The right clavicle is usually stronger and shorter. 

The weakest part of the clavicle is the junction of its middle and lateral thirds. 

What happens when you fracture the clavicle and why?  (IE - the medial portion goes where?  The lateral portion goes where?) 

How will the patient present? 

The SCM elevates the medial portion. 

The pectoralis major pulls the lateral portion medially. 

Patient will have an easily palpable elevated portion with a drooping shoulder. Patients often support the shoulder with the other limb.  

What is a greenstick fracture? 

What is an impacted fracture? 

A greenstick fracture is an incomplete break of the bone where one side is broken and the other is bent. 

An impacted fracture is where one bone is driven into another

What is the most common fracture spot for the proximal end of the humerus? What is most likely damaged here? 

Define an intercondylar fracture of the humerus. 

Most common fracture spot @ proximal end = surgical neck. Axillary groove and posterior circumflex humeral are most likely damaged. 

Intercondylar fracture - Olecranon of the ulna driven between the medial and lateral condyles of the humerus.

What nerves are in direct contact with the humerus at the: 

- surgical neck

- radial groove

- distal end of humerus

- medial epicondyle

- surgical neck: axillary n. 

- radial groove: radial n. 

- distal end of humerus: median n. 

- medial epicondyle: ulnar n. 

Where are the radius and ulna usually fractured? 

What is a colles fracture? Which direction does the bone typically go? What is the clinical presentation? 

The medial 1/3 

 Colles fracture: A fracture of the distal end of the radius (styloid process).  The bone typically displaces dorsally and is often a comminuted fracture (pieces). 

The clinical presentation of a colles fracture is the dinner fork deformity which results because the ulna is now longer than the radius and the radius is displaced dorsally. 

An epiphysial plate injury occurs in children and is where the epiphysial plate was transected by a fracture.  

This may result in malalignment of the epiphyseal plate, leading to growth deformities.

What is the most frequently fractured carpal bone? 

Where will pain occur? What movements?

What is the possible complication with this fracture and why? 

Scaphoid. 

Pain occurs on the lateral side of the wrist during dorsiflexion and abduction. 

Avascular necrosis of the proximal fragment may occur because this part receives poor blood supply.  This may lead to degenerative joint disease of the wrist. 

What may be injured when the hook of hamate is fractured? 

What is "boxer's fracture"? 

Ulnar n. and ulnar a. 

Boxer's fracture: fracture of the 5th metacarpal

Poland Syndrome: The pectoralis major and minor are both absent. Also seen - breast hypoplasia and ribs 2-4. 

What is innervated by the long thoracic nerve? 

What condition occurs when the LTN is paralyzed? 

Why is paralysis of the LTN more common? 

Serratus Anterior Posterior

Winged scapula. 

Also, the upper limb can't be abducted above horizontal 

The LTN runs superficial to the serratus anterior

Define the boundaries of the Triangle of Auscultation

What is the clinical significance of this triangle

Trapezius, Latissimus dorsi, medial border of the scapula

It's a good place to auscultate the posterior lungs. 

What occurs when the accessory nerve (CN XI) is paralyzed?  

What is innervated by CN XI?

SCM and trapezius 

SCM - loss of ipsilateral flexion and contralateral rotation. Torticolles. 

Trapezius - shoulder drop. Inability to shrug shoulders against resistance. 

What does the thoracodorsal nerve innervate?

What happens when the TD is paralyzed? 

Latissimus dorsi 

The person is unable to raise the trunk with the upper limbs (no climbing). Latissimus is responsible for medial rotation, adduction, extension of the shoulder. 

What is innervated by the dorsal scapular nerve? 

What happens when it's paralyzed? 

Rhomboid major, Rhomboid minor, Levator scapulae

The scapula shifts laterally. 

What is innervated by the axillary nerve? 

What happens when the axillary nerve is paralyzed? 

Teres minor, deltoids

Deltoid atrophies and the shoulder appears flattened with a hollow underneath the acromion.  Loss of sensation over the lateral side of the proximal arm (superior lateral cutaneous n.) 

What are the SITS muscles? 

What muscle is most commonly torn?

