CLINICAL NOTES ON UPPER LIMB

1. CLINICAL NOTES ON UPPER LIMB By: Dr. Mujahid Khan

2. Lymphatic Drainage of Breast • Its importance is the relation to the spread of cancer from breast • The lymph vessels from the medial quadrants of breast pierce 2nd, 3rd and 4th intercostal spaces • Enter the thorax to drain into the internal thoracic lymph nodes

3. Lymphatic Drainage of Breast • The lymph vessels from the lateral quadrants of the breasts drain into pectoral group of axillary nodes • Cancer occurring in the lateral quadrant of breast tends to spread to the axillary nodes • Lymph nodes of axilla can be removed surgically but thoracic metastases are difficult or impossible to treat

4. Lymphatic Drainage of Breast • 60% of breast cancers occur in the upper lateral quadrant • The lymphatic spread of the cancer to the opposite breast, abdominal cavity or to the root of the neck is caused by obstruction of the normal lymphatic pathways by malignant cells or destruction of lymph vessels by surgery or radiotherapy

5. Lymphatic Drainage of Breast • In localized breast cancers, simple mastectomy or lumpectomy, followed by radiotherapy of axillary lymph nodes The excised mass includes following: • The large area of skin overlying the tumor including the nipple • All the breast tissue • The pectoralis major muscle and fascia

6. Lymphatic Drainage of Breast The excised mass includes following: • Pectoralis minor and fascia • All the fat, fascia and lymph nodes in the axilla • Fascia covering the upper part of the rectus sheath • Serratus anterior, subscapularis and latissimus dorsi muscles • Axillary blood vessels, brachial plexus and nerves to serratus anterior and latissimus dorsi are preserved

7. Fractures of the Clavicle • Clavicle is exposed to trauma because of its position • It is the most commonly fractured bone in the body • Its fracture usually occur as a result of a fall on the shoulder or outstretched hand • The force is transmitted along the clavicle and breaks it at the weakest point, that is the junction of the middle and outer third • After the fracture, the lateral fragment is depressed by the weight of the arm and is pulled medially and forward

8. Fractures of the Clavicle • The medial end is tilted upward by the sternocleidomastoid muscle • The close relationship of the supraclavicular nerves to the clavicle may result in their involvement is callus formation after the fracture • This may be the cause of persistent pain over the side of the neck

9. Compression of Brachial Plexus • The interval between the clavicle and the first rib in some patients may become narrowed and thus is responsible for compression of nerves and blood vessels

10. Fractures of Scapula • They are usually occur in a runover accident victims or occupants of automobiles involved in crashes • Injuries are usually associated with fractured ribs • Most fractures of scapula require little treatment because the muscles on the anterior and posterior surfaces adequately splint the fragment

11. Humeral Head Fracture • Humeral head fracture can occur during the process of anterior and posterior dislocations of the shoulder joint • The fibrocartilaginous glenoid labrum of the scapula produces the fracture • Labrum can become jammed in the defect making the reduction of the shoulder joint difficult

12. Greater Tuberosity Fracture • It can be fractured by direct trauma, displaced by the glenoid labrum during dislocation of shoulder joint • When associated with a shoulder dislocation, severe tearing of the rotator cuff with the fracture can result in the greater tuberosity remaining displaced posteriorly after the shoulder joint is reduced • Open reduction of the fracture is necessary to attach the rotator cuff back into place

13. Lesser Tuberosity Fracture • Lesser tuberosity fracture accompanies posterior dislocation of the shoulder joint • The bone fragment receives the insertion of the subscapularis tendon, a part of the rotator cuff

14. Surgical Neck Fracture • Surgical neck of the humerus lies immediately distal to the lesser tuberosity • It can be fractured by a direct blow on the lateral aspect of the shoulder • In indirect manner by falling on the stretched hand

15. Fracture of Shaft of Humerus • Fractures of humeral shaft is common • The radial nerve can be damaged where it lies in the spiral groove on the posterior surface of the humerus under cover of the triceps muscle

16. Fracture of the Distal End of Humerus • Supracondylar fractures are common in children • Occur when the child falls on the outstretched hand with the elbow partially flexed • Injuries to the median, radial and ulnar nerves are common • Damage to or pressure on the brachial artery can occur at the time of fracture or from swelling of the surrounding tissues

17. Fracture of the Distal End of Humerus • The circulation to the forearm may be interfered • Leading to Volkmann’s ischemic contracture • Ulnar nerve can undergo irritation on the irregular bony surface after the bone fragments are reunited

18. Rotator Cuff Tendinitis • Rotator cuff consists of the tendons of the subscapularis, supraspinatus, infraspinatus and teres minor muscles • These muscles are fused to the underlying capsule of the shoulder joint • Plays an important role in stabilizing the shoulder joint • Lesions of the cuff are a common cause of pain in the shoulder region

