficulty in making a fist because of absence of
opposition
o Cannot flex 4th and 5th digits at DIP
o Claw hand
11 Cubital Tunnel Syndrome
Cubital tunnel formed by tendinous arch joining the
humeral and ulnar heads of attachment of the FCU
Signs and symptoms same as ulnar nerve lesion
o

12 Injury of Radial Nerve in Forearm

Usually due to fracture of humeral shaft
o Proximal to the motor branches wrist drop
Injury to deep branch: penetrating wounds
o Inability to extend the thumb and MP joints
o Integrity tested by extending the MP joints of
other digits while providing resistance
o If intact: long extensor tendons should appear
prominently on the dorsum of hand
Deep branch: loss of sensation does not occur
Arterial Anastomoses Around Scapula

Dorsal scapular, suprascapular, and sub scapular (via

circumflex scapular) arteries

Collateral circulation made possible by these

ansatosomes becomes apparent when ligation of a
lacerated subclavian or axillary artery is necessary

Vascular stenosis of the axillary artery may result from

atherosclerotic lesions that causes reduced blood flow
(direction of blood flow is in the subscapular artery is
reversed, enabling blood to reach the third part of the
axillary artery)

Slow occlusion of the axillary artery often enables

sufficient collateral circulation to develop, preventing
ischemia (loss of blood supply).

Sudden occlusion usually does not allow sufficient time

for adequate collateral circulation to develop
inadequate supply of blood to the arm, forearm and
hand

Potential collateral pathways exist around the shoulder

joint proximally, and elbow joint distally, surgical ligation
of the axillary artery betwee the origins of the

subscapular artery and the profunda brachii artery will

cut off the blood supply to the arm because the collateral
circulation is inadequate
Compression of Axillary Artery

Compression of distal part - against humerus

o profuse bleeding (stab or bullet wound in the
axilla)

Compression at proximal site between the clavicle and

inferior attachment to sternocleidomastoid
Aneurysm of Axillary Artery

Enlargement of first part and compression of the trunks

of the brachial plexus
o Pain and anesthesia

Baseball pitchers, football quarterback (rapid and

forceful arm movements)
Injuries to Axillary Vein

Usually involved in wounds in the axilla because of its

large size and exposed position

Wound in the proximal part is particularly dangerous

o Profuse bleeding
o Air may enter the blood air emboli (air
bubbles)
Roles of Axillary Vein in Subclavian Vein Puncture

Vein actually punctured is terminally part of the axillary

vein
Enlargement of Axillary Lymph Nodes

Infection in the upper limb

Lymphagitis inflammation

Humeral group usually first to be involved

Warm, red, tender streaks in the skin

Metastatic Cancer nodes usually adhere to axillary

vein

May obstruct cephalic vein superior to pectoralis minor

Dissection of Axillary Lymph Nodes

For staging and determination of appropriate treatment

of a cancer

Lymphedema swelling as a result of accumulated

lympg

Two nerves at risk

o Long thoracic nerve
o Thoracodorsal
o Sometimes sacrificed when nodes around it are
malignant
Variation of Brachial Plexus

Contributions may be made by C4 and T2 (prefixed

brachial plexus)

C6 and T2 (postfixed brachial plexus)

Variations in formation of trunks, divisions and cord

In some individuals, trunk and cord divisions may be

absent
Brachial Plexus Injuries

Caused by disease, stretching, and wounds in the lateral

cervical region of neck, or in the axilla

Paralysis and anesthesia

o Complete paralysis no movement detectable
o Incomplete paralysis weakened

Superior (C5, C6)

o From excessive separation of neck and
shoulder Erb-Duchenne Palsy

Thrown from motorcycle, lands on the

shoulder)

Neonates during delivery (pull the

head)

Waiters Tip adducted shoulder,

medially rotated arm, extended elbow

Paralysis of deltoid, biceps, brachialis

o Backpackers Palsy

Chronic microtrauma carry heavy

backpacks for long periods of time

Motor and sensory deficits in the

distribution of the musculocutaneos
and radial nerves

Muscle spasms, severe disability

Acute brachial plexus neuritis (neuropathy)

o Unknown cause
o Characterized by sudden onset of severe pain,
usually around the shoulder
o May be followed by neurologic amyotrphy
o Often preceded by some event (eg upper respi
infection, vaccination, trauma)

Compression of cords
o result from prolonged hyperabduction of the
arm (over head) painting the ceiling
o cords compressed between coracoid process
and pectorilis minor tendon
o pain radiating down the arm, numbness,
paresthesia, erythema (capillary dilation),
weakness of hands
o hyperabduction syndrome compression of
axillary vessels and nerves

