Some Clinical Points and Memory Aids

Winged Scapula

Damage to the long thoracic nerve to serratus anterior (which courses

superficially over the muscle) causes "winging" of the scapula as its medial
border lifts away from the thorax when the arm is raised. This is accentuated
when the individual leans on the hand or pushes the upper limb against a
wall. Most importantly, the arm cannot be abducted above the horizontal
plane because glenoid cavity cannot be rotated upward without the action of
the serratus anterior.

Fracture of the Clavicle

Common, especially in children

Usually results from a fall on outstretched hand or direct trauma to the
shoulder
Fractures of middle third are most frequently seen
Sternocleidomastoid muscle pulls the proximal fragment superiorly and the
shoulder pulls the distal fragment inferiorly
Small lump may remain after the clavicle has healed

Calcific Supraspinatus Tendonitis

Inflammation and calcification of the subacromial bursa resulting in pain,

tenderness and limitation of movement of the shoulder joint
Calcium deposits frequently also seen in the supraspinatus tendon
Pain is especially severe with the arm abducted between 50 to 130 degrees
(the painful arc) as the supraspinatus tendon is in contact with the inferior
surface of the acromion here

Shoulder Dislocation

High mobility and instability of the glenohumeral joint leads to frequent

dislocation
95% of dislocations are in anteroinferior direction, caused by excessive
extension and lateral rotation of humerus (e.g., in the throwing motion)
Humeral head places stress on joint capsule, which may be torn anteriorly,
with elements of the rotator cuf
Axillary and musculocutaneous nerves may also be injured
Posterior dislocation is uncommon, but may occur during epileptic seizure or
electrocution

Rotator Cuff Injury

Musculotendinous rotator cuf may be damaged by trauma or degenerative

disease

One or more of tendons may be torn when the arm is forcefully abducted,
leading to pain in the anterosuperior aspect of the shoulder
Supraspinatus tendon is most commonly involved in degenerative tendonitis
Leads patient's arm to drop suddenly at approximately 90-degree abduction,
when instructed to lower it slowly from a fully abducted position

Rotator cuff muscles: SITS = Supraspinatus, Infraspinatus, Teres minor,

Subscapularis
Fracture of the Humerus

most common at the surgical neck

Especially common in elderly individuals with osteoporotic bone, falling on an
outstretched arm
The axillary nerve vulnerable to damage here
Direct blow to the arm may fracture humerus through its midshaft, with risk
of injury to the radial nerve
Fracture humerus at distal end, risking damage to the median nerve

Biceps Tendonitis

inflammation of the tendon of the long head of the biceps

Tendon is susceptible to wear and tear as it moves back and forth within the
intertubercular groove
Degenerative wear a common cause of shoulder pain
Inflammation also caused by repetitive microtrauma, seen in certain sports
such as tennis

Rupture of the Biceps Brachii

"Popeye deformity" with muscle forming a ball in distal part of the anterior
arm
Tendon of long head has the highest rate of spontaneous rupture of any
tendon in the body
Rupture of the tendon on background of chronic tendonitis usually afects
those older than 40
Traumatic rupture may occur in younger individuals, but is rare

Cubital fossa (from medial to lateral): MADELINE BROWNS BIG RED PURSE
Madeline -Median Nerve
Brown's -Brachial Artery
Big -Biceps tendon
Red -Radial Nerve

Purse -Posterior interosseous nerve

Subluxation of the Radial Head (Nursemaid Elbow)

Caused by sudden pulling on the upper limb with the forearm pronated
Distal attachment of the annular ligament is torn and radial head slips out,
trapping the ligament between it and the capitulum
Preschool children, especially girls, most vulnerable
Head of radius is repositioned by supinating forearm fully and then flexing
elbow

Bursitis of the Elbow

Repeated pressure or friction on a bursa may cause it to become inflamed

and tender
Subcutaneous olecranon bursitis ("student's elbow") most common, often
occurring in students (from resting elbows on desk), darts players and from
falls and abrasions to the elbow
Subtendinous olecranon bursitis less common, as is bicipitoradial bursitis

Epicondylitis

Activities involving repetitive movements of wrist may lead to localized elbow

pain
Repeated extension of wrist causes lateral epicondylitis ("tennis elbow")microtrauma of common extensor muscle origin, with pain felt over the
lateral aspect of the elbow
Medial epicondylitis ("golfer's elbow") from repeated wrist flexion, with pain
felt over the medial epicondyle, especially on resisted wristflexion
Bursitis or synovitis may coexist with epicondylitis

Radial nerve innervates the BEST!