Muscles that stabilize the rotator cuff --

Supraspinatus

Infraspinatus

Teres minor

Subscapularis 

Supraspinatus. 

What demarcates the parts of the axillary artery? 

What is in each part? 

Axillary I - border of 1st rib --> pectoralis minor

** Superior thoracic artery

Axillary II - Pectoralis minor 

** Thoracoacromial trunk

** Lateral thoracic artery

Axillary III - Posterior to pectoralis minor --> inferior border of teres major (Axillary then becomes brachial a.)

** Subscapular artery 

** Anterior and Posterior circumflex humeral 

What vessels join to form the scapular anastamoses? What are their origins? 

Will ligation of the axillary artery between the subscapular a. and profundi brachii a. produce ischemia? 

Dorsal scapular a. (subclavian), suprascapular a. (subclavian), subscapular a. (axillary). NOTE: The subscapular a. becomes the scapular circumflex a.

Yes. Collateral circulation between the elbow anastamoses and shoulder anastamoses is not sufficient. 

If the first part of the axillary a. enlarges, what is likely compressed? 

Who does axillary aneurysms likely occur in? 

The brachial plexus (trunks) 

Baseball pitchers due to repeated forceful arm movements. 

Does the axillary vein sit anterior or posterior to the axillary artery?

Where does the axillary vein become the subclavian vein? 

The axillary vein is ANTERIOR to the axillary a. 

As the first rib is crossed. 

Define lymphangitis. 

If there in an infection in the upper limb, what lymph nodes are usually involved first? 

What are the clinical signs? 

lymphangitis - inflammation of the lymphatic vessels

The humeral nodes

Warm, red, tender steaks in the skin around the infection. 

If there is an infection in the pectoral or breast region, what lymph nodes are most likely involved? 

Describe the typical lymph node drainage of the upper limb.

The axillary lymph nodes. 

Humeral nodes, pectoral nodes, subscapular nodes all drain into the central nodes.  Central nodes drain into the apical nodes which drain out of the axillary lymph region to the supraclavicular nodes and subclavian lymphatic trunk. 

Define prefixed brachial plexus. 

Define postfixed brachial plexus. 

What are possible complications of a prefixed BP? 

Prefixed BP arises from C4-C8.  

Postfixed BP arises from C6-T2.

Since a lower spinal nerve is involved, it may become impinged on the 1st rib and cause neurovascular issues. 

Describe Erb's palsy and what injury it results from.

What muscles are most likely involved? 

What is another superior brachial plexus injury caused by carrying heavy packs? 

Erb's palsy (waiter's tip) - medial rotation of the limb, adducted shoulder, extended elbow

Injuries to the upper brachial plexus (C5-C6)

Deltoid, biceps, brachialis, brachioradialis

Backpacker's palsy

Describe Klumpke's paralysis. 

What is the physiological cause? 

What actions may cause this? 

Klumkpe's paralysis: (claw hand) inability to flex the 4th and 5th digit

Injury to the lower brachial plexus 

Upper limb is suddenly pulled superiorly 

Deep cervical lymph nodes 

Axillary lymph nodes

What are the boundaries of the clavipectoral (deltopectoral) triangle? 

What runs through it? 

Superior - clavicle 

Medial - Pectoralis major 

Lateral - Deltoid

cephalic vein

What does the bicipital myotatic reflex test? 

Define and describe the mechanism for biceps tendinitis. 

What is a clinical symptom for biceps tendinitis? 

integrity of the musculocutaneous n. and C5/C6

Biceps tendinitis - inflammation of the biceps tendon usually due to wear on the synovial sheath surrounding the tendon in the intertubercular groove.  

Usually due to repeated wear. Sports - throwing a ball, use of a raquet

Crepitus and tenderness

Where is the biceps tendon most likely to rupture? 

What is the likely clinical appearance? 

supraglenoid tubercle 

The detached muscle forms an anterior ball near the distal aspect of the arm. 

If the brachial artery is clamped mid-shaft, will the distal arm become ischemic? Why or why not? 

What is the flow of blood in this area?