Injuries to Inferior parts Klumpke Paralysis

o Upper limb suddenly pulled superiorly
o Claw hand
Brachial Plexus Block

Injection of anesthetic solution in axillary sheath

interrupts conduction of impulses of peripheral nerves
(anesthesia to structures supplied)

Sensation is blocked in all deep structures of the upper

limb and skin distal to arm

Combined with occlusive tourniquet technique to retain

anesthetic agent used by surgeons in surgery without
general anesthesia

ARM AND CUBITAL FOSSA

Bicipital Myotatic Reflex

Biceps reflex

Examiners thumb firmly placed on the biceps tendon,

and the reflex hammer is briskly tapped at the base of
the nail bed of the examiners thumb

Fracture of Humeral Shaft

Midhumeral fracture may injure the radial nerve in the

radial groove

fracture is not likely to paralyze the triceps because of

the high origin of the nerves to two of its three heads

Normal (positive) response brief jerk-like flexion of the

elbow
o Confirms integrity of C5, C6 and
musculocutaneous
Excessive, diminished or prolonged response
o CNS or PNS disease, or metabolic disorders

Biceps tendinitis

Inflammation of biceps tendon

Tendon of long head of biceps is enclosed by synovial

sheath (back and forth movement of the humerus)

Wear and tear of this mechanism shoulder pain

Common in sports involving throwing and use of a

racquet

Tight, narrow, rough intertubercular sulcus may irritate

and inflame tendon tenderness and crepitus (crackling
sound)
Dislocation of Tendon of Long Head of Biceps

In young persons during traumatic separation of the

proximal epiphysis of humerus

Older persons with a history of biceps tendinitis

Sensation of popping or catching is felt during arm

rotation
Rupture of Tendon of Long Head of Biceps Brachii

Results from wear and tear, forceful flexion against

excessive resistance, repetitive overhead motions
(swimmers, baseball pitchers)

Often in >35 years old

Usually tendon is torn from its attachments

Snap or pop

Detached muscle belly forms a ball near the center of

the distal part of the anterior aspect of the arm Popeye
deformity
Interruption of Blood Flow in Brachial Artery

Hemostasis - stopping bleeding through manual or

surgical control of blood flow

Best place to compress the brachial artery to control

hemorrhage medial to the humerus near the middle of
the arm; distal to the origin of the deep artery of the arm

Ischemia of the elbow and forearm

o Muscles and nerves can tolerate up to 6 hours
o After this fibrosis (Volkman or ischemic
contracture)
o Flexion of the fingers and sometimes the wrist
results in loss of hand power (irreversible
necrosis of the forearm flexors)

Ulnar and radial arteries will still receive sufficient blood

through the anastosomes around the elbow (collateral
circulation)

fracture of distal part of humerus supra- epicondylar

fracture; may be displaced anteriorly or posteriorly
branched of brachial vessel related to the humerus may
be injured by displaced bone fragment

Injury to Musculocutaneous Nerve

typically inflicted by a weapon (knife)

paralysis of coracobrachilais, biceps, brachialis

Weakened flexion at shoulder joint, elbow joint and

supination of forearm (still possible due to
brachioradialis and supination supplied by radial nerve)
Injury to Radial Nerve in Arm

Superior to radial groove - paralysis of the triceps,

brachioradialis, supinator, extensor muscles of wrist and
fingers

Inferior to radial groove weakened cos only medial

head is affected

Wrist drop

Venipuncture in Cubital Fossa

Common site for sampling and transfusion of blood, and

intravenous injections because of accessibility and
prominence of veins

Bicipital aponeurosis grace Deux tendon (arterial

hemorrhage was usually avoided

Median cubital vein site for the introduction of cardiac

catheters to secure blood samples from the great
vessels and chambers of the heart

may also be used for coronary angiography

Variations in Cubital Fossa

20% of people median antebrachial vein divides into a

median basilica vein and a median cephalic vein (clear
M formation is produced)

either the median cubital vein or the median basilica

vein, whichever pattern is present, crosses superficial to
the brachial artery, from which it is separated by the
bicipital aponeurosis

good sites for drawing blood

not ideal for injecting irritating drug because of the

danger of injecting it into the brachial artery

Dupuytren Contracture of Palmar Fascia

Disease of the palmar fascia resulting in progressive

shortening, thickening, and fibrosis of the palmar
fascia and aponeurosis.

