Trunk and Upper limb
Yee - Back
Lumbar puncture/spinal tap: withdraw CSF from
subarachnoid space for CNS disorder diagnosis (ex.
Meningitis)
 Draw between spinous processes of L4/L5 or
L3/L4
Epidural anesthesia: anesthetic affects nerve roots of
cauda equina
 Can also be injected into sacral hiatus
Yee - Back Pain
Degenerative joint disorders that cause spinal stenosis  nerve entrapment syndrome
 Spondylolysis (scotty dog): fracture of bone connecting superior and inferior
articular processes
o Spondylolithesis: bilateral fracture leading to dislocation between the
vertebrae
 Commonly L5/S1 due to downward tilt of disc
 Osteoarthritis
 Herniated IV disc: Circumferential tears of annulus leads to nucleus pulposus
herniation  direct pressure on nerve
o Common in posterolateral due to thin annulus and narrow posterior
longitudinal ligament
o Traps lumbar nerve of the space below
o Sciatica: pain felt along sciatic nerve distribution & weakness in muscles
supplied by sciatic n.
Osteoporosis: higher bone resorption  low bone mass  reduction in weight bearing
capacity of vertebral column
 May lead to compression fractures and increased thoracic kyphosis
Spina bifida occulta
Transitional vertebra
Surgical laminectomy performed to relieve pressure on spinal cord/nerve roots
Cullen – Scapular, Pectoral & Breast
Dislocation of shoulder joint most commonly occurs inferior & anterior to triceps
Supraspinatus is most commonly injured rotator cuff muscle
Winged scapula: Injury to the long thoracic nerve causes loss of function of serratus
anterior
Peau d’orange: dimpled appearance of breast indicative of tumors pulling on the
suspensory ligaments of cooper
Anterior axillary lymph nodes: drain 75% of breast lymph, SENTINEL nodes for breast
cancer
 Parasternal nodes drain medial tissue, Subdiaphragmatic nodes drain inferior region
Cullen – Axilla & Brachial Plexus
Shoulder anastomoses: suprascapular, dorsal scapular, circumflex scapular arteries
Deep brachial artery anastomoses with posterior humeral circumflex artery
Lower trunk (C8/T1) injury: results from extreme tension and abduction or pulling arm
overhead
 Ulnar nerve damage  hyperextension of MP & flexion at IP joints of 4th & 5th digits
 Claw hand (Klumpke paralysis)
 Median nerve effected
 Medial pectoral, medial brachial cutaneous, medial antebrachial cutaneous lost
Upper trunk (C5/C6) injury: results from extreme force stretching the neck laterally

Lose most of median & musculocutaneous nerve, axillary & radial nerves also
effected  Erb-Duchenne (waiter’s tip)
o Unable to flex arm, limb hangs extended & medially rotated
Compression syndromes: compression of brachial plexus or axillary/subclavian arteries
 Limb pain, paresthesia, muscle weakness & fatigability, decreased skin temp, edema,
cyanosis, distension of distal veins
 Thoracic Outlet Syndrome: compression between thoracic outlet & insertion of
pec minor
 Costoclavicular Syndrome: compression between clavicle & first rib
 Hyperabduction Syndrome: compression between coracoid due to prolonged
hyperabduction
Cullen – Arm & Forearm
Muscle injury often occurs when muscle is forcefully extended while contracting
Isometric contraction: no change in length, support/resist force
Eccentric contraction: lengthen, slowly relax, against gravity
DeQuervain’s/Washer Woman’s Sprain: tendonitis of Abductor pollicis longus & extensor
pollicis brevis (1st compartment)
 Due to overuse of thumb  washing clothes, texting, gaming
 Use Finkelstein test to diagnose and steroid injection to treat
Lateral epicondylitis/Tennis Elbow: overuse of extensors causes swelling, tenderness,
pain on wrist extension
 Usually ECRB, ED
 Due to repetitive wrist extension, overuse of computer mouse
Medial epicondylitis/golfer/forehand/pitcher/bowler’s elbow: swelling and pressure
on median nerve due to inflamed flexors
 Especially pronator teres (median n runs through the heads of PT)
Cullen – Wrist & Hand
Dupuytren’s contracture: thickening/shortening/tightening of palmar fascia &
aponeurosis causes wrinkling at creases and finger flexion (especially at 4th & 5th digits)
Carpal Tunnel Syndrome: Thenar muscle wasting, problems with lumbricals 1 & 2, loss of
innervation to skin on lateral half of palmar surface & distal dorsal surface (3½)
 Most common neuropathy of upper limb
 Rest, reduce swelling, change ergonomics, last choice is surgery to slice transverse
carpal ligament
Laceration of the palm: can cut flexor digitorum profundus and flexor digitorum
superficialis tendons causing severed flexion of IP joints
Cullen – Joints of the Upper Limb
Clavicular injuries: first bone to calcify, easiest to break (even during birth)
 Fall on an outstretched arm drives acromion posterior and weight falls forward
Glenohumeral joint is weakest inferiorly (most able to dislocate)
 Dislocation has a high risk of injury to axillary n and radial n.
Tommy John Surgery: grafted Palmaris Longus tendon to replace the torn Ulnar collateral
ligament (typ injured from abduction)
Nursemaid’s Elbow: radius dislocation from annular ligament
 Subluxation: bone aligned but completely out of ligament
 Dislocation: bones overlap ends
Fall on an outstretched hand: most often breaks scaphoid, can injure the radial a., radius
second most common bone to break
Colles’ fracture (dinner fork deformity): hyperextension causes the distal radius to be
displaced dorsally
Smith’s fracture (spade deformity): hyperflexion causes the distal radius to be displaced
anteriorly
Mallet finger: DIP hyperflexed due forceful avulsing of distal extensor tendon from
instertion (baseball/basketball injury)
Boutonnieres’ deformity: Rupture of middle extensor tendon, PIP hyperflexed, DIP
hyperextended (sports injury)
Swan Neck deformity: Tear of middle palmar plate, PIP hyperextended, DIP hyperflexed
(opposite of boutonnieres)
Radial Nerve Injuries
 At wrist: superficial radial causes loss of sensory to dorsal hand
 At distal humerus: superficial only will be sensory to dorsal hand, deep radial will be
wrist and finger extensors, or both
 At proximal humerus: hand sensory, wrist/finger extensors, forearm extension
(triceps innervation), weak supination
o Wrist Drop: inability to extend hand, MCP, and to fully extend forearm
Median Nerve Injuries
 Median recurrent: loss of opposition, weak thumb flexion/abduction
 Wrist (at carpal tunnel): thenar wasting, sensory loss, MCP flexion of digits 2 & 3
 Humerus (vulnerable at cubital fossa or fracture of distal humerus): causes the
Hand of Benediction – no pronation, flexion lost to digits 1/2/3, thenar unable to
oppose & has weak abduction/flexion, weak wrist flexion + abduction
Ulnar Nerve Injuries
Vulnerable at posterior medial epicondyle
Claw Hand: unopposed extension of MCP 4/5 & unopposed flexion of IP 4/5 (lumbricals),
unable to flex DIP 4/5 if FDP injured
Ulnar Tunnel/Guyon’s Canal Syndrome: entrapment of ulnar n as it passes through
hamate & pisiform: cutaneous loss to medial 1½ digits & weakness of
intrinsic hand muscles