Brachioradialis
Extensors
Supinator
Triceps

Muscles that flex the elbow: Three B's

Bend the elBow

Brachialis Biceps
Brachioradialis

Colles' Fracture

Complete transverse fracture within the distal 2 cm of the radius

Distal fragment displaced dorsally, giving the classic "dinner fork deformity"
Ulnar styloid may also be avulsed
Results from forced dorsiflexion of the hand, such as in breaking a fall with an
outstretched, pronated hand
Most common fracture in adults older than 50 years old
Seen most frequently in elderly women
Healing usually good as the bone has a rich blood supply

Scaphoid Fracture

Scaphoid is the most commonly fractured bone of the carpus

Proximal pole of the bone has a poor blood supply and as a result, fracture
may take several months to heal
This increases risk of avascular necrosis and subsequent degenerative joint
disease at the wrist
Fracture often difficult to spot on initial radiographs, which should be
repeated at 2 to 3 weeks in any patient presenting with a severely sprained
wrist

Dupuytren's Contracture

Progressive fibronodular thickening of the palmar fascia

Leads to fixed flexion deformity of the fingers (most commonly the fourth and
fifth digits)
Condition often bilateral and usually afects middle-aged males of Northern
European decent, suggesting hereditary predisposition
Risk factors include alcohol, liver disease, and antiepileptic medication
Treatment is surgical

Carpal bones (lateral to medial): Some Lovers Try Positions That They Can't
Handle
PROXIMAL ROW

Some- Scaphoid
Lovers- Lunate
Try- Triquetral
Positions- Pisiform

DISTAL ROW

That- Trapezium ("Trapezium over the thumb")

They- Trapezoid
Can't- Capitate
Handle- Hamate

Note: If you forget if you're starting at the lateral or medial side of each row,
remember that the Scaphoid is in the anatomical snufbox and the trapeziUM is at
the base of the thUMb.
Flexor carpi superficialis and profundus insertions: Superficialis splits the two,
to permit profundus to pass through
Interossei muscles:

Palmar interossei ADduct the digits (PAD)

Dorsal interossei ABduct the digits (DAB)

Brachial Plexus Injury

Disease, trauma or excessive stretching (because of birth trauma) of the

posterior triangle of the neck or axilla may damage brachial plexus
Results in paralysis and anaesthesia in the distribution of the afected nerves
Various terms used to describe the diferent lesions
Erb's palsy afects areas supplied by nerves from superior part of the plexus
Klumpke's palsy afects areas supplied by nerves from the inferior part

Carpal Tunnel Syndrome

compression of the median nerve as it passes under flexor retinaculum

Compression caused by any process that significantly reduces the size of the
carpal tunnel: inflammation of the synovial sheaths, fluid retention, and
infection
Pain or paraesthesia felt in the lateral 3 digits, may radiate toward the
elbow and is often worse at night
Also loss of sensation and diminished control of the median nerve-innervated
muscles
Surgical division of the flexor retinaculum may be necessary to relieve
symptoms

Ulnar Nerve Injury

Ulnar nerve may be compressed as it passes behind medial epicondyle of the

humerus or through the Guyon canal at the wrist
Pain and/or paraesthesia felt at medial aspect of the elbow radiating to the
medial forearm and medial 1 digits
Also may be weakness of the intrinsic muscles of the hand

Radial Nerve Injury

Palsy of the radial nerve common after prolonged pressure on the back of the
arm by resting it against a hard surface (such as back of movie theater seatthe "Saturday night palsy")

Nerve may also be injured in fractures of humerus as it winds along spiral

groove
Extensors of the wrist are paralyzed, resulting in a wrist drop
Triceps not afected unless the nerve is injured proximally in the axilla

Parts of the brachial plexus: Really Thirsty? Drink Cold Beer

Roots, Trunks, Divisions, Cords, Branches

Terminal nerves of plexus: MARMU (Musculocutaneous, Axillary, Radial,
Median, Ulnar)

Muscles supplied by median nerve supply in hand:

LOAF
Lumbricals (lateral), Opponens pollicis, Abductor pollicis brevis, Flexor pollicis
Brevis

Branches of brachial plexus medial cord: Money Makes Many Men Unhappy

Medial pectoral nerve

Medial branch of median nerve
Medial cutaneous nerve of arm
Medial cutaneous nerve of forearm
Ulnar nerve