The fibrous degeneration of the longitudinal

bands of the palmar aponeurosis on the medial
side of the hand pulls the 4th and 5th fingers into
palmar flexion at the metacarpophalangeal joint
and proximal interphalangeal joints.

Contracture is frequently bilateral

Seen in some men > 50 years of age

Cause is unknown (evidence points to hereditary

predisposition)

Mechanism:
o First manifests as painless nodular
thickenings of palmar aponeurosis that
adhere to the skin
o 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.

Treatment:
o Usually involves surgical excision of all
fibrotic parts of the palmar fascia to free the
fingers

Hand Infections

Swellings resulting from hand infections usually

appear on the dorsum of the hand because fascia
there is thinner (as compared to palmar fascia
thick and strong)

Potential palmar spaces of the palm are important

because they may become infected.

Fascial spaces determine the extent and direction of

the spread of pus formed by infections.

Depending on site of infection, pus will accumulate

in:
o Thenar
o Hypothenar
o Midpalmar
o Adductor compartments

Treatment:
o Antiobiotic therapy: made infections that
spread beyond one of the the fascial
compartments rare

Untreated infection:
o Can spread proximally from the midpalmar
space through the calpar tunnel into the
forearm, anterior to the pronator quadratus
and its fascia.
Tenosynovitis

Digital synovial sheaths

Injuries such as puncture of a finger by a

rusty nail can cause infection here

Tenosynovitis s the inflammation of the tendon

and synovial sheath

Mechanism: The digit swells and movement

becomes painful because the tendons of the 2nd, 3rd,
and 4th fingers nearly always have separate synovial
sheaths, the infection is usually confined to the
infected finger.
If left untreated:

Proximal ends of sheaths may rupture,

allowing the infection to spread to the
midpalmar space.
Little finger

Synovial sheath is usually continuous with

the common flexor sheath

Tenosynovitis in this finger may spread to

the common flexor sheath and thus through
the palm and carpal tunnel to the anterior
forearm, draining into the space between
the pronator quadratus and the overlying
flexor tendons (Parone space).

Thumb

Tenosynovitis in this finger may

spread via the continuous synovial
sheath of the FPL (radial bursa).

How far an infections spreads depends on

variations in their connections with the
common flexor sheath.

1.

Quervain tenovaginits stenosans

Tendons of the APL and EPB are in the same

tendinous sheath on the dorsum of the wrist.
o Excessive friction 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.

Pain in the wrist that radiates proximally to the

forearm and distally toward the thumb.

Local tenderness is felt over the common flexor

sheath on the lateral side of the wrist.

2.

Digital tenovaginits stenosans

Also called trigger finger or snapping finger

Thickening of the fibrous digital sheath on the

palmar aspect of the digit produces stenosis of
the osseofibrous tunnel the result of the
repetitive forceful use of the fingers.

If the tendons of the FDS and FDP enlarge

proximal to the tunnel, the person is unable to
extend the finger.

When finger is extended passively, a snap is

audible.

Flexion produces another snap as the tendon

moves.

Laceration of Palmar Arches

Bleeding is usually profuse

It may not be sufficient to ligate only one forearm

artery when the arches are lacerated because these
vessels usually have numerous communications in
the forearm and hand and thus bleed from both
ends.
To obtain a bloodless surgical operating field, it may
be necessary to compress the brachial artery and its
branches proximal to the elbow (using a pneumatic
tourniquet).
o This procedure prevents blood from
reaching the ulnar and radial arteries
through the anastomoses around the elbow.

Ischemia of Digits (Fingers)

Intermittent bilateral attacks of ischemia of the digits

Marked by cyanosis and often accompanied by

paresthesia and pain

Characteristically brought on by cold and emotional

stimuli

This condition may result from an anatomical

abnormality or and underlying disease

When the cause Is idiopathic (unknown) or primary,

it is called Raynaud Syndrome (disease)

The arteries of the upper limb are innervated by

sympathetic nerves.

Postsynaptic fibers from the sympathetic ganglia

enter nerves that form the brachial plexus and are
distributed to the digital arteries through branches
arising form the plexus.

Treatment:
o Raynaud syndrome: Necessary to perform
a cervicodorsal presynaptic sympathectomy
(excision of a segment of a sympathetic
nerve) to dilate the digital arteries.
Lesions of Median Nerve

Usually occur in two places: forearm and wrist.

Most common is where the nerve passes through

the carpal tunnel.
1.

Carpal Tunnel Syndrome

Results from any lesion that

o Significantly reduces the size of the
carpal tunnel, or more commonly
o Increases the size of some of the nine
structures or their coverings that pass
through it (inflammation of synovial
sheaths)

Fluid retention, infection, and excessive exercise

of the fingers may cause swelling of the tendons
and their synovial sheaths.