19. Rotator Cuff Tendinitis • Excessive overhead activity of the upper limb may be the cause of tendinitis • During abduction of the shoulder joint, the supraspinatus tendon is exposed to friction against the acromion • Under normal conditions, the amount of friction is reduced to a minimum by the large subacromial bursa

20. Rotator Cuff Tendinitis • Degenerative changes in the bursa are followed by degenerative changes in the underlying supraspinatus tendon • These may extend into the other tendons of the rotator cuff • Clinically the condition is known as subacromial bursitis, supraspinatus tendinitis or pericapsulitis • It is characterized by the presence of a spasm of pain in the middle range of abduction

21. Rotator Cuff Tendinitis • In advanced cases, the necrotic supraspinatus tendon can become calcified or rupture • Causes serious interference in the normal abduction of the shoulder joint • Patient will be unable to initiate the abduction of the arm • If the arm is passively assisted for the first 15° of abduction • Deltoid can then take over and complete the movement to a right angle

22. Sternoclavicular Joint Injuries • The strong costoclavicular ligament firmly holds the medial end of the clavicle to the first costal cartilage • Violent forces directed along the long axis of the clavicle usually result in fracture of the bone • Dislocation of sternoclavicular joint takes place occasionally

23. Sternoclavicular Joint Injuries Anterior Dislocation • It results in the medial end of the clavicle projecting forward beneath the skin • It may also pulled upward by the sternocleidomastoid muscle

24. Sternoclavicular Joint Injuries Posterior Dislocation • It usually follows direct trauma applied to the front of the joint that drives the clavicle backward • Displaced clavicle may press on the trachea, esophagus and major vessels • If the costoclavicular ligament ruptures completely, it is difficult to maintain the normal position of the clavicle once reduction has been accomplished

25. Acromioclavicular Joint Injuries • A severe blow on the point of the shoulder, during blocking or tackling in football can result in the acromion being thrust beneath the lateral end of the clavicle, tearing the coracoclavicular ligament • The condition is known as shoulder separation • The displaced outer end of clavicle is easily palpable • The dislocation is easily reduced but withdrawal of support results in redislocation

26. Stability of Shoulder Joint • The shallowness of the glenoid fossa and lack of support provided by weak ligaments make this joint unstable • Its strength almost entirely depends on the tone of the short muscles that bind the upper end of humerus to scapula • The tendons of these short muscles form the rotator cuff • The least supported part of the joint lies in the inferior location

27. Anterior Dislocation of Shoulder Joint • Sudden violence applied to the humerus with joint fully abducted tilts the humeral head downward onto the inferior week part of the capsule • The humeral head comes to lie inferior to the glenoid fossa • The strong flexors and adductors of the shoulder pull the humeral head forward and upward

28. Posterior Dislocation of Shoulder Joint • Posterior dislocations are rare • Usually caused by direct violence to the front of the joint • The rounded appearance of the shoulder is lost • A subglenoid displacement of the humeral head can cause axillary nerve damage • Downward displacement of humerus can also stretch and damage the radial nerve

29. Dermatomes and Cutaneous Nerves • Dermatomes for the upper cervical segments C3 to 6 are located along the lateral margin of the upper limb • C7 dermatome is situated on the middle finger • C8, T1 and T2 dermatomes are along the medial margin of the limb

30. Dermatomes and Cutaneous Nerves • Skin over the shoulder point and halfway down the lateral surface of deltoid is supplied by supraclavicular nerves C3 & 4 • Pain may be referred to this region as a result of inflammatory lesions involving diaphragmatic pleura or peritoneum • Pleurisy, peritonitis, subphrenic abscess or gall bladder disease may be responsible for shoulder pain

31. Venipuncture and Blood Transfusion • The superficial veins are used for venipuncture, transfusion and cardiac catheterization • When the patient is in shock, the superficial veins may not be visible • The cephalic vein lies in the superficial fascia posterior to the styloid process of radius

32. Venipuncture and Blood Transfusion • The median cubital vein in the cubital fossa is separated from the underlying brachial artery by the bicipital aponeurosis • This protects the artery from a mistaken injection of irritating drugs into it • In extreme hypovolemic shock, excessive venous tone may inhibit venous blood flow and thus delay the introduction of intravenous blood into the vascular system

33. Lymphangitis and Lymphadenitis • Once the infection reaches the lymph nodes, they become enlarged and tender, known as lymphadenitis • Most of the lymph vessels from the fingers and palm pass to the dorsum of the hand before passing up into the forearm • The frequency of inflammatory edema, or abscess formation may occur on the dorsum of the hand after infection of the fingers and palm

