Clinical Correlates: Upper Limb
Selected joint movements are used to test myotomes:
C5 - aBduction of the arm at the glenohumeral joint
C6 – flexion of the forearm at the elbow joint
C7 – extension of the forearm at the elbow joint
C8 – flexion of the fingers
T1 – aBduction and aDduction of the index, middle and ring fingers
Unconscious patients:
1. Tap on the tendon of the biceps in the cubital fossa
2. Tap on the tendon of the triceps posterior to the elbow:
C6
C7
Sidenote: C4 controls diaphragm, testing arm can determine potential breathing issues
impacted through damage of the spinal cord just below C4
Fractures of the arm:
Surgical neck: Axillary n. posterior
Posterior circumflex a. (must check for axillary n. continuity before resetting)
Midshaft of humerus: Radial
Medial Epicondyle:
Ulnar
Fracture of the clavicle/Dislocation of the acromio-clavicular joint
1. Clavicle typically fractured at the middle 3rd
2. Posterior dislocation of the clavicle at the acromio-clavicular joint can impinge on the
vessels underlying:
a. Aorta
b. Vagus n., cardiac n., phrenic n.
Dislocations of the glenohumeral joint:
1. Anterior dislocation (antero-inferior) – glenoid labrum can be torn, leaves joint susceptible
to repeated dislocation.
a. Can result in injury to the axillary nerve
b. Stetching of the humerus may cause radial nerve paralysis
2. Posterior dislocations: extremely rare. Should focus on cause (rigorous muscle
contraction(seizures)
Rotator Cuff Disorders:
1. Impingement: space is fixed in dimensions - swelling of the supraspinatus can result in
impingment during aBduction
2. Tendinopathy: blood supply to supraspinatus is poor, repeated injury can lead to
degeneration
Trapezius: The accessory (XI) nerve can be assessed by evaluating “shrugging” of shoulders
Quadrangle Space Syndrome:
Hypertrophy of the muscles or fibrosis of the edges may impinge on axillary nerve
-
Atrophy of the teres minor
Axillary Space:
“Insiders Really Can’t Suntan Like Irish And Professional Students Must Study and Pretend To Stay Lucid”
Inlet: (Insiders really can’t suntan)
-
Rib 1
Clavicle
Superior part of coracoid process
Medial Wall: (Must Study)
-
Serratus anterior
Anterior Wall: (And Professional Students)
-
Pec major/minor
Subclavius m.
Lateral Wall: (Like Irish)
-
Intertuburcular sulcus
Posterior Wall: (Pretend to stay lucid)
-
Subscapulars m.
Teres major
Lattisimus dorsii
Cubital Fossa: Please Bend The Big
-
Protonator teres
Brachoradialis
o Tendon of biceps brachii
o Brachial a.
o Median n.
Carpal Tunnel:
Contains Flexor digitorum superficialis and profundus tendons
Intercostalbrachial nerve: only nerve that passes through the medial wall of the axillary inlet
-
From ant. Ramus of T2 (think armpit)
Damage of the long thoracic nerve:
-
Serratus anter. Results in winging of the scapula when arm is pushed forward
Trauma to arteries:
-
-
Fracture of rib 1
o Rapid deceleration may cause fracture
o Anastomosis between axillary and subclaving  collateral flow
Anterior dislocation of humeral head
o May compress the axillary a.
o May damage w/ brachial plexus, very often requires surgical intervention
Subclavian pinch-off syndrome:
-
The “subclavian route” for access to veins is actual entry into the axillary v.
Good for longterm access
Vein should be punctured at the midclavicular line
o Care to be taken to avoid entry of vein when it is flush with the subclavius
muscle, as constant action will result in damage to vein/catheter
-
Lymphatic drainage from breast passes through part of axilla
If lymphatics are removed, arm may swell and pitting edema (lymheda) may occur
-
Humeral: posteromedial to axillary vein, receive most drainage from upper limb
Pectoral: inferior margin of pectoralis minor, receive drainage from abdominal wall
and mammary gland
Subscapular: posterior axillary wall, lymphatic drain from back, neck, shoulder
Central: in axillary fat, receive from humeral, subscapular and pec nodes
Apical: most superior, accompany cephalic vein and drain superior mammary
Breast Cancer:
Lymphatics:
-
-
Axillary process: mass of lymph nodes in armpit
Rupture of the biceps:
-
Most common of the rupturing is tendon of the long head of biceps brachii
o Popeye sign upon forearm flexion
-
Proximal arm: lies on medial side
Distal arm: moves laterally to median
Passes through the cubital fossa
Brachial Artery:
Blood Pressure measurement:
-
Uses syphngomonometer, measured using brachial artery
Radial Nerve Injury
-
Radial n. is bound with the profunda brachii artery in the radial groove
Injury indicated by wrist drop, sensory change on dorsum of hand
Median Nerve injury
-
Usually not injured by trauma, usually impacted by compression under flexor
retinaculum (carpal tunnel)
Occasionally, embryologic remanent of coracobrachialis m. (Struthers ligament) can
calcify and compress
Weakness of thenar and forearm flexion muscles
Elbow Joint Injury:
-
