Kaan Yücel M.D., Ph.D.
20.March.2012 Tuesday
Enlargement of Axillary Lymph
Nodes
Lymphangitis
(inflammation of lymphatic vessels)
Cause: An infection in the upper limb
Humeral group – first to be involved
Enlargement of Axillary Lymph
Nodes
Metastatic cancer of the apical group
adhere to axillary vein
excision of part of the axillary vein
Enlargement of the apical nodes
obstruction of the cephalic vein
superior to pectoralis minor
Enlargement of Axillary Lymph
Nodes
Arterial Innervation and Raynaud’s Disease
o The arteries of the upper limb are
innervated by sympathetic nerves
through the brachial plexus.
o Vasospastic diseases involving digital
arterioles, such as Raynaud’s disease,
may require a cervicodorsal
preganglionic sympathectomy to
prevent necrosis of the fingers.
o The operation is followed by arterial
vasodilatation, with consequent
increased blood flow to the upper limb.
Aneurysm of Axillary Artery
The first part of the axillary artery may enlarge (aneurysm of the
axillary artery) and compress the trunks of the brachial plexus,
causing pain and anesthesia (loss of sensation) in the areas of the
skin supplied by the affected nerves.
Spontaneous Thrombosis of the Axillary Vein
Spontaneous thrombosis of the axillary vein occasionally occurs
after excessive and unaccustomed movements of the arm at the
shoulder joint.
Dermatomes and Cutaneous Nerves of the Upper Limb
Checking the integrity of
the spinal cord segments on the skin
Dermatome: Skin area supplied by a spinal
segment
C3-C6 lateral margin of the limb
C7
middle finger
C8-T2 medial margin of the limb
Shoulder Pain
The skin over the point of the shoulder and
halfway down the lateral surface of the
deltoid muscle is supplied by the
supraclavicular nerves (C3 and 4)
The afferent stimuli reach the spinal cord via
the phrenic nerves (C3, 4, and 5).
Differential diagnosis time
 Inflammatory lesions involving the diaphragmatic
pleura or peritoneum
 Pleurisy
 Peritonitis
 Subphrenic abscess
 Gallbladder disease
Complete lesions involving all the
roots of the plexus are rare.
Incomplete injuries are common and
are usually caused by traction or
pressure; individual nerves can be
divided by stab wounds.
Upper Lesions of the Brachial Plexus
(Erb-Duchenne Palsy)
Excessive displacement of the head to the opposite side & depression
of the shoulder on the same side.
Result-Excessive traction or even tearing of C5 and 6 roots
Infants during a difficult delivery
In adults after a blow to or fall on the shoulder
The actor Martin Sheen,
however, is on record as
mentioning a birth accident in
which forceps "mangled" his
shoulder.
shoulder dystocia
Nerves derived from C5 & C6 roots affected
Suprascapular nerve
Nerve to the
subclavius
MusculocutaneousMuscles
nerve Axillary
nerve
paralyzed
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Supraspinatus (abductor of the shoulder)
Infraspinatus (lateral rotator of the shoulder)
Subclavius (depresses the clavicle)
Biceps brachii (supinator of the forearm, flexor of the
elbow, weak flexor of the shoulder)
Greater part of the brachialis (flexor of the elbow)
Coracobrachialis (flexor of the shoulder)
Deltoid (abductor of the shoulder)
Teres minor (lateral rotator of the shoulder)
Limb hanging by the side
Medially rotated
[unopposed sternocostal part of
pectoralis major]
Forearm pronated loss of
biceps brachii action
Waiter’s tip position
Loss of sensation down the
lateral side of the arm
Lower Lesions of the Brachial Plexus (Klumpke Palsy)
Usually traction injuries caused by excessive abduction of the arm
First thoracic nerve
Median & ulnar nerves
Hand- Clawed appearance
Hyperextension of metacarpophalangeal joints
Flexion of interphalangeal joints
Loss of sensation medial side of the arm
C8 nerve damaged, medial side of the forearm, hand, and medial two
fingers.
Long Thoracic Nerve Injuries
Serratus anterior muscle
Blows to or pressure on the
posterior triangle of the neck
During the surgical procedure of
radical mastectomy
Difficulty in raising the arm above
the head.
