Upper Extremity Forum
1) Describe the lymphatic circulation of the mammary gland
-75% drain laterally and superiorly to the Axillary Node, via the lymphatic vessels
-Remaining drainage: parasternal nodes in the anterior thoracic wall
-some drainage go through the lateral branches of posterior intercostal arteries and
connect with intercostal nodes (near head and necks of ribs)
Axillary nodes drain into subclavian trunks
Parasternal nodes drain into bronchomediastinal trunks
Intercostal nodes drain to thoracic duct or bronchomediastinal trunks
2) Describe the characteristic features of Erb-Duchenne palsy and Klumpke’s paralysis
Duchenne Palsy
-paralysis of arm specifically the deltoid, biceps and brachialis muscles caused by injury
to C5-C6 on the upper trunk
-mainly arise from shoulder dystocia during a difficult birth, which is when the shoulder
has a difficulty passing through the pubic symphysis
-also can be caused by a traumatic fall on the side of the shoulder where the brachial
plexus is (any trauma to that area)
-Paralysis can either resolve on its own, rehabilitative therapy or require surgery
-characterized by the arm hanging and rotated medially, forearm is extended and
pronated) (waiter’s tip)
Klumpke’s paralysis
-partial paralysis of lower roots of brachial plexus
-involves muscles of the forearm and hand, injury to C8 and T1 (flexors of wrist/fingers)
-Claw hand is a characteristic of it (Ulnar nerve)
-can be caused by shoulder dystocia
3) Describe the arterial supply of the hand and layers of the palmar region
-The radial and ulnar arteries form two interconnected vascular arches (superficial and deep) in
the palm. The vessels to the various parts of he hands originate from these two arches (plus the
parent arteries)
**Posteriorly and anteriorly:
-The radial artery : thumb an lateral side of the index finger
-Ulnar artery: remaining digits and medial side of index finger
Layers of Palmar region:
Superficial to Deep
I.
II.
III.
IV.
V.
Palmar aponeurosis
Flexor digitorum superficialis and its tendons
Lumbricals, Thenar (Abductor pollicis brevis, flexor pollicis brevis,
opponens pollicis) and Hypothenar muscles (abductor digiti minimi,
flexor digiti minimi, opponens digiti minim), tendons of flexor digitorum
profundum
Palmar interossei
Dorsal interossei
4) Describe the cutaneous innervation of the upper limb
5) Describe the rotator cuff muscles and the avulsion fracture of the greater tubercle
-composed of subscapularis, supraspinatus, infraspinatus, teres minor
-main function to rotate the arm
Avulsion fracture of the greater tubercle – posterior muscles of rotator cuff will not do any
lateral rotation; will have a medially rotated humerus (greater tubercle is broken off, so the
attachments lost will cause symptoms)
6) Describe the scapular arterial anastomosis and its clinical importance
-system connecting each subclavian artery and the corresponding axillary artery forming an
anastomosis
-allows blood to flow past the joint regardless of the position of the arm
-provides an alternate path for collateral circulation to the arm from arteries
-Transverse cervical artery, transverse scapular artery, branches of subscapular artery,
branches of thoracic aorta
7) Describe the pathogenesis of claw hand, ape hand, hand of benediction and wrist drop
Claw hand – (ulnar nerve) fracture of medial epicondyle of humerus; loss of sensation in medial 1 ½
digits
Inability to extend IP joints and flex MP joints simultaneously; will only be able to completely
flex medial two fingers (if damage is at elbow instead of wrist, will not be able to flex medial two fingers)
Ape hand - inability to oppose the thumb and limited abduction of the thumb. Caused by damage to the
median nerve either at the wrist or elbow. Impairs the thenar muscles (thumb cannot be used)
Hand of benediction - results from a severed median nerve at the level of the elbow or upper arm;
ability to flex digits 2-3 of the metacarpophalangeal joints, proximal interphalangeal joints and distal
interphalangeal joints is lost; will also have an ape hand
Wrist drop - midshaft humerus fracture; due to failure of extensor muscles, and sensory changes in
dorsum of hand
8) Describe the borders and content of the cubital fossa, medial and lateral axillary spaces
Cubital Fossa – Boundaries: Brachioradialis (lateral) and Pronator teres (medial), base is imaginary line
between medial and lateral epicondyles of humerus
Content: Biceps brachii tendon, brachial artery, median nerve (lateral to medial)
Medial axillary space/triangular space - Boundaries: Long head of triceps brachii, teres major
Content: Profunda brachii artery, radial nerve
Lateral axillary space/quadrangular space – Boundaries: Post: teres minor, surg. Neck of humerus, teres
major, long head of triceps brachii
Ant: subscapularis, surg. Neck of humerus, teres
major, long head of triceps brachii
Content: Axillary nerve, Posterior circumflex humeral artery
Fracture of rib 1 or anterior dislocation of humeral head may compress axillary artery (anastomoses with
subclavian artery prevent ischemia)
9) Describe the carpal tunnel syndrome and the Dupuytren’s contracture
Carpal tunnel syndrome - weakness of thenar muscles (trouble with opposition), pain and tingling in
palmar surface of lateral 3 ½ digits and lateral side of palm and middle of wrist; caused by damage to
median nerve at the wrist (at the elbow causes hand of benediction, which is actual motor loss, as
opposed to sensory loss at wrist)
Dupuytren’s contracture – pathological thickening and contracture of the palmar aponeurosis; draws
fingers (usually digits 4-5) into the palm to such a degree that they become useless. Can mimic an ulnar
claw since it commonly affects digits 4-5. One interpretation of “hand of benediction”.
10) Describe the anatomical snuff box – borders, content
Borders: Tendons of pollicis abductor and extensors
Content: Radial nerve and artery, cephalic vein
11) Describe the spinal cord levels associated with upper limb movements and reflexes
C5-T1
Reflexes:
C6 – tap on tendon of the biceps in the cubital fossa (mainly C6)
C7 – tap on tendon of the triceps posterior to the elbow