Median nerve
o The most sensitive structure in the
tunnel
o Has two terminal sensory branches
that supply the skin of the hand hence

Paresthesia (tingling)

Hypoesthesia (diminished
sensation)

Anesthesia (absence of
sensation may occur in the
lateral three ahd a half digits.
o Two terminal sensory branches:

The palmar cutaneous

branch of the median nerve
arises proximal to and does
not pass through the carpal
tunnel; thus sensation in the
central palm remains
unaffected.

The terminal motor branch,

the recurrent branch, which
serves the three thenar
muscles.
Progressive lose of coordination and strength in
the thumb may occur if the cause of
compression is not alleviated.
Individuals with carpal tunnel syndrome are:
o Unable to oppose thumb
o Have difficulty buttoning a shirt or
blouse as well as gripping things such
as comb
As the condition progresses, sensory changes
radiate into the forearm and axilla
Symptoms of compression can be reproduced
by compression of the median nerve with your
finger at the wrist for approximately 30 seconds.
To relieve both the compression and the
resulting symptoms, carpal tunnel release is
necessary (partial or complete surgical division
of the flexor retinaculum)
o Incision for carpal tunnel release is
made toward the medial side of the
wrist and flexor retinaculum to avoid
possible injure to the recurrent branch
of the median nerve.

2.

Trauma to Median Nerve

Laceration of the wrist often causes median

nerve injury because this nerve is relatively
close to the surface.

In attempted suicides by wrist slashing, the

median nerve is commonly injured just proximal
to the flexor retinaculum.
o Results in the paralysis of the thenar
muscles and the first two lumbricals.
o Opposition of the thumb is not possible
and fine control movements of the 2nd
and 3rd digits are impaired.
o Sensation is also lost over the thumb
and adjacent two and a half fingers.

Most nerve injuries in the upper limb affect

opposition of the thumb.

Injuries to the nerves supplying the intrinsic

muscles of the hand, especially the median
nerve, have the most severe effects on this
complex movement.

3.

If median nerve is severed at forearm of wrists,

the thumb cannot be opoposed, but the APL
and adductor pollicis (supplied by the posterior
interosseous and ulnar nerves) may imitate
opposition, although ineffective.
Median nerve injury from a perforating wound in
the elbow region results in loss of flexion of the
proximal and distal interphalangeal joints of the
2nd and 3rd digits.
Ability to flex the metacarpophalangeal joints of
these fingers is also affected because digital
branches of the median nerve supply the 1st and
2nd lumbricals.

Simian hand

Refers to the deformity in which thumb

movements are limited to flexion and extension
of the thumb in the plane of the palm.

Cause: Inability to oppose and by limited

abduction of the thum.

The recurrent branch of the median nerve to the

thenar muscles lies subcutaneously and may be
severed by relatively minor lacerations of the
thenar eminence.
o Severance of this nerve paralyzes the
thenar muscles, and the thumb loses
much of its useless.

Ulnar Canal Syndrome

o Compression of the ulnar nerve may occur at the
wrist where it passes between the pisiform and the
hook of the hamate.
o Also called Guyon tunnel syndrome is manifest by
hyposthesia in the medial one and a half fingers and
weakness of the intrinsic muscles of the hand.
o Clawing of the 4th and 5th fingers may occur, but, their
ability to flex is unaffected and there is no radial
deviation of the hand.
Handlebar Neuropathy

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, which
compresses their ulnar nerves.
Results in sensory loss on the medial side of the
hand and weakness of the intrinsic hand muscles.

Radial Nerve Injury in Arm and Hand Disability

o Radial nerve supplies no muscles in the hand
o Radial nerve injury in the arm can produce serious
hand disability.
o Inability to extend the wrist resulting from paralysis of
extensor muscles of the forearm.
1.

Wrist-drop
o The hand is flexed at the wrist and lies
flaccid
o The fingers of the relaxed hand also remain
in the flexed position at the
metacarpophalangeal joints.
o Interphalangeal joint can be extended
weakly through the action of the intact
lumbricals and interossei.

Dermatoglyphics
o The science of studying ridge patterns of the palm
o A valuable extension of the conventional physical
exmainatio of people with certain congenital
anomalies and genetic diseases.
Palmar Wounds and Surgical Incisions
o Location of superficial and deep palmar arches
should be kept in mind when examining wounds of
the palm and when making palmar incisions.
o Superficial palmar arch is at the same level as the
distal end of the common flexor sheath.