2Tips …Have a plan and stick to it!! Rest – take regular breaks and get your sleep If you can easily turn it into an exam question Warwick have probably thought of it too! Ask if you need help…. ask anyone!
4What is a dermatome?Area of skin innervated by a single spinal nerveGroup of muscles innervated by a single nerve rootA branching network of vessels or nervesNerve cell cluster or a group of nerve cell bodies located in the peripheral nervous system
5What is a dermatome?Area of skin innervated by a single spinal nerve - DermatomeGroup of muscles innervated by a single nerve root - MyotomeA branching network of vessels or nerves - PlexusNerve cell cluster or a group of nerve cell bodies located in the peripheral nervous system – Ganglion
7Anterior compartment of the arm. Biceps brachii – Flexion at the elbow, supination of the forearm(Short head: coracoid process of the scapula. Long head: supraglenoid tubercle)Brachialis – Flexion of the elbow (most powerful flexor)Coracobrachialis – Flexion at the elbow, flexion of the shoulder, ?abduction of the armPosterior compartment of the arm:Triceps brachii – elbow extensionLateral, medial and middle heads.Anconeous – stabilises the elbow during movementAnterior compartment of the forearm:Pronator teresFlexor carpia radialisPalmaris longusFlexor digitorum superficialisFlexor digitorum profundusFlexor pollicis longus Median – interosseous nervePronator quadratus
8Axilary Nerve Musculocutaneous Median Nerve Radial Nerve Ulnar Nerve (Long thoracic nerve)Musculocutaneous: C5-7Median: C6 - T1Redial: C5 - T1Ulnar: C8 & T1Axillary*: C5 & 6*Strictly speaking not part of the branches. But important nontheless
9Axillary Nerve (C5) Innervates: Deltoid Teres minor Vulnerable during: Shoulder dislocationFracture of the surgical neck of the humerus Intramuscular injection (Runs 5cm below the aromiom)Damage can result in:Paralysis of deltoid and teres minorLimb hang limp by sideLoss of shoulder contourSensory Loss over lateral shoulder (regimental badge area)
10Musculotaneous nerve (C5 – 7) InnervationBBCBiceps BrachiiBrachialisCoracobrachialisVulnerable during:‘Stretch’ injury during dislocationDamage results in:Weakness of flexionWeakness of supinationSensory loss over the lateral forearm
11Why in musculocutaneous nerve damage is it still possible to flex the elbow? Flexion is still possible as the brachioradialis also performs this function and it is innervated by the radial nerve
12Thenar wasting is a sign of damage to which nerve? Ulnar nerveMedian nerveRadial nerveAxillary nerve
13Thenar wasting is a sign of damage to which nerve? Ulnar nerveMedian nerveRadial nerveAxillary nerve
15Median Nerve InjuryDamage at the Elbow or proximalCan’t make fist with digits 2&3 (hand of ‘benediction’)No active flexion of IP joints of digits 2&3Weaker flexion of digits 4&5 = No FDS but FDP from ulnar nerveNo forearm pronationWeak wrist flexion that deviates to adduction (FCU = ulnar nerve)Plus damage seen with wrist injury below......XXDamage at the WristThenar wasting & opposition not possibleThumb laterally rotated & adductedDigits 2 & 3 lag in fist making as lumbricals 1 & 2 paralysedR G Tunstall 2014
16Carpal Tunnel Syndrome “Compression of the median nerve in the carpal tunnel”What are the symptoms a patient may complain of with carpal tunnel?Sensory loss in the lateral 3.5 digitsNocturnal pain in the lateral 3.5 digitsThenar wastingWhat conditions can increase the chance/are associated with carpal tunnel syndrome?PregnancyHypothyroidismWhat passes through the carpal tunnel?4 tendons of flexor digitorum superficialis4 tendons of flexor digitorum profundusFlexor policis longusMedian nerveDescribe the surface anatomy of the carpal tunnel.The canal starts at the distal wrist crease and passes distally by about 2cm
17What make the roof of the carpal tunnel? Extensor retinaculumFlexor retinaculumBiceps aponeurosisCarpal bones
18What make the roof of the carpal tunnel? Extensor retinaculumFlexor retinaculumBiceps aponeurosisCarpal bones
19“Wrist drop” is a sign of damage to which nerve? AxillaryMedianRadialUlnarMusculocutaneous
20“Wrist drop” is a sign of damage to which nerve? AxillaryMedianRadialUlnarMusculocutaneous
21Radial Nerve (C5 – T1)What does the radial nerve supply?All of the posterior compartments of the arm and forearmPLUS brachioradialisWhere is the radial nerve injured?Axilla – Shoulder dislocation, crutches, falling asleep over upper limb ‘Saturday night palsy’Spiral groove - Humeral fracture (sleeping on the arm)Head/neck of the radius - #
22What travels with the radial nerve in the radial groove? Brachial arteryProfunda brachii arteryAxillary arteryCutaneous branch of the radial nerve
23What travels with the radial nerve in the radial groove? Brachial arteryProfunda brachii arteryAxillary arteryCutaneous branch of the radial nerve
24X X X Radial Nerve Injury All function lost No elbow extension Damage in axillaAll function lostNo elbow extensionWristdropNo digit extensionSensory loss on dorsolateral forearm & handXXDamage in spiral grooveElbow extension preserved but weakerWristdropNo digit extensionSensory loss on dorsolateral forearm & handXDamage at radial head/neckElbow extension normalMinimal wristdrop (ECR supplied earlier)No sensory loss - motor nerveR G Tunstall 2014
25Why do patient with wrist drop lose their power grip? The wrist needs to be held in the neutral (anatomical) position by extensors in order to bring about a power grip. Lack of extensor action means wrist flexion occurs when FDP & FDS contract, thus rendering them mechanically unable to flex the digits tightly.