34. Biceps Brachii and Osteoarthritis of the Shoulder Joint • The tendon of the long head of biceps is attached to the supraglenoid tubercle within the shoulder joint • Advanced osteoarthritic changes in the joint can lead to erosion and fraying of the tendon by osteophytic outgrowths • Rupture of the tendon may also occur

35. Fractures of Radius and Ulna • Fracture of the head of radius can occur from fall on the outstretched hand • Fractures of neck of the radius occur in young children from falls on the outstretched hand • Fractures of the shafts of the radius and ulna may or may not occur together • Displacement of the fragment is usually considered

36. Fractures of Radius and Ulna • Fracture of one forearm bone may be associated with a dislocation of the other bone • In Monteggia’s fracture the shaft of the ulna is fractured • Anterior dislocation of the radial head with rupture of the anular ligament • In Galezzi’s fracture the proximal third of the radius is fractured and distal end of ulna is dislocated at the distal radioulnar joint

37. Fractures of Radius and Ulna • Colles’ fracture is a fracture of the distal end of radius resulting from a fall on the outstretched hand • Commonly occurs in older than 50 years • Posterior displacement of the fragment referred as dinner-fork deformity

38. Fractures of Radius and Ulna • Smith’s fracture of the distal end of the radius occurs from a fall on the back of the hand • It is reversed Colles’ fracture • The distal fragment is displaced anteriorly

39. Injuries to the Bones of the Hand • It is common in young adults • Unless treated properly, the fragments will not unite • Permanent weakness and pain of wrist will result • Dislocation of the lunate bone occasionally occurs in young adults falling on an outstretched hand that causes hyperextension of the wrist joint • Involvement of median nerve is common

40. Injuries to the Bones of the Hand • Fractures of metacarpal bones may occur as a result of direct violence • Clenched fist striking a hard object • The boxer’s fracture commonly produces an oblique fracture of the neck of the fifth or fourth metacarpal bones • The distal fragment is commonly displaced proximally • Shortening the finger posteriorly

41. Injuries to the Bones of the Hand • Bennett's fracture is a fracture of the base of the metacarpal of the thumb • Caused by a violence applied along the long axis of the thumb or the thumb is forcefully abducted • The fracture is oblique and causes instability to the carpometacarpal joint of the thumb

42. Compartment Syndrome of Forearm • The forearm is enclosed in a sheath of deep fascia • This sheath with interosseous membrane and fibrous muscular septa divides the forearm into several compartments • Any edema can cause secondary vascular compression of blood vessels • The deep fascia must be incised surgically • A delay of even 4 hours may cause an irreversible damage to the muscles

43. Anatomic Snuff Box • The term commonly used for a triangular skin depression on the lateral side of the wrist • Bounded medially by the tendon of extensor pollicis longus and laterally by abductor pollicis longus and extensor pollicis brevis • Scaphoid bone can easily be palpated here • Pulsations of the radial artery can be felt here

44. Tennis Elbow • It is caused by a partial tearing or degeneration of the origin of the superficial extensor muscles from lateral epicondyle of humerus • It is characterized by pain and tenderness over the lateral epicondyle • Pain radiating down the lateral side of forearm • It is common in tennis players

45. Dupuytren’s Contracture • It is a localized thickening and contracture of palmar aponeurosis • It commonly starts near the root of the ring finger and draws that finger into the palm • Later the condition involves the little finger in the same manner • In long standing cases, the pull on the fibrous sheaths of these fingers results in flexion of the proximal interphalangeal joints • The distal interphalangeal joints are not involved

46. Trigger Finger • There is a palpable or even audible snapping when a patient is asked to flex and extend the fingers • Caused by the presence of a localized swelling of one of the long flexor tendons that catches on a narrowing of the fibrous flexor sheath anterior to the metacarpophalangeal joint • Can be treated surgically by incising the fibrous flexor sheath

47. Fascial Spaces of Palm and Infections • The fascial spaces of the palm are clinically important because they can become infected • Distended with pus as a result of the spread of infection in acute suppurative tenosynovitis • They can be infected after a penetrating wounds such as falling on a dirty nail

48. Pulp Space Infection • The pulp space of the fingers is a closed fascial compartment situated in front of the terminal phalanx of each finger • Infection of such a space is common and serious • Commonly occurring in the thumb and index finger • Bacteria are usually introduced into the space by pinpricks or sewing needles

49. Pulp Space Infection • Each space is subdivided into numerous smaller compartments by fibrous septa • Accumulation of inflammatory exudate within the compartment causes quick rise in pressure • If the infection is left without decompression, infection of terminal phalanx can occur

50. Pulp Space Infection • In children, pressure on the blood vessels could result in necrosis of diaphysis • The close relationship of the proximal end of the pulp space to the digital synovial sheath accounts for the involvement of the sheath in the infectious process when the pulp-space infection has been neglected