Brachial plexus:
The following nerves are derived from which nerve path?
Dorsal Scapular - Long Thoracic- Nerve to subclavius- Suprascapular
Supraclavicular
Brachial plexus:
The following nerves are derived from which nerve path?
Lateral pectoral
Musculocutaneous
Median
Median Pectoral
Medial brachial cutaneous
Medial antebrachial cutaneous
Ulnar
Upper Subscapular
Thoracodorsal
Lower Subscapular
Axillary
Radial
Infraclavicular
Injuries to the brachial plexus can affect?
Movements
Sensations
What can cause brachial plexu injuries?
Disease
Stretching
Wounds/surgical procedures
Viruses
What are signs and symptoms of brachial plexus injury?
Paralysis/weakness
Anesthesia
How can you test for degree of paralysis from brachial plexus injury?
ROM and MMT
How can you test for anesthesia from brachial plexus injury?
Sensation testing, pain testing (e.g., from a pin prick)
Where is the injury?
Usually results from an excessive increase in the angle between the neck and the shoulder. This stretches or tears the superior part of thebrachial plexus.
Injury e.g. being thrown from a motorcycle or horse, wrestling
New born babies when excessive stretching of the neck occurs during delivery.
“waiter’s tip position”
Injury to superior parts of C5 and C6
Brachial plexus injury:
What has the following clinical presentation? (4 conditions)
adducted shoulder
medially rotated arm
extended elbow
loss of sensation
Erb palsy
Duchenne palsy
Duchenne-Erb Palsy
Upperradicular syndrome
Brachial plexus injury:
Produces motor and sensory deficitsin the distribution of themusculocutaneous and radial nerves.This may result in muscle spasmsand be very disabling.
Backpacker's palsy
Brachial plexus injury:
Sudden onset of severe pain usually around the shoulder. Pain begins at night and is followed by muscle weakness and sometimes atrophy.
Brachial Plexus Injury:
May resultfrom prolonged hyper abductioneg. Overhead activities such as painting or plastering a ceiling.Cords impinged or compressed between the coracoid processof the scapula and the pectoralis minor tendon.
cord compression
Brachial Plexus Injury:
Common neurologicalsymptoms are:
Pain runningdown the arm
Numbness
Paresthesia (tingling)
Erythema (redness of the skin caused bycapillary dilation) Weaknessof the hands.
Cord compression
These signs and symptoms result from compression of the axillary vessels and nerves.
Brachial Plexus Injury:
May occur when the upper limb is suddenly pulled superiorly – e.g. grasping something to prevent afall or breech birth
These events injure the inferior trunk of the brachial plexus (C8 andT1) and may pull (avulse) the dorsal and ventral roots of the spinal nerves from the spinal cord. The short muscles of the hand are affected and claw hand results.
Injuries to inferior parts of the plexus
Which nerve?
May beinjured when the GH jointdislocates because of itsclose relation of theinferior part of thearticular capsule of thehead of the humerus intothe quadrangular spacedamages the nerve.
Result: paralysis of thedeltoid and loss ofsensation in a small areaof skin covering thecentral part of the deltoid.
Axillary nerve injury
Which nerve?
injury to thisnerve in the axilla resultsin paralysis ofcoracobrachialis, biceps,and brachialis. Flexion ofthe elbow joint andsupination of the forearmare greatly weakened.
Loss of sensation on the lateral surface of the forearm supplied by thelateral antebrachial cutaneous nerve.
Musculocutaneous Nerve Injury
Which nerve?
Injuries superior to the origin of its branches to the Triceps brachii results in paralysis of the triceps, brachioradialis,supinator, and extensor muscles of the wrist and digits
Results in an inability to extend the wrist upward when the hand is palm down and inability to straighten the fingers.
Loss of sensation in areas ofskin supplied by this nerve also occurs ( numbness of the back of the hand and wrist).
Radial Nerve Injury
Radial nerve injury:
Name the condition:
Results from falling asleep with one’s arm hanging over the arm rest of achair, compressing the radial nerve at the spinalgrove.
Saturday night palsy
Radial Nerve Injury:
Name the condition:
Results from another individual sleeping on and compressing one’sarm overnight.
Honeymoon palsy
Radial Nerve Injury:
Name the condition:
Rrom tight handcuffs compressing the superficial branch of the distal radial nerve
Handcuff Neuropathy
Which nerve is injured?
Commonly occurs where the nerve passes posterior to the medial epicondyle of the humerus
The injury results when the lateral part of the elbow hits a hard surface, fracturing the medial epicondyle (“funny bone”).
Ulnar nerve
Which nerve is injured?