26Explain why forearm supination is still possible in the damaged limb following radial nerve damage (2 marks)?Supination is brought about by two muscles, supinator (radial nerve innervated and therefore paralysed) and biceps brachii (musculocutaneous nerve innervated and therefore working).
27Wasting of the 1st dorsal interosseous is a sign of damage to which nerve? AxillaryMedianUlnarRadialMusculocutaneous
28Wasting of the 1st dorsal interosseous is a sign of damage to which nerve? AxillaryMedianUlnarRadialMusculocutaneous
29Ulnar nerve C8 – T1 What does this nerve innervate? Flexor carpi ulnarisFlexor digitorum profundus to digits 4 & 5All intrinsic muscles in the hand EXCEPT thenar and lumbrical 1 & 2Where can damage to this nerve occur?Medial epicondyle – fracture or compressionGuyon’s canal – compression
30Ulnar Nerve InjuryDamage at the elbow or proximalNo flexion of distal IP joint of Digits 4 & 5 = Lack of FDPWrist abducts on flexion = Lack of FCUNo digit ab-or adduction (except thumb abduction)Some clawing of digits 4 & 5 at rest = loss of lumbricals &interosseiNo clawing of digits 2 & 3 as lumbricals 1 & 2 OKPlus damage seen with wrist injury below.....XDamage at the wristLoss of most intrinsic hand musclesHypothenar & interosseous wastingClawing of digits 4 & 5 worse in low lesion as FDP remainsinnervated and exacerbates IP joint flexionXR G Tunstall 2014
31Describe the resting appearance of someone with ulnar claw. This is extension of the MCP and flexion of the corresponding IP jointsDescribe the ulnar paradoxIf you damage the ulnar nerve at the wrist you will get more clawing and more damage than if you damaged the ulnar nerve more proximally.The reason this happens is because if you damage the ulnar nerve at elbow you also paralyse the flexor digitorum profundus for digits 4 & 5 and therefore get far less clawing of digits 4 & 5.If you damage the ulnar nerve at the wrist the flexor digitorum profundus for digits 4 & 5 is still innervated and will produce greater clawing.
32Where do you test for sensory loss following damage to the: Axillary nerveRadial nerveUlnar nerveMedian nerve
33Where do you test for sensory loss following damage to the: Axillary nerve – Regimental badge areaRadial nerve – First dorsal interosseousUlnar nerve – Hypothenar eminanceMedian nerve – Thenar eminance
34Winging of the scapula is a sign of damage to which nerve? Axillary nerveMusculocutaneous nerveLong thoracic nerveLateral cutaneous nerve of the
35Winging of the scapula is a sign of damage to which nerve? Axillary nerveMusculocutaneous nerveLong thoracic nerveLateral cutaneous nerve of the
36Long Thoracic Nerve (C5 – 7) What muscle does this nerve supply?Which ribs does this muscle attach to?How can this nerve be damaged?What movements may a patient find difficult?