as elbow develops in children, secondary ossification centers arise, can be mistaken
for break
sometimes epiphyses and apophyses can be pulled off
ossification sites and ages
o capitulum – 1 year
o head of radius - 5 years
o med. Epicondyle – 5 years
o trochlea – 11 years
o olecranon - 12 years
o lateral epicondyle – 13 years
Supracondylar fraction of humerus
-
transverse fracture of distal humerus
fraction tends to impede blood flow, is devastating in children
o Volkmans ischemic fracture
Transection of radial or ulnar arteries
-
Due to superficial location, if one is severed its cool
-
Children under 5, caused by sharp pull of hand
Pulled radius from elbow, can be fixed by supination
Pulled elbow
Fracture of the head of radius
-
Fall with outstretched hand
Loss of full extension
Head fills with fluid, elevating fat  Fat pad
-
Golf or tennis elbow: overuse or strain of flexors
Lateral epicondyle: tennis
Medial epicondyle: golf
Epicondylitis
Ulnar nerve injury
-
Cubital tunnel location covered by retinaculum
Results in potential for impingement in elderly
Forearm:
Fractures of the radius and ulna
-
Monteggias: proximal third of ulna and anterior dislocation of radius
Galeazzi’s: distal third of radius with subluxation (partial disloc) of ulna at wrist
Colles’: distal end of radius, posterior displacement
- Palmaris longus: absent in 15% of population
- Flexor carpi radialis: cant be easily palpated, important landmark for finding pulse in radial artery just
lateral to it
- Ulnar artery in distal forearm remains tucked under anterolateral lip of flexor carpi ulnaris, not easily
palpatable
Vasculature:
Radial a.
-
Radial recurrent: elbow, lateral forearm
Small palmar carpal branch: carpal bones
Superficial palmar: passes through thenar muscales at base of thumb, superficial
palmar arch
-
Larger than radial
Ulnar a.
-
Ulnar recurrent (ant and post branches): elbow
Common interosseus: interosseus membrane
Dorsal and carpal supply wrist
- palmar branch from median nerve branches from median n. before carpal tunnel, innervates
cutaneous of the base and central palm and is unaffected by carpal tunnel syn. Important for
distinguishing higher level impaction on nerve
Wrist:
-
Because radial styloid extends farther distal than ulnar styloid, hand can be
aDducted farther than it can be aBducted
Fracture of the scaphoid:
-
Fracture across waist of scaphoid
In 10% of people, there is direct supply of radial into proximal scaphoid, fracture
leaves avascular necrosis of distal
Carpal Tunnel:
-
Tinels sign: gentle tapping of median nerve produces pins and needles, weakness of
muscles
Allens test:
-
Compress both radial and ulnar arteries, release one and watch filling pattern
Should indicate any problems with anasthamoses between the two
o Deep and superficial palmar a. disconnect  only thumb and lateral index
finger becomes red when radial alone is released
Venipuncture
-
Cephalic vein in anterocubital fossa is preferred
Ulnar n. of hand injury
-
Clawing of the hand on digits 3-5
Elbow: flexion of carpi ulnaris lost, less severe clawing due to ulnar half of flexor
digitorum prof. being lost.
Again, look at the dorsal branch that innervates the dorsopalmar skin, loss of
sensation indicates proximal wrist injury of nerve
Radial n. of hand injury
-
Two branches, superficial and deep after elbow
-
Most common is damage in radial groove of humerus
o Wrist drop
Severing posterior interosseus nerve (deep branch of radial)
o Results in loss of ability to extend fingers
Drop Arm Test- patient cannot slowly return the arm from 90* angle back medially to the body, the
arm “drops” back to the body
4 rotator cuff muscles, supraspinatus (first 15* of motion) which is innervated by the
camera for reparative surgery would likely go through the clavipectoral triangle (pg. 686) so as not to
be required to pass through much muscle
tear in the serratus anterior (innervated by long thoracic nerve) causes “winged scapula”
sternocleidomastoid- used when gasping for breath
Deltoid- movement from 15 to 90*, axillary nerve innervation
Pectoralis major- origin @ clavicular head and sternocostal head
ROTATOR CUFF
Moro reflex- test infants falling/”startle” reflex, showing if nerve function, this can happen during a
difficult delivery if damage is caused to the brachial plexus
If neck is extended during delivery, C5 and C6 can get ripped, causing Erb’s palsy
-Biceps tendon- reflex tests C5
-Brachioradialis tendon- reflex tests for C6
-Triceps tendon- reflex tests C7
-Finger movements- test C8 & T1
C8, T1 injusry occurs if yanking motion is made on the arm (mother to child, jumping grabbing branch
and pulling of the arm)
Brachial plexus injuries
-Claw hand, papal benediction,
Wrist drop- characteristic of an injury to the radial nerve, usually from a humerus midshaft fracture
Subclavian pinch-off syndrome- cathereterization of the subclavian vein/axillary vein