No.  There is collateral circulation to the elbow as long as the occlusion occurs after the profundi brachii 

Axillary a. --> Profundi brachii --> Middle and radial collateral branches --> radial recurrent a. --> radial a. 

Axillary a. --> Superior ulnar collateral a. --> ulnar recurrent (also meets with inferior ulnar collateral) --> ulnar

What is most likely injured by a midhumeral fracture?

What are the clinical manifestations of this injury? 

Describe the course of this nerve?

Radial n. 

Loss of extension distal to the injury. Loss of dorsolateral sensation in the forearm

Enters the arm on the posterior aspect (posterior to the brachial a.) --> descends inferolateral with the profundi brachii --> radial groove --> lateral epicondyle --> divides deep and superficial at supinator --> superficial continues lateral to radius; deep becomes posterior interosseous

deep fascia.

Provides protection to the median n. and brachial a. 

What actions are weakened or lost by a musculocutaneous n. injury?  What muscles are involved?

What sensation is lost? 

Describe tennis elbow

Describe "mallet finger" or "baseball finger".

What can't these people do? 

Tennis elbow (elbow tendinitis) is pain that radiates from the lateral epicondyle down the posterior surface of the arm.  It's caused by repetitive use of the superficial extensor muscles.  

Mallet finger is when the attachment of the extensor tendon to the base of the distal phalanx is avulsed. 

Cannot extend their distal interphalangeal joint. 

What is a superficial ulnar artery?

What is the danger here? 

Where is pulse commonly measured? 

When the ulnar a. descends superficial to the flexor muscles. 

The ulnar artery may be mistaken for the cubital venous and used for venipuncture or drug injection. 

Radial a. lateral to the flexor carpi radialis 

What happens when the median nerve is injured proximally (elbow) ?

What is the clinical sign for this? 

Flexion in PIP joints lost or weakened. 

Flexion in DIP joints lost in 2nd and 3rd

Flexion of MC joints in 2nd and 3rd

Thenar muscle function is lost. 

This produces "hand of benediction"

AKA - inability to flex 2nd and 3rd digit when trying to make a fist. 

What is pronator syndrome? 

Between what two muscles does it typically occur?

Pronator syndrome: entrapment of the median n. at the elbow. 

Can occur due to compression between the pronator teres heads by the elbow

Where do ulnar n. injuries typically occur? (4)

Describe "Claw Hand" 

It results from what? 

1 - posterior to medial epicondyle of humerus - "funny bone"

2 - cubital tunnel formed by flexor carpi ulnaris 

3 - at the wrist - "Guyon's Tunnel Syndrome" 

4 - in the hand

Claw Hand: Inability to flex DIP of 4th or 5th digit and can't extend DIP or PIP due to paralysis of lumbricals. 

Claw hand results from a distal ulnar injury

Where is the radial n. usually injured in the arm? 

What is the classic sign? 

What are the consequences of a deep radial n. injury? 

What muscles are unaffected?

Commonly by a fracture of humeral shaft

Wrist drop

Inability to extend the thumb and MP joints. No loss of sensation (that's all superficial branch)

Extensor carpi radialis longus and brachioradialis 

When the superficial branch of the radial nerve is transected, what is the result? 

Why is this area not what you would expect?

Loss of sensation in a coin-shaped area distal to the base of the 1st and 2nd metacarpals. 

There is overlap of sensation with the medial and ulnar nerves

What is dupuytren contracture of the palmar fascia? 

What does it cause? 

Another sign may be ___ ____ on the palmar skin from the wrist to the 4th and 5th digits

Dupuytren contracture: A progressive shortening, thickening, and fibrosis of the palmar fascia

It causes the digits to flex at the MC and PIP joints. 

Raised ridges

Define tenosynovitis

Name and describe the contents of the palmar synovial sheaths? 

Which two sheaths communicate at the wrist?  

Tenosynovitis: pain and tenderness due to a swelling of the synovial sheaths.

Common flexor sheath: DFP, DFS, 5th digit

Fibrous digital sheaths: 2nd, 3rd, 4th MC --> end

Flexor pollicis longus

Common flexor sheath and flexor pollicis longus

What is Quervain tenovaginitis stenosans? 

What is digital tenovaginitis stenosans?

