May 8, 2009
UPPER LIMB CLINICAL CORRELATIONS + LOWER LIMB CLINICAL CORRELATIONS
Fracture Clavicle: Occurs at middle/lateral thirds. Upward displacement of proximal segment (sternocleidomastoid muscle) and downward displacement of distal segment (deltoid muscle and gravity).
Injury to lower brachial plexus and hemorrhage of subclavian vein. Calcification Superior Transverse Scapular Ligament: May trap or compress the suprascapular nerve affecting functions of the supraspinatus and infraspinatus muscle.
Fracture of Humeral Greater Tuberosity: Occurs by direct trauma and affects the supraspinatus, infraspinatus, and teres minor muscles, all which attach there by tendons.
Fracture of Humeral Lesser Tuberosity: Accompanies posterior dislocation of the shoulder joint, and the bone fragment has the insertion of the subscapularis tendon.
Fracture of Humeral Surgical Neck: May injure the axillary nerve and the posterior humeral circumflex artery as they pass through the quadrangular space.
Fracture of the Humeral Shaft: May injure the radial nerve and profunda brachial artery in the spiral groove.
Fracture of the Humeral Medial Epicondyle: May damage the ulnar nerve which may be compressed in the groove behind the medial epicondyle ‘funny bone.’
Humeral Supracondylar Fracture: Are common in children and occur when the child falls on the outstretched hand with the elbow partially flexed and may injure the median nerve.
Colle’s Fracture of the Wrist: Is a fracture of the lower end of the radius in which the distal fragment is displaced posteriorly, producing the dinner fork deformity. If distal fragment is displaced anteriorly, this is then the reverse Colle’s fracture known as Smith’s fracture.
Fracture of the Scaphoid: Occurs with a fall on the outstretched hand and may damage the radial artery.
Fracture of the Hamate: May injure the ulnar nerve and artery. Also the ulnar nerve and artery may be compressed in Guyon’s canal formed between the hook of the hamate and the pisiform.
Bennett’s Fracture: Is a fracture of the base of the metacarpal of the thumb. Boxer’s Fracture: Is a fracture of the necks of the second and third metacarpals (experienced boxer) or fifth metacarpal (unskilled boxer).
Dislocation of Acromiclavicular Joint: Results from a fall on the shoulder with the impact taken by the acromion. It is called shoulder separation because the shoulder is separated from the clavicle with possible rupture of the coracoclavicular ligament.
Inferior Dislocation of Humerus: Is not uncommon because the inferior aspect of the shoulder joint is not supported by muscle tendons of the rotator cuff. It may damage the axillary nerve and the posterior humeral circumflex vessels.
Rupture of Rotator Cuff: May occur by chronic wear and tear and is manifested by severe limitation of shoulder joint motion, mainly abduction. Chiefly the supraspinatus tendon is injured which causes subacromial bursitis and a painful shoulder. Similar to Impingement Syndrome: which impinges on the subacromial space. Positive impingement tests are: Hawkins (flex arm 90deg and internal rotate), Mire (fully pronate arm and lift overhead), Jobe (empty beer cans and lift against resistance).
Breast Cancer: Occurs in upper lateral quadrant (60% of time) producing dimpling of skin or inverted nipple. A mastectomy may injure the long thoracic and thoracodorsal nerves.
Tennis Elbow (Lateral Epicondylitis): Caused by chronic irritation of the tendons of the extensor muscles of the forearm which originate in the lateral epicondyle.
Golfer’s Elbow (Medial Epicondylitis): Caused by chronic irritation of the tendons of the flexor muscles of the forearm which originate in the medial epicondyle.
Cubital Tunnel Syndrome: Is compression of the ulnar nerve behind the medial epicondyle.
Dupuytren’s Contracture: Progressive thickening and shortening of the palmar aponeurosis producing a flexion deformity of the third and fourth fingers.
Volkmann’s Contracture: Ischemic muscular contracture (flexion deformity) of the fingers and wrist produced by necrosis of the forearm flexor muscles (wearing a tight cast).
Carpal Tunnel Syndrome: Caused by compression of the median nerve. It results from either inflammation of flexor retinaculum, arthritis of carpal bones, or inflammation of the synovial sheaths of the flexor tendons (FDS & FDP). Will cause atrophy of the thenar muscles.
Tenosynovitis: Is an inflammation of the tendon and synovial sheath. Little finger is the ulnar bursa and may spread to the carpal tunnel. Thumb is the radial bursa.
DeQuervain’s Tenosynovitis: Inflammation of the abductor pollicis longus and the extensor pollicis brevis (two tendons of bottom of snuffbox), which travel through the first dorsal compartment tunnel. Shows a positive Finklestein test.
Injury to Long Thoracic Nerve: Results in paralysis of the serratus anterior muscle and inability to elevate the arm above the horizontal. Produces winged scapula in which medial border of scapula protrudes.