An injury to the nerve in the distal part of the forearm denervates most intrinsic handmuscles. Power of adduction is impaired and when an attempt is made to flex thewrist, the hand is drawn to the lateral side by the flexor carpi radialis
Ulnar nerve
Which nerve is injured?
Patients have difficulty making a fist because they can’t flex their 4th and 5th digits at the DIP joints. This results in claw hand deformity.This is due to atrophy of the interosseous muscles of the hand supplied by the this nerve. The claw is produces by the opposed action of the entensors and flexor digitorum profundus muscles.
Ulnar nerve
Which nerve is injured?
Flexion of the PIP joints of digits 1 to 3 is lost and flexion of digits 3 to 5 is weakened
Flexion of the DIP joints of the 2nd and 3rd digits is also lost The 4th and 5th are not affected
Flexion of metacarpopharangeal joints of the 2nd and 3rd digits will beaffected
Median Nerve
Median Nerve Injury:
When a patient attempts to make a fist, digits 2 and 3 remain partiall extended.
Hand of benediction
Median Nerve Injury:
Caused by compression of the median nerve near theelbow. The nerve may be compressed between the heads of the pronatorteres. Symptoms follow activities that involve repeated elbow movements
Pronator Syndrome
Treatment for Median Nerve Injury in elbow region
Non operative RX: Changing activities of daily living and in work enviornmentsmay require an ergonomic evaluation. Splinting wrist in neutral position.
Which Syndrome?
Pain out ofproportion to the eliciting event.
Disease that develops from an initialnoxious/painful event.
Spontaneous pain (pain with lighttouch) occurs. Hyperesthesia(increased sensitivity with touch)occurs beyond the territory of a single peripheral nerve and isdisproportionate to the inciting event
Complex Regional Pain Syndrome (CRPS)
Which type of CRPS is this?
Disease that develops from an initial noxious event. Cannot be linked to any pathologic process.
Type I
Which type of CRPS is this?
Associated with an identifiablenerve injury
Type II
Pain state maintained bysympathetic efferent innervation,circulating catecholamines, orneurochemical action. Patients have apositive response to sympatheticblockade.
SMP
Pain state in which patients donot respond to sympathetic blocs.
SIP
After fracture of the ______, the sternocleidomastoid muscle elevates the medial fragment of the bone. Because the trapezius muscle is unable to hold the lateral fragment up because of theweight of the upper limb, the shoulder drops.
clavicle
The following are symptoms of what?
Sagging shoulder (down and forward)
Inability to lift the arm because of pain
A grinding sensation if an attempt is made to raise the arm
A deformity or “bump” over the break
Bruising, swelling and/or tenderness over the area
Broken clavicle
These injuries are common in elderly people, especially those with osteoperosis.
Are often the result of a minor fall on the hand
humerus fracture
Usually results from a fall on the hand when the arm is abducted
humerus fracture ->avulsion fracture of the greater tubercle
_________ fractures of the body of the humerus frequently result from a direct blow to the arm. The pull of the deltoid carries the proximal fragment of the fractured humerus laterally.
Transverse
_____ fractures are the result of an indirect injury resulting from a fall on the outstretched hand (rotational component).
Spiral
______ fractures of the humerus result from a severe fall on the “point” of elbow flexion. The olecranonof the elbow is driven like a wedge into the condyle ofthe humerus, separating one or both parts from the humeral body.
Intercondylar
The following part of the humerus are in direct contact with which nerve and may be injured when the associated part of the humerus is fractured:
Surgical neck
Axillary nerve
The following part of the humerus are in direct contact with which nerve and may be injured when the associated part of the humerus is fractured:
Radial groove
Radial nerve
The following part of the humerus are in direct contact with which nerve and may be injured when the associated part of the humerus is fractured:
Medial epicondyle
Ulnar nerve
The following part of the humerus are in direct contact with which nerve and may be injured when the associated part of the humerus is fractured:
Distal end of humerus
median nerve
Which joint?
• ball and socket joint
• wide range of movements
• relatively unstable
Glenohumeral Joint
Name the rotator cuff muscles.
(SITS) muscles:
Supraspinatus
Infraspinatus
TeresMinor
Subscapularis.
What is the function of the glenohumeral ligaments?
Strengthens anterior aspect of joint
What is the function of the coracohumeral ligament?
strengthens capsule superiorly
intrinsic ligaments – part of the fibrous capsule
What is the function of the transverse humeral ligament?
strengthens the capsule and bridges the gap between the greater and lesser tubercles of the humerus.