Pain in the wrist that radiates thumb to forearm.  

Caused by a fibrous thickening and fibrosis of the common sheath for the abductor pollicis longus and extensor pollicis brevis. Excessive friction. 

Digital tenovaginitis stenosans is a fibrous thickening of one of the fibrous digital sheaths. Causes an inability to extend the finger. 

What are the branch of the median nerve doesn't pass through the carpal tunnel? Significance?

What are the symptoms of carpal tunnel disorder? 

Superficial palmar cutaneous branch

Sensation isn't lost to the palm of the hand in carpal tunnel disorder. 

paresthesia/hypoesthesia/anesthesia in lateral 3.5 digits, thenar muscle loss (abduction may be OK because of radial innervation for abd. pollicis longus)

Describe ape hand

What is this caused by? 

Inability to oppose thumb and weakened abduction 

Injury to the recurrent median n. 

Describe what symptoms occur in guyon tunnel syndrome.

How are those different from a proximal n. injury?

Loss of sensation in the medial 1.5 digits. 

Weakness in OAF of digit 5, Adductor policis 

Claw hand of 4th and 5th digit

Ability to flex (FCU and 1/2 FDP) is unaffected

What is handlebar neuropathy?

Symptoms?

Riding bikes people but pressure on the hook of hamate which injuries the ulnar n. 

Loss of sensation to medial side of hand and weakness in the intrinsic hand muscles. 

What ligament is torn in shoulder separation? 

What tears in a Grade III or severe shoulder separation?

What is one of the signs of a Grade III separation?

Acromioclavicular 

Grade III: both the acromioclavicular and the coracoclavicular ligaments are torn. 

The clavicle may be superior to the acromion and the acromion is prominent

Define calcific scapulohumeral bursitis

What does it cause?

Calcific scapulohumeral bursitis: calcification of the subacromial bursa due to calcium deposits in the supraspinatus tendon

Painful arc syndrome: pain in the first 15-30 degrees of abduction

Degenerative tendonitis of the rotator cuff results because humeral head may impinge on ______ arch.  Attrition of the _________ tendon may also occur. 

What is the test for degenerative tendonitis?

coracoacromial arch. 

supraspinatus tendon. 

Ask the person to adduct their arm from above their head slowly and smoothly.  In Degenerative tendonitis, the limb will suddenly drop from about 90 degrees

Most glenohumeral joint dislocations occur in what direction? 

Who is particularly at risk?

Anterior and inferior 

Young athletes.  Caused by excessive extension and lateral rotation of the humerus

Who is most likely to tear the glenoid labrum?

Where does a tear most commonly occur?

Athletes who have repetitive throwing motion and a hx of glenohumeral joint instability (dislocations) 

Anterosuperiorly 

What is "frozen shoulder"?

What are the symptoms? 

Adhesive capulitis: fibrosis and scarring of the capsule around the glenohumeral joint, rotator cuff, and subacromial bursa

Can't abduct arm

Bursitis of the elbow involves which bursa? 

What is this commonly known as? 

Subtendinous olecranon bursitis is caused by excessive friction between the _________ and the _________

Subcutaneous olecranon bursa

"Dart thrower's elbow" and "Miner's elbow"

Subtendinous olecranon bursitis is caused by friction between the olecranon and triceps

What can result if a child's arm is jerked upwards while the limb is protonated?

What has occurred? 

What complication can occur? 

Nursemaid's elbow

The anular ligament has slipped and the radius has moved out of place.  

The ligament can become trapped between the radius and the capitulum of the humerus 

Why is dislocation of the lunate serious? 

What is arthrodesis and what is it used for? 

The lunate can compress the median n. and mimic carpal tunnel disorder.  It also doesn't have good blood supply and so necrosis can occur and require surgical excision. 

Arthrodesis: surgical fusion of the wrist carpals

Used to treat degenerative joint disorder of the wrist

What is "bull rider's thumb"?

What is "skier's thumb"?

What does it result from? 

Sprain of the radial collateral ligament and an avulsion fracture of the thumb PIP 

rupture or laxity of the 1st MP joint ligament

Caused by hyperabduction of the MP joint