Case- based Learning, session 1
Orthopedic Case
Spring Semester 2019- 2020
Anatomy & Physiology Block- 211
(PMED, PDNT, PPH)
Dr. Ismail Memon
Assistant Professor Anatomy
Basic Sciences Department, COSHP,
KSAU, Riyadh KSA
Clinical case 1 (Orthopedic case)
A 50-year-old lady presents to the emergency
department with severe pain just above her right wrist
joint. She gives history of forced dorsiflexion of the hand
on outstretched upper limb as a result of fall. On
inspection the area above the wrist is swollen with distal
2 cm of the radius displaced dorsally. On palpation
generalized muscular pain in forearm muscles and
localized tenderness just above the wrist is present.
Reverse relation between the radial and ulnar styloid
processes is found. X - Ray examination of the forearm
suggests complete transverse fracture of distal 2 cm of
the radius. A diagnosis of Colle’s fracture with dinner fork
deformity was made.
Clinical case 1 (Orthopedic case)
• A 50-year-old lady presents to the emergency department with
severe pain just above her right wrist joint.
• She gives history of forced dorsiflexion of the hand on
outstretched upper limb as a result of fall.
• On inspection the area above the wrist is swollen with distal 2
cm of the radius displaced dorsally.
• On palpation generalized muscular pain in forearm muscles and
localized tenderness just above the wrist is present.
• Reverse relation between the radial and ulnar styloid processes
is found.
• X - Ray examination of the forearm suggests complete
transverse fracture of distal 2 cm of the radius.
• A diagnosis of Colle’s fracture with dinner fork deformity was
made.
Clinical case 1 (Orthopedic case)
Students will be able to (Learning objectives):
1. List the bones of the forearm and hand.
2. Describe important features of radius, ulna and hand bones.
3. Enumerate the joints of the forearm and hand (inferior radioulnar, wrist, intercarpal, and metacarpophalangeal joints).
4. Name of the muscle groups of forearm and hand with their
actions.
5. Discuss radiographic normal appearance of the bones of the
forearm and hand.
6. Discuss reverse relation between the radial and ulnar styloid
processes.
7. Discuss Colle’s fracture with dinner fork deformity
Describe the following:
• dorsiflexion of the hand
• inspection
• palpation
• forearm
• tenderness
• reverse relation
• Colle’s fracture
Common activities or accidents that case fracture of
Scaphoid Bone
Dr. Ismail Memon
The forearm
• The forearm is the part of the upper limb
that extends between the elbow joint and
the wrist joint
• The bones of the forearm are the radius
(lateral) and the ulna (medial)
• The radius articulates, proximally, with
capitulum of the humerus, and distally, with
the carpal bones of the hand where it forms
the wrist joint
• The ulna is large proximally and small distally
• Proximal and distal joints between the radius
and the ulna allow the pronation and
supination of the hand
LO-1
Dr. Ismail Memon
List the bones of the forearm and hand.
Bones of the forearm
• Radius
• Ulna
Bones of the hand.
Carpal (wrist) bones: there are 8 carpal (wrist)
bones arranged in two, proximal and distal,
rows
Proximal row, from lateral to medial, consists
of:
1. scaphoid, 2. lunate, 3. triqurtral, 4. pisiform
Distal row, from lateral to medial, consists of:
1. trapezium, 2. trapezoid, 3. capitate, 4.
hamate
LO-1
Features of Radius
• The radius has proximal end, shaft and distal end
• The proximal end of the radius consists of a
head, a neck, and the radial tuberosity
• The head of the radius is a thick disc-shaped. The
superior surface is concave for articulation with
the capitulum of the humerus.
• The neck is a short and narrow between the head
and the radial tuberosity
• The radial tuberosity is a large projection which
provide attachment for the biceps brachii tendon
• The shaft of the radius is triangular in crosssection, with: three borders (anterior, posterior,
and interosseous) and three surfaces (anterior,
posterior, and lateral)
• The distal end is broad and somewhat flattened
which articulates with the distal end of the ulna
and two carpal bones (the scaphoid and lunate)
LO-2
Dr. Ismail Memon
The ulna
• The ulna has proximal end, shaft and distal end
• The proximal end larger and consists of the
olecranon, the coronoid process, the trochlear
notch, the radial notch, and the tuberosity of ulna
• The trochlear notch articulates with the trochlea of
the humerus
• The coronoid process projects anteriorly from the
proximal end of the ulna
• The lateral surface is marked by the radial notch
for articulation with the head of the radius
• The tuberosity of ulna, is the attachment site for
the brachialis muscle
• The shaft of the ulna is triangular in cross-section
and has: three borders (anterior, posterior, and
interosseous); and three surfaces (anterior,
posterior, and medial
• The distal end of the ulna is small and
characterized by a rounded head and the ulnar
styloid process
LO-2
Dr. Ismail Memon
HAND
The hand is the region of the upper limb. It is
subdivided into three parts:
• the wrist (carpus)
• the metacarpus
• the digits (five fingers including the thumb)
• The hand has an anterior surface (palm) and a
dorsal surface (dorsum of hand)
Bones
• There are three groups of bones in the hand:
• the eight carpal bones are the bones of the
wrist
• the five metacarpals are the bones of the
metacarpus
• the phalanges are the bones of the digits
• the thumb has only two, the rest of the digits
have three
LO-2
Dr. Ismail Memon
HAND
Carpal bones
• The small carpal bones of the wrist