Deposition of calcium in thesupraspinatus tendon is common.inflammation and calcification of the subacromial bursa results in pain,tenderness and limitation of movement of the glenohumeral joint
Calcific Supraspinatus Tendinitis
The calcium deposit in the supraspinatus tendon may also irritate the overlying subacromail bursa producing andinflammatory condition called ________ ________
The pain usually develops in males 50 yearsor older after unusual or excessive use of the shoulder (e.g., during atennis game).
Subacromial bursitis
The pain from subacromial bursitis occurs during 50-130 degrees of abduction because during this arc the supraspinatus tendon is in intimate contact with the inferior surface of the acromion. This is called the ...
painful arc syndrome
Commonly injured during repetitive use of the upper limb above the horizontal (e.g.,during throwing or racquet sports, swimming and lifting weights).
Common cause of shoulder pain
Rotator cuff injuries
Rotator Cuff Injuries:
positive when the subjectcannot hold the arm elevated against gravity.
Drop Arm Sign
What are the 3 clinical signs of rotator cuff injury?
Pain
Loss of motion
Loss of strength
Pain is primary clinical manifestation, usually over the lateral aspect of the deltoid.
Rotator Cuff Injury:
Pain with elevation of the arm between 70 and 120 degrees of abduction
Painful Arc
What are 3 treatments for rotator cuff injuries?
Steroid injections
Pendular exercises
Graded strength exercises
What direction are most dislocations of the humeral head?
Downward due to the presence of the coracoacromial arch and the support of the rotator cuff
Occurs most often in young adultscaused by excessive extension and lateral rotation of the humerus.
Anterior dislocation of the GH joint
Occurs in athletes who throw a baseball or football or in those who have shoulder instability and partial dislocation (subluxation) of the glenohumeral joint.
Results in sudden contraction of the biceps or forceful subluxation of the humeral head over the glenoid labrum. Usual symptom is pain while throwing, especially during the deceleration phase, but a sense of catching or snapping may be felt in the GH joint during abduction and lateral rotation of the arm.
Glenoid Labrum Tear
Adhesive fibrosis and scarringbetween the inflamed articular capsule of the GH joint, RC, subacromialbursa and deltoid. Patient will have difficulty abducting arm. They can obtain an apparent abduction of up to 45° by elevating and rotating the scapula.
Conditions that may initiate acute ______ _____are glenohumeral dislocation, calcific supraspinatus tendinitis, partial tearing ofthe rotator cuff and bicipital tendinitis.
Adhesive Capsulitis (Frozen Shoulder)
True or false?
Isolated fractures of the radius or ulna may occur, but are rare.
True
True or false?
Fractures of the distal end of theradius are common in adults older 50 + years, more women than men (osteoporosis).
True
the most common fracture of the forearm and results from forced dorsiflexion of the hand.
Colles' fracture
The subcutaneous olecranon bursa is exposed to injury after a fall on the elbow and to infection from abrasions of the skin covering the olecranon. Repeated excessive pressure and friction may cause this bursa to become inflamed
Bursitis of the elbow
Known as “student’s elbow”, “miners elbow” or dart thrower’s elbow.
Bursitis of the elbow
May occur when children fall on their hands with their elbows flexed.
Results from hyperextension or a blow that drives the ulna posterior or posterolateral.
The distal end of the humerus is driven through the weak anterior part of thefibrous capsule as the radius and ulna dislocate posteriorly.
The ulnar collateral ligament is often torn and an associated fracture ofthe head of the radius, coronoid process or olecranon may occur resulting in numbness of the little finger and weakness flexion and adduction of the wrist.
Dislocation of the elbow joint
Results when the child is lifted bythe upper limb while the forearm is pronated (e.g. lifting a child into a bus)
The child may refuse to use the limb.
Tears the distal attachment of the anular ligament where it is loosely attached to the neck of the radius.
Preschool children are at risk for incomplete dislocation of the head of the radius
Pulled elbow
What condition is the following treatment for?
Treatment consists of supinationof the child’s forearm with theelbow in a flexed position andusually heals in a sling in 2 weeks.
Pulled elbow
Caused by overuse. It is the inflammationof the tendons that join the forearms muscles on the outside of the elbow. Forearm muscles and tendons become damaged from repeating the same motions over and over again.
Pain and tenderness on the outside of the elbow and may have a weak grip.
Tennis Elbow (Lateral Epicondylitis)
Like tennis elbow but onthe medial aspect of the elbow leads tomedial epicondylitis in trailing arm.
Golfer's Elbow
True or false?
Majority of spinal cord injuries are complete.
False, most are incomplete
Where is the lesion?
Upper limbs more profoundly affected. There is oftenflaccid weakness of the arms, due to the lower motor neuron (LMN) lesionsand spastic patterning in the arms and legs due to upper motor neuron(UMN) injury.