Winged scapula
The vertebral border & inferior angle of the
scapula will no longer be kept closely applied
to the chest wall and will protrude posteriorly
Axillary Nerve Injuries
Posterior cord of the brachial plexus
(C5 & 6)
Pressure of a badly adjusted crutch
pressing upward into the armpit
Vulnerable @ quadrangular space
Downward displacement of the
humeral head in shoulder dislocations
Fractures of the surgical neck of the
humerus
Axillary Nerve Injuries
Deltoid & teres minor paralysis
Loss of skin sensation over the lower half of the deltoid muscle
Radial Nerve Injuries
@Axilla
• Badly fitting crutch pressing up into
the armpit
• Drunkard falling asleep with one arm
over the back of a chair
• Fractures and dislocations of the
proximal end of the humerus
Motor
Triceps,anconeus, extensors of the wrist
paralyzyed
No extension of elbow, wrist & fingers
Wristdrop- flexion of the wrist
Supination ok intact biceps brachii
(musculocutaneous nerve)
Radial Nerve Injuries @ Axilla
Sensory
A small loss of skin sensation
Down posterior surface of lower
part of the arm
Down a narrow strip on the back
of the forearm
Variable area of sensory loss on
the lateral part of the dorsum of
the hand &on the dorsal surface
of the roots of the lateral 3 ½
fingers.
Area of total anesthesia
relatively small
because of the overlap of sensory
innervation by adjacent nerves
Radial Nerve Injuries @ Spiral Groove of Humerus
Fracture of the shaft of the humerus
The pressure of the back of the arm
on the edge of the operating table
Most common@ distal part of the groove
Motor
Wristdrop
Sensory
Variable small area of anesthesia over
the dorsal surface of the hand & dorsal
surface of the roots of 3 ½ fingers
Radial Tunnel Syndrome
o Tenderness & pain the forearm
just below the elbow
oWatch out for
lateral epicondylitis (tennis elbow)
o Differential diagnosis made on
history & physical exam
oThe difference between these two
conditions: where the elbow is most
tender
oLateral to the elbow the radial
nerve travels below the supinator
muscle
Tennis Elbow (Lateral epicondiylitis)
o Small area of chronic pain @ lateral
elbow
o Pain on wrist extension, pain when
shaking hands, weakened grip
o More common 30 -50 yrs of age
o Many conditions for the cause;
not only tennis
o Repeated use of of the forearm
extensor muscles
extensor carpi radialis brevis
lateral epicondyle to 2nd metacarpal
Injuries to the Deep Branch of the Radial Nerve
Motor nerve to the extensor muscles in the posterior compartment of
the forearm
Fractures of the proximal end of the radius
Dislocation of the radial head
No sensory loss- Motor nerve
Supinator (posterior interosseus nerve continuation of deep branch) &
extensor carpi radialis longus (radial nerve) undamaged, and because
the latter muscle is powerful, it will keep the wrist joint extended, and
wristdrop will not occur.
Injuries to the Superficial Radial Nerve
Sensory
As in a stab wound;
A variable small area of anesthesia over the dorsum of the hand &
dorsal surface of the roots of the lateral 3 ½ fingers
Musculocutaneous Nerve Injuries
o Rarely injured
o Protected beneath the biceps brachii
muscle
o Injured high up in the arm;
o Biceps & coracobrachialis paralyzed
brachialis muscle is weakened (also
supplied by radial nerve).
o Flexion of the forearm at the elbow
produced by the remainder of the
brachialis & flexors of the forearm.
Musculocutaneous Nerve Injuries
Sensory loss along the lateral side of the forearm
lateral cutaneous nerve of the forearm
continuation of the musculocutaneous nerve beyond the cubital fossa
Median Nerve Injuries
Occasionally in the elbow in
supracondylar fractures of the
humerus
Most commonly injured by stab
wounds or broken glass
proximal to the flexor
retinaculum:
Here it lies in the interval between
the flexor carpi radialis & flexor
digitorum superficialis tendons,
overlapped by the palmaris
longus.
Median Nerve Injuries @ the Elbow
Motor
o Pronator muscles of the forearm
o Long flexor muscles of the wrist &
fingers
paralyzed
Exception
flexor carpi ulnaris & medial half of flexor
digitorum profundus
 Forearm in supine position; weak wrist
flexion accompanied by adduction
 No flexion @ interphalangeal joints of
the index & middle fingers
Median Nerve Injuries @ the Elbow
Ask the patient to make a fist
o Index finger, lesser extent
middle finger straight
o Ring & little fingers flex
o No flexion @ thumb’s terminal
phalanx
flexor pollicis longus
paralysis
Thenar eminence flattened
thenar muscles wasted
Thumb laterally rotated &
adducted
Hand flattened
«ape-like» hand
Orator’s hand posture
Median Nerve Injuries @ the Elbow
Sensory
Skin sensation loss
Lateral half or less of the palm of the hand
Palmar aspect of lateral 3 ½ fingers
Vasomotor Changes
Warmer & drier skin
arteriolar dilatation and absence of sweating
resulting from loss of sympathetic control
Trophic Changes
Dry skin and scaly
Nails crack easily
Atrophy of the pulp of the fingers
Median Nerve Injuries @ the Wrist
Motor
Thenar muscles paralyzed
Thenar eminence flattened
Thumb laterally rotated &
adducted
No opposition of the thumb
«ape-like» hand
First two lumbricals paralyzed
When the patient is asked to make a
fist slowly, index & middle fingers
tend to lag behind the ring & little
fingers.