Injury to Posterior Cord: Caused by pressure of a crutch resulting in paralysis of the arm called crutch palsy (Saturday Night Palsy). It results in loss of function of the extensors of the arm and forearm and produces wrist drop.
Injury to Axillary Nerve: Caused by a fracture of the surgical neck of the humerus or inferior dislocation of the humerus. It results in weakness of lateral rotation and abduction of the arm
Injury to Radial Nerve: Caused by a fracture of the midshaft of the humerus. Results in loss of function of the extensors of the forearm and hand, producing wrist drop.
Injury to Musculocutaneous Nerve: Results in weakness of supination (biceps) and forearm flexion (brachialis and biceps).
Injury to Median Nerve: May be caused by supracondylar fracture of humerus or compression in the carpal tunnel. Results in loss of pronation and opposition of thumb, loss of flexion of the lateral two IP joints and impairment of medial two IP joints. Produces flattening of the thenar eminence and is referred to as Ape Hand.
Injury to Ulnar Nerve: Caused by a fracture of the medial epicondyle and results in Claw Hand. Ring and little finger are hyperextended at MC joint and flexed at IP joint. Fingers have loss of abduction and adduction (palmar and doral interossei are paralyzed). Thumb cannot adduct because of paralysis of adductior pollicis muscle.
Upper Trunk Injury / Erb-Duchenne Paralysis: Caused by birth injury or violent displacement of the head from the shoulder. Results in loss of abduction, flexion, and lateral rotation of arm, producing a Waiter’s Tip Hand.
Lower Trunk Injury / Klumpke’s Paralysis: Caused by breech birth, or cervical rib, or scalene syndrome. The injury results in Claw Hand.
Axillary Artery Ligated: The blood from anastomoses in the scapular region arrives at the subscapular artery in which blood flow is reversed to reach the axillary artery distal to the ligature.
Brachial Artery Ligated: The blood from anastomoses around the elbow allow blood to reach the ulnar and radial arteries.
Ulnar Artery: May be compressed or felt for the pulse on the anterior aspect of the flexor retinaculum on the lateral side of the pisiform bone. Allen Test: Is a test for occlusion of the radial or ulnar artery Trigger Finger: Results from stenosing tenosynovitis or if flexor tendon develops swelling. Symptoms are pain at joints and a clicking when moving joint.
Mallet Finger: A finger with permanent flexion of the distal phalanx due to an avulsion of the lateral bands of the extensor tendon.
Boutonniere Deformity: Abnormally flexed middle phalanx with an extended distal pahalanx due to an avulsion of the central band of the extensor tendon.
Olecranon Bursitis / Student’s Elbow: Swollen, tender mass at elbow which produces pain on flexion of elbow.
Dislocation of Femoral Head: Is usually associated with advanced age (osteoporosis) and presents with a shortened lower limb with medial rotation.
Pertrochanteric Fracture: Is a femoral fracture through the trochanters and is a form of extracapsular hip fracture.
Fracture of Neck of Femur: Interrupts blood supply from medial femoral circumflex artery and presents with a shortened lower limb with lateral rotation.
Dislocated Knee or Fractured Distal Femur: May injure the popliteal artery because of its deep position adjacent to the femur and the knee joint capsule.
Transverse Patellar Fracture: Results from a blow to the knee. The proximal fragment of the patella is pulled superiorly with the quadriceps tendon and the distal fragment remains with the patellar ligament.
Bumper Fracture: Is a fracture of the lateral tibial condyle, caused by an automobile bumper, and is associated with a common peroneal nerve injury.
Dupuytren’s Fracture / Pott’s Fracture: Is a fracture of the lower end of the fibula, often accompanied by a fracture of the medial malleolus or rupture of the deltoid ligament. Caused by forced eversion of the foot.
Pilon Fracture: Is a fracture of the distal metaphysis of the tibia extending into the ankle joint.
Fracture of the Fibular Neck: May cause injury to common peroneal nerve which laterally winds around the neck of the fibula. This results in paralysis of al musclesin the anterior/lateral compartments of the leg and presents with Foot Drop.
March Fracture / Stress Fracture: Is a fatigue fracture of one of the metatarsals produced from prolonged walking or ballet dancing.
Coxa Valga: Is an alteration of the angle made by the axis of the femoral neck to the axis of the femoral shaft so that the angle exceeds 135 degrees, this pushes the femur laterally.
Coxa Vara: Is an alteration of the angle made by the axis of the femoral neck to the axis of the femoral shaft so that the angle is less than 135 degrees, this pulls the femur medially.
Hemarthrosis: This is blood in the joint which produces rapid swelling of joint, mainly knee.
Drawer Sign: An anterior drawer sign (tibia sliding forward) is due to rupture of anterior cruciate ligament. A posterior drawer sign (tibia sliding backward) is due to a rupture of posterior cruciate ligament. Medial Meniscus: Is more frequently torn in injuries than the lateral because of its strong attachment to the tibial (medial) collateral ligament.