Central Cord Lesion
Where is the lesion?
Upper limb is weak or flaccid.
Nerve conduction studies used to determine if brachial plexus lesion exists ,only an intact nerve will produce muscle contraction. It is important to identify such a lesion at the earliest opportunity in order to facilitate a primary repair
Brachial Plexus Lesion
Characterized by progressive andirreversible deterioration of upper anlower motor neurons, resulting in bothupper and lower motor signs.Degeneration within the corticospinaland corticobulbar tracts gives rise toupper motor weakness andhypertonia. The hardening of thetracts as the degenerated neurons arereplaced by gliosis explains the term“lateral sclerosis”.
Motor Neuron Disease
Leads to lower motor weakness, wasting and involuntary flickering of muscle fibres, which is known as fasciculations. The atrophyof denervated muscle fibres leads to the use of term Amyotrophy
Motor Neuron Disease
What is a classical amyotrophic lateral sclerosis?
ALS
Makes up 2/3rds of theMND population
What are the signs of classical amyotrophic lateral sclerosis?
progressiveweakness with muscle wasting.
What is the principle member of a group of disorders known as demyelinating diseases.These diseases have animmune-mediated destructionof myelin as the primarypathological finding.
MS - Multiple Sclerosis
What are 2 symptoms of MS?
Tremor – some MS patientsmay have a tremor which in its most severe form can be incapacitating such that any attempt to move the limbs precipitates violent uncontrollable movements.
Spasticity – one of the mostcommon symptoms and is often associated with painful cramps and spasms.
An accident with rapidly developing clinical signs of focal or global disturbance of cerebral function with symptoms lasting 24 hours or longer or leading to death with no apparent cause other than of vascular origin.
May have motor and/or sensory impairments in the upper limb.
cerebrovascular accident (CVA) - aka stroke
Symptom of stroke:
loss of detection to touch sensation, proprioception loss,vibration, light touch and loss of pin prick sensation.
Sensory impairment
Symptom of stroke:
shoulder subluxation, spasticity,frozen shoulder, rotator cuff injury, complex regional pain syndrome and altered sensitivity.
Hemiplegic Shoulder pain
Symptom of stroke:
Is caused by a lack of adequate support of the shoulder while the patient is in the upright position causing overstretchingof the joint capsule as a result of the gravitational pull on the weak/inactive arm.
Shoulder Subluxation
True or false?
Swelling of the hand is a symptom of stroke.
True, the lack of movement and muscle activity can lead to swelling.
What condition?
Broken pieces of cartilage in joint
Common in the capitullum
Gradual onset (1 to 2 years), throwingcurveballs, gymnastics, wrestling, trauma
Limited ROM, clicking, locking,
Treatment: Rest from stress.
Good prognosis if diagnosed early
Surgery for severe cases.
Osteochondritis Dissecans
Which condition?
Disruption of biceps from attachment (usuallydistal)
Pain at area of biceps
Quick forceful biceps contraction
Discontinuity of biceps with bulge
Loss of elbow flexion strength
May need surgical intervention
Biceps Muscle Rupture
Which condition?
One-third of all elbow fractures males > females 30 to 40 years old, pain overthe radial head.
Stiff joint, unable to fully flex or extend, pain with supination-pronation.
Immobilization for short period, ROM once fracture is stable, progressive strengthening.
Radial Head Fracture
Which condition?
Calcification of muscle
From Trauma
Decreased ROM. Palpation of mass.
Treatment is Rest, Gentle ROM and medical management of symptoms.
Myositis Ossificans
Which condition?
Parasthesia in thumb, index finger, middle fingerthat is aggravated with activity, also have pain on thevolar aspect of the forearm.
Symptoms include weakness in the muscles of theforearm and hand innervated by the median nerve(FCR, PL, FD).
Pronator Teres Syndrome
Which condition?
Median nerve compression
Sudden severe arm pain that resolves in a fewhours, no loss of sensation
Weakness of FPL, PQ, FDP; unable to pinchtip to tip.
Treatment: relative rest, splinting
Anterior Interosseous Syndrome
Pain over the lateral humeral epicondyle,tender radial head, numb radial nerve.
Resisted middle finger extension.
Radial Tunnel Syndrome
Radial nerve compression at arcade of Frohse.
Tender to palpation distal from lateralepicondyle.
Symptoms with resisted wrist extension,unable to extend thumb or fingers at MCP.
Treatment: relative rest, splinting
Posterior Interosseous Syndrome
True or false?
Pain is a part of healing.
True, it serves as a warning signal that assists us in making the correct decisions regarding motions and tissue loading patterns.