Median Nerve Injuries
Perhaps most serious disability of all in median nerve injuries :
Loss of ability to oppose the thumb to the other fingers
Loss of sensation over the lateral fingers
Delicate pincer-like action of the hand is no longer possible.
Ulnar Nerve Injuries
Most commonly injured at the elbow
where it lies behind the medial
epicondyle
usually associated with fractures
of the medial epicondyle
Most commonly injured at the wrist
where it lies with ulnar artery in
front of flexor retinaculum
Ulnar Nerve Injuries @ the Elbow
Motor
Flexor carpi ulnaris & medial half of the
flexor digitorum profundus paralyzed
ASK YOUR PATIENT TO MAKE A
FIST
o No observation/thightening of the
flexor carpi ulnaris tendon passing to
the pisiform bone
o No fxn of the profundus tendons
No flexion of ring & little fingers’
terminal phalanges
Flexion of the wrist joint will result in
abduction, owing to paralysis of the
flexor carpi ulnaris.
Ulnar Nerve Injuries @ the Elbow
Medial border of the front of the forearm flattens
wasting of underlying ulnaris & profundus muscles
Small muscles of the hand paralyzed
except thenar muscles & first 2 lumbricals
-median nerve-
Ulnar Nerve Injuries @ the Elbow
Unable to grip a piece of paper
placed between the fingers
No adduction & abduction of
fingers
No adduct the thumb
Paralyzed adductor pollicis
Extensor digitorum abduct fingers
to a small extent, when
metacarpophalangeal joints
hyperextended
FROMENT’S SIGN
Ask your patient to grip a
piece of paper between the
thumb & index finger:
S/he does so by strongly
contracting flexor pollicis
longus & flexing the terminal
phalanx
Ulnar Nerve Injuries @ the Elbow
 Metacarpophalangeal joints
hyperextended
 Interphalangeal joints
flexed
Lumbrical & interosseous muscles
paralysis
4th & 5th fingers
Ulnar Nerve Injuries @ the Elbow
 In longstanding cases the hand
assumes the characteristic “claw”
deformity (Main en griffe).
 Flattening of the hypothenar
eminence
 Loss of the convex curve to the medial
border of the hand
 Examination of the dorsum of the
hand:
Hollowing between the metacarpal bones caused
by wasting of the dorsal interosseous muscles.
Ulnar Nerve Injuries @ the Elbow
Sensory
Loss of skin sensation
o Anterior & posterior surfaces of the medial
third of the hand
o Medial 1 ½ fingers
Vasomotor Changes
Warmer and drier skin
arteriolar dilatation & absence of sweating
resulting from loss of sympathetic control
Ulnar Nerve Injuries @ the Wrist
Motor
Small muscles of the hand-except thenar & first 2 lumbricals
Clawhand more obvious
flexor digitorum profundus not paralyzed,
marked flexion of terminal phalanges
Ulnar Nerve Injuries @ the Wrist
Sensory
Main ulnar nerve & its palmar cutaneous branch usually severed
Posterior cutaneous branch, arises from the ulnar nerve trunk about
2.5 in. (6.25 cm) above the pisiform bone usually unaffected
Sensory loss confined to
o Palmar surface of medial 1/3 of the hand
o Medial 1 ½ fingers
o Dorsal aspects of middle & distal phalanges of the same fingers
Ulnar Nerve Injuries
o With ulnar nerve injuries,
the higher the lesion is the less obvious is the clawing deformity of the
hand.
o Unlike median nerve injuries, lesions of the ulnar nerve leave a
relatively efficient hand.
Sensation over the lateral part of the hand is intact, pincer-like action
of the thumb and index finger is reasonably good, although there is
some weakness, owing to loss of the adductor pollicis.