Unhappy Triad of the Knee: May occur when foot is firmly planted and knee is struck from lateral side.
1 Rupture of the tibial collateral ligament (excessive abduction of tibia).
2 Tearing of anterior cruciate ligament (forward displacement of tibia).
3 Injury to medial meniscus. Knock-Knee / Genu Valgum: Is a deformity in which the tibia is bent or twisted laterally. It may occur as a result of collapse of lateral compartment of knee and rupture of tibial collateral ligament.
Bowleg / Genu Varum: Is a deformity in which the tibia is bent medially. It may occur as a result of collapse of the medial compartment of the knee and rupture of lateral collateral ligament.
Patellar Tendon Reflex: Tap on the patellar tendon elicits extension of the knee joint.
Prepatellar Bursitis / Housemaid’s Knee: Is inflammation and swelling of the prepatellar bursa.
Hallux Valgus: Is a lateral deviation of the big toe vs. Hallux Varus which is a medial deviation of the big toe.
Gluteal Gate / Gluteus Medius Limp: Is a waddling gait characterized by the pelvis falling toward the unaffected side when the opposite leg is raised. It results from paralysis of the gluteus medius muscle, and damage to the superior gluteal nerve.
Piriformis Syndrome: Is a common condition in which the pirformis muscle irritates and places pressure on the sciatic nerve, this pain is called ‘sciatic.’ Positive Trendelenburg’s Sign: Is seen in a fracture of the femoral neck or dislocated hip joint. If the right gluteus medius is paralyzed then the unsupported left side will drop.
Anterior Tibial Compartment Syndrome: Ischemic necrosis of the anterior muscles. It results from a compression of the anterior tibial artery by swollen muscles. Intermittent Claudication is a condition of limping due to ischemia.
Popliteal / Baker’s Cyst: Is a firm swelling behind the knee caused by herniation of synovial membrane, this impairs flexion and extension.
Shin Splint: Caused by swollen muscles of the anterior compartment particularly the tibialis anterior in athletes.
Tarsal Tunnel Syndrome: Results from compression of the tibial nerve in the tarsal tunnel. May be caused by flat feet and excess weight.
Rupture of Achilles Tendon: Disables the triceps surae (gastrocnemius and soleus), and cannot plantar flex the foot.
Forced Eversion of Foot: Avulses the medial malleolus and ruptures the deltoid ligament.
Ankle Sprain / Forced Inversion: Results from rupture of the calcaneofibular and talofibular ligaments and a fracture of the lateral malleolus.
Flat Foot / Pes Planus / Talipes Planus: Disappearance of the medial longitudinal arch with eversion and abduction of the foot, stretches the plantar muscles and strains the spring ligament.
Pes Cavus: Exhibits an exaggerated height of the medial longitudinal arch. Clubfoot / Talipes Equinovarus: Foot is plantarflexed, inverted and adducted.
Foot Deformities: Equinas = plantarflexed. Calcaneus = dorsiflexed. Valgus = heel lateral.
Varus = heel medial. Damage to Obturator Nerve: Causes a weakness of adduction and a lateral swinging of the limb.
Damage to Femoral Nerve: Causes impaired flexion of the hip and impaired extension of the leg, due to paralysis of quadriceps femoris.
Injury to Superior Gluteal Nerve: Weakened gluteus medius and a gluteal gate.
Damage to Sciatic Nerve: Causes impaired extension at hip and impaired flexion at the knee, loss of dorsiflexion and plantarflexion at the ankle.
Damage to Common Peroneal Nerve: May occur from fracture of fibula and results in Foot Drop, loss of dorsiflexion.
Damage to Superficial Peroneal Nerve: Causes no foot drop but loss of eversion of foot.
Damage to Deep Peroneal Nerve: Results in Foot Drop and a high stepping gate.
Damage to Tibial Nerve: Causes loss of plantar flexion of the foot and impaired inversion resulting from paralysis of tibialis posterior.
Medial Femoral Circumflex Artery: Supplies most of the blood to the head and neck of femur.
Cruciate Anastomosis of Buttock: Bypasses an obstruction to the femoral artery.
Popliteal Aneurysm: Blood can bypass through the genicular anastomoses and reach the popliteal artery distal to the ligation.
Pes Aserinus: Inflammation of the anserine bursa (gracilis, sartoris, semitendinosis) and presents with knee pain and swelling on anterior/proximal/medial tibia.
Jumper’s Knee / Patellar Tendonopathy: Repetitive loading causes anterior knee pain.
Genu: Knee (varum=tibia medial & valgum = tibial lateral) Coxa: Hip (vara=femur medial & valga = femur lateral) A femur/neck angle of 95 degress (less than normal) will cause Coxa Vara and Genu Valgum. A femur/neck angle of 155 degrees (more than normal) will cause Coxa Valga and Genu Varum.