37Long Thoracic Nerve (C5 – 7) What muscle does this nerve supply?Serratus anteriorWhich ribs does this muscle attach to?Ribs 1 – 8Inserts into medial border of the scapulaHow can this nerve be damaged?At risk during axillary surgery.This is because the LTN lies on the superficial layer of muscle as opposed to the deep layer as most other nerves are.What movements may a patient find difficult?Punching outReaching out
38What is a painful arc indicative of? Supraspinatus impingementCalcific tendonosisAdhesive capsulitisAxillary nerve damage
39What is a painful arc indicative of? Supraspinatus impingementCalcific tendonosisAdhesive capsulitisAxillary nerve damage
40Klumpke’s Palsy C8 – T1 Erb’s Palsy C5 – 6 Traction injuryCancer at lung apex****Compession via cervical ribUlnar nerve and Median nerve effectedErb’s PalsyC5 – 6Stab woundsIatrogenicShoulder dystocia -SuprascapularLateral pectoralAxillaryMusculocutaneousDorsal scapula
41Erb’s PalsyMedially Rotated Shoulder: loss of supra and infraspinatis resulting in unopposed medial rotation from the sternal head of pec majorLimp & loss of shoulder contour: Result of loss of deltoidPronated forarm: Loss of biceps brachiiPartial wrist drop: Loss of extensor carpi radialis
42Erb’s PalsyMedially Rotated Shoulder: loss of supra and infraspinatis resulting in unopposed medial rotation from the sternal head of pec majorLimp & loss of shoulder contour: Result of loss of deltoidPronated forarm: Loss of biceps brachiiPartial wrist drop: Loss of extensor carpi radialisSuprascapulaLateral PectoralAxillaryMusculocutaneousDorsal Scapula
43Klumpke’s PalsyC8 – T1How does Klumpke’s Palsy present (3 marks)?Paralysis & wasting of ALL small muscles of handClawing of digits 2-5 at rest due to unopposed action of extensors on MCP joint & long flexors on IP jointsAnaesthesia = medial elbow, forearm & arm
44Horner’s SyndromeWhat are the signs of Horner’s syndrome?Ptosis – Droopy eyelidMiosis – Constricted pupilEnophtalmos – Sunken eyesAnhydrosis – Lack of sweatingRed flush skin - VasodilationWhat are the causes of Horner’s syndrome?Pancoast tumourTumour of skull baseLymphadenopathyIatrogenicTrauma
45What are the anatomical boundaries of the anatomical snuff box? Ventro-lateral: abductor pollicis longus & extensor pollicis brevisDorso-medial: Extensor pollicis longusFloor :formed by the scaphoid and trapeziumWhat are the contents of the anatomical snuff box (3 marks)?Radial arteryCutaneous branch of the radial nerveCephalic Vein
47What should pain in the anatomical snuff box arouse suspicion of? Superficial radial nerve damageDe Quervain’sScaphoid fractureUlnar nerve damage
48What should pain in the anatomical snuff box arouse suspicion of? Superficial radial nerve damageDe Quervain’sScaphoid fractureUlnar nerve damage
49What is the most common method of fracturing your scaphoid? Falling on an outstretched armWhat is a big concern in fractures of the scaphoid, explain why this is so anatomically.A fraccture of the scaphoid may result in avascular necrosis, however this is more common in the proximal 1/3 as blood supply is retrograde from branches of the radial artery supplying the distal part of the bone first and then the more proximal part.
50What are the borders of the cubital fossa? Lateral: BrachioradialisMedial: Pronator TeresSuperior Border: Inter-epicondyle lineRoof: Aponeurosis of bicepsWhat are the contents of the cubital fossa from lateral to medial (3 marks)?Biceps TendonBrachial ArteryMedian NerveWhich veins are accessed in this area (3 marks)?Cephalic Basilic Median cubital vein
52What are the borders of the axilla? Anterior: Pectoral Muscles - Anterior Axillary foldPosterior: Subscapularis and scapula, Posterior Axillary fold (Lat dorsi and teres major)Medial: Serratus Anterior and lateral thoracic wallLateral: Intertubercular grooveWhat are the names of the axillary lymph nodes?CentralHumeralApicalPectoralSubscapular(NOTE: Think CHAPS)
54An F1 is performing an injection in a patient’s butt! To ensure that the needle is placed in a safe area they draw a vertical line through highest point of crest and another line from PSIS to the greater trochanter and inject into the upper outer quadrant of the patient's gluteal region.What nerve is the Dr trying to avoid by employing this method?Pudendal nerveSuperior gluteal nerveInferior gluteal nerveSciatic nerve
55An F1 is performing an injection in a patient’s butt! To ensure that the needle is placed in a safe area they draw a vertical line through highest point of crest and another line from PSIS to the greater trochanter and inject into the upper outer quadrant of the patient's gluteal region.What nerve is the Dr trying to avoid by employing this method?Pudendal nerveSuperior gluteal nerveInferior gluteal nerveSciatic nerve
56What are the nerve roots of the sciatic nerve? L4 – S3
57Which nerve do you suspect is damaged based on the following observation of a patient’s gait? “Gait in which trunk lurches back on heel strike to prevent it from toppling forward”Inferior gluteal nerveSuperior gluteal nerveSciatic nerveFemoral nerve
58Which nerve do you suspect is damaged based on the following observation of a patient’s gait? “Gait in which trunk lurches back on heel strike to prevent it from toppling forward”Inferior gluteal nerveSuperior gluteal nerveSciatic nerveFemoral nerve
59A 35 year old male tears his medial collateral ligament during a football match. What else might be damaged and with what consequence?A 17 year old female is hit by a moving car on the lateral side of her knee. Why is she at risk of foot drop?A 76 year old man presents to you with a deep laceration to the region behind his medial malleolus. Examination reveals that crude flexion-extension movement of his toes is possible, but they splay whilst weight-bearing and he is unable to curl/scrunch his toes up. Why?A 56 year old male suffers a supracondylar fracture of the femur. 30 minutes later the pain is considerably worse and the back of his thigh is swollen, and he was loosing sensation in, and functioning of, his leg and foot. What might be damaged and with what consequence?