are arranged in two rows, a
proximal and a distal row, each
consisting of four bones
• Proximal row from lateral to medial
the consists of: the scaphoid; the
lunate; the triquetrum; and the
pisiform
• Distal row from lateral to medial
consists of: the trapezium; the
trapezoid; the capitate, and the
hamate
• All of them articulate with each other, and the carpal bones in the
distal row articulate with the metacarpals of the digits
LO-2
Dr. Ismail Memon
HAND
Metacarpals
• Each of the five metacarpal bones is related to
one digit:
• 1st metacarpal related to the thumb; 2nd -5th
metacarpals are related to the index, middle,
ring, and little fingers, respectively
• Each metacarpal consists of a base, a shaft and
distally, a head
• All of the bases of the metacarpals articulate
with the carpal bones
Phalanges
• The phalanges are the bones of the digits
• the thumb has two-a proximal and a distal phalanx; the rest of the
digits have three-a proximal, a middle, and a distal phalanx
LO-2
Dr. Ismail Memon
Enumerate the joints of the
forearm and hand
• Elbow joint
• Inferior radio-ulnar
• Wrist joint
• Intercarpal joints
• Carpometacarpal joints
• Metacarpophalangeal joints
• Proximal phalangeal joints
• Distal phalangeal joints
LO-3
Name of the muscle groups of forearm and hand with their
actions
The forearm is divided into anterior and
posterior compartments by:
• a lateral intermuscular septum, which
passes from radius to deep fascia
surrounding the forearm
• an interosseous membrane, between
the radius and ulna
• Muscles in the anterior compartment
of the forearm flex the wrist and
digits (fingers) and pronate the hand
• Muscles in the posterior
compartment extend the wrist and
digits and supinate the hand
•
Major nerves and vessels supply or
pass through each compartment
LO-4
Dr. Ismail Memon
Muscles of the forearm
ANTERIOR COMPARTMENT OF THE FOREARM
• Muscles in the anterior (flexor) compartment
of the forearm occur in three layers:
superficial, intermediate, and deep
• Generally, these muscles are associated with:
movements of the wrist joint; flexion of the
fingers including the thumb; and pronation
• All muscles in the anterior compartment of
the forearm are innervated by the median
nerve, except for the flexor carpi ulnaris
muscle and the medial half of the flexor
digitorum profundus muscle, which are
innervated by the ulnar nerve
Superficial layer consists of four muscles:
1. Flexor carpi ulnaris, 2. Flexor carpi radialis, 3.
Pronator teres, 3. Palmaris longus
LO-4
Dr. Ismail Memon
Muscles of the forearm
Intermediate layer consists of:
Flexor digitorum superficialis
Deep layer
• There are three deep muscles in the anterior
compartment of the forearm: 1. Flexor digitorum
profundus, 2. Flexor pollicis longus, and 3. Pronator
quadratus
LO-4
Dr. Ismail Memon
Muscles of the forearm
POSTERIOR COMPARTMENT OF THE FOREARM
Muscles
• Muscles in the posterior compartment of
the forearm occur in two layers: a
superficial and a deep layer
• The muscles are associated with:
movement of the wrist joint; extension of
the fingers and thumb; and supination
• All muscles in the posterior compartment
are innervated by the radial nerve
Superficial layer
• There are seven muscles in the superficial
layer. 1. Brachioradialis, 2. Extensor carpi
radialis longus, 3. Extensor carpi radialis
brevis, 4. extensor digitorum, 5. Extensor
digiti minimi, 6. Extensor carpi ulnaris, and
7. Anconeus
LO-4
Dr. Ismail Memon
Muscles of the forearm
POSTERIOR COMPARTMENT OF THE FOREARM
Deep layer
• The deep layer of the posterior compartment of
the forearm consists of five muscles: 1. Supinator,
2. Abductor pollicis longus, 3. Extensor pollicis
brevis, 4. Extensor pollicis longus, and 5. Extensor
indicis
LO-4
Dr. Ismail Memon
MUSCLES OF THE HAND
• All muscles are in the palm of the hand (none
on the dorsal side)
• All hand muscles move the metacarpals and
fingers. They are involved in controlling
precise movements (e.g., threading a needle)
• Flexion: Lumbricals: Flex
metacarpophalangeal joints while extending
interphalangeal joints
• Adductors: Plamer interosei: adductors of
fingers
• Abductors: Dorsal interossei: abductors of
fingers
LO-4
Dr. Ismail Memon
MUSCLES OF THE HAND
•
•
•
•
•
Thumb:
Flexion: Flexor pollicis longus and brevis:
Extension: extensor pollicis longus and brevis
Abduction: Abductor pollicis longus and brevis:
Adduction: Adductor pollicis: also aids
opposition
• Opposition: Opponens pollicis:
LO-4
Dr. Ismail Memon
LO-5
Colles fracture
• A broken wrist is what we often call a
Colles fracture. Despite this, it is the
radius bone in the forearm that breaks
and not the carpal bones of the wrist.
• It was named for the surgeon who
first described it.
• Typically, the break is located about
an inch (2.5 centimeters) below
where the bone joins the wrist.
• A Colles fracture is a common
fracture that happens more often in
women than men.
• In fact, it is the most common
broken bone for women up to the
age of 75.
LO-6
Reverse relation between the radial and ulnar styloid processes
• Normally the radial styloid process projects farther distally than the
ulnar styloid.
• In Colle’s Fracture this relationship is reversed because of the
shortening of the Radius.
Colles' fracture
1. A Colles' fracture is a fracture of the distal
metaphysis of the radius with dorsal angulation
(dinner fork deformity).
2. Advancing age
3. Women with osteoporosis.
4. It is an extra-articular, but it can be intraarticular.
5. Uncomplicated and stable fracture.
6. Signs of instability is radial shortening