Quadrangular Space Syndrome
Compression of axillary nerve & posterior circumflex humeral artery
@ quadrilateral space
o Downward displacement of the humeral head in shoulder
dislocations
o Fractures of the surgical neck of the humerus
Deltoid & teres minor paralysis
Loss of skin sensation lower half of deltoid muscle
Rotator Cuff Tendinitis
Stabilizing the shoulder joint
Common cause of pain
in the shoulder
Excessive overhead activity of the upper limb may be the cause of
tendinitis, although many cases appear spontaneously.
Rotator Cuff Tendinitis
Subacromial bursa-Supraspinatus
Good for the ease of friction during
abduction of the shoulder
Subacromial bursitis, supraspinatus
tendinitis, or pericapsulitis
Characterized by the presence of a spasm
of pain in the middle range of abduction,
when the diseased area impinges on the
acromion.
Rupture of the Supraspinatus Tendon
o In advanced cases of rotator cuff tendinitis, the necrotic
supraspinatus tendon can become calcified or rupture.
o Inability to initiate abduction of the arm
o However, if the arm is passively assisted for the first 15° of
abduction, the deltoid can then take over and complete the
movement to a right angle.
Communications Between Median & Ulnar Nerves
o Important clinically
o Even with a complete lesion of the median
nerve, some muscles may not be paralyzed.
o Erroneous conclusion that the median nerve
has not been damaged.
Measuring Pulse Rate
The common place:
o Where radial artery lies on the
anterior surface of distal end of
the radius, proximal to the wrist,
between flexor carpi radialis &
brachioradialis tendons.
o Here the artery is covered by
only fascia and skin.
o Anatomical snuff box between extensor
pollicus longus & brevis.
Venipuncture
For straightforward blood tests antecubital
vein
it may not always be visible, but it is easily
palpated.
Cephalic vein
for short-term intravenous cannula
Anatomical snuffbox
Why an important clinical region?
1) Palpating the scaphoid bone to asses a fracture – when hand is in
ulnar deviation
2) Pulse of the radial artery
Anatomical snuffbox
Lateral border
Abductor pollicis longus &
Extensor pollicis brevis tendons
Medial border
Extensor pollicis longus tendon
Floor
Scaphoid & trapezium, distal ends of
the extensor carpi radialis longus
&extensor carpi radialis brevis
tendons
Radial artery passes via anatomical
snuffbox, deep to extensor tendons
of the thumb adjacent to scaphoid &
trapezium
Peripheral mononeuropathy of the upper
limb
Compression of the median
nerve as it passes through the
carpal tunnel into wrist
Lies immediately beneath
palmaris longus tendon and
anterior to the flexor tendons
Conditions
Diabetes mellitus
Rheumatoid arthritis
Acromegaly
Hypothyroidism
Pregnancy
Tenosynovitis
Gradual onset of numbness and
tingling in the median nerve
distribution of the hand
Breast Quadrants
For the anatomical location and description of tumors and cysts, the
surface of the breast is divided into four quadrants.
Mammography
o Radiographic examination of the
breasts, mammography, is one of the
techniques used to detect breast
masses.
o A carcinoma appears as a large, jagged
density in the mammogram.
o Surgeons use mammography as a guide
when removing breast tumors, cysts,
and abscesses.
Mastectomy –breast excisionSimple mastectomy
Breast is removed down to the
retromammary space.
Radical mastectomy
More extensive surgical procedure
Removal of the breast, pectoral
muscles, fat, fascia, and as many
lymph nodes as possible in the
axilla and pectoral region.
Gynecomastia
Breast hypertrophy in males after puberty
Relatively rare (<1%)
• Age or drug related
• Imbalance between estrogenic and androgenic hormones
• A change in the metabolism of sex hormones by the liver
Rule out important potential causes, e.g. suprarenal or testicular
cancers
Polymastia
(supernumerary breasts)
Only a rudimentary nipple & areola mistaken
for a mole (nevus)
Polythelia
(accessory nipples)
Amastia
No breast development
@ Axillary fossa
or
anterior abdominal wall
Extra breasts along a line from
axilla to groin
embryonic mammary crest
milk line
Auscultatory Triangle
Site on the back where breath sounds
may be most easily heard with a
stethoscope
Boundaries
Latissimus dorsi
Trapezius
Medial border of the scapula
Stiff Neck
Levator scapulae connects the neck and
shoulder
Pain when trying to turn the head to the
side where it hurts, often turning the
body instead of the neck to look behind
Common causes
• Turning the head to one side while
typing
• Long phone calls without a headset
• Sleeping without proper pillow
support with the neck tilted or rotated
• Activities such as vigorous tennis,
swimming the crawl stroke