Kaan Ycel 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 Raynauds Disease o The arteries of the upper limb are innervated by sympathetic nerves through the brachial plexus. cervicodorsal preganglionic sympathectomy o Vasospastic diseases involving digital arterioles, such as Raynauds 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-C6lateral margin of the limb 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- 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.Martin Sheen shoulder dystocia Nerves derived from C5 & C6 roots affected Suprascapular nerve Nerve to the subclavius Musculocutaneous nerve Axillary nerve Muscles paralyzed 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 Waiters 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 Clawed appearance Hand- Clawed appearance Hyperextension of metacarpophalangeal joints Flexion of interphalangeal joints Loss of sensation 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 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 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 humerusMotor Triceps,anconeus, extensors of the wrist paralyzyed No extension of elbow, wrist & fingers Wristdrop Wristdrop- flexion of the wrist Supination ok Supination ok intact biceps brachii (musculocutaneous nerve) Radial Nerve 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 fingers. Area of total anesthesia relatively small because of the overlap of sensory innervation by adjacent nerves Radial Nerve 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 distal part of the grooveMotor WristdropSensory Variable small area of anesthesia over the dorsal surface of the hand & dorsal surface of the roots of 3 fingers Radial Tunnel Syndrome o Tenderness & pain the forearm just below the elbow o Watch out for lateral epicondylitis(tennis elbow) lateral epicondylitis (tennis elbow) o Differential diagnosis made on history & physical exam o The difference between these two conditions: where the elbow is most tenderwhere the elbow is most tender o Lateral to the elbow the radial nerve travels below the supinator muscle Tennis Elbow (Lateral epicondiylitis) o Small area of chronic lateral elbow o Pain on wrist extension, pain when shaking hands, weakened grip o More common 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 Supinator posterior interosseus nerve extensor carpi radialis longus (radial 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. No sensory loss- Motor nerve Injuries to the Superficial Radial NerveSensory As in a stab wound; dorsum of the hand dorsal surface of the roots of the lateral 3 fingers A variable small area of anesthesia over the dorsum of the hand & dorsal surface of the roots of the lateral 3 fingers Musculocutaneous Nerve Injuries o Rarely injured biceps brachii muscle o Protected beneath the biceps brachii muscle o Injured high up in the arm; o Biceps & coracobrachialis o Biceps & coracobrachialis paralyzed brachialis muscle is weakened (also supplied by radial nerve). brachialis flexors of the forearm 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 supracondylar fractures of the humerus Occasionally in the elbow in supracondylar fractures of the humerus Most commonly injured by stab wounds or broken glass proximal to the flexor retinaculum proximal to the flexor retinaculum: flexor carpi radialis flexor digitorum superficialis Here it lies in the interval between the flexor carpi radialis & flexor digitorum superficialis tendons, overlapped by the palmaris longus. Median Nerve the Elbow Motor o Pronator muscles of the forearm o Long flexor muscles of the wrist & fingers paralyzedException flexor carpi ulnaris medial half of flexor digitorum profundus flexor carpi ulnaris & medial half of flexor digitorum profundus Forearm in supine position; weak wrist flexion accompanied by adduction No interphalangeal joints of the index & middle fingers Most of the muscles in the anterior compartment of the forearm (except for the flexor carpi ulnaris muscle and the medial half of the flexor digitorum profundus muscle) In the hand Three thenar muscles associated with the thumb Two lateral lumbrical muscles associated with movement of the index and middle fingers Flex metacarpophalangeal joints & extend interphalangeal joints Skin over the palmar surface of the lateral 3 digits and over the lateral side of the palm and middle of the wrist. Median Nerve the Elbow Ask the patient to make a fist o Index finger, lesser extent middle finger straight o Ring & little fingers flex o No thumbs terminal phalanx flexor pollicis longus paralysis flexor pollicis longus paralysis Thenar eminence flattened thenar muscles wasted thenar muscles wasted Thumb laterally rotated & adducted Hand flattened ape-like hand Orators hand posture Median Nerve the Elbow Sensory Skin sensation loss Lateral half or less of the palm of the hand Palmar aspect of lateral 3 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 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 behind the medial epicondyle where it lies behind the medial epicondyle usually associated with fractures of the medial epicondyle Most commonly injured at the wrist in front of flexor retinacul um where it lies with ulnar artery in front of flexor retinacul um Flexor carpi ulnaris muscle & medial half of the flexor digitorum profundus muscle All intrinsic muscles of the hand (except for the three thenar muscles and the two lateral lumbrical muscles) Skin over the palmar surface of the little finger, medial half of the ring finger, and associated palm and wrist, and the skin over the dorsal surface of the medial part of the hand Ulnar Nerve the Elbow Motor Flexor carpi ulnaris medial half of the flexor digitorum profundus 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 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 the Elbow Unable to grip a piece of paper placed between the fingers No adduction & abduction of fingers No adduct the thumb adductor pollicis Paralyzed adductor pollicis Extensor digitorum abduct fingers to a small extent, when metacarpophalangeal joints hyperextended FROMENTS 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 the Elbow Metacarpophalangeal joints hyperextended Interphalangeal joints flexed Lumbrical & interosseous muscles paralysis 4th & 5th fingers Ulnar Nerve 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 the Elbow Sensory Loss of skin sensation o Anterior & posterior surfaces of the medial third of the hand o Medial 1 fingers Vasomotor Changes Warmer and drier skin arteriolar dilatation & absence of sweating resulting from loss of sympathetic control Ulnar Nerve the Wrist Motor Small muscles of the hand-except thenar & first 2 lumbricals Clawhand more obvious flexor digitorum profundus not paralyzed flexor digitorum profundus not paralyzed, marked flexion of terminal phalanges Ulnar Nerve the Wrist Sensory Main ulnar nerve its palmar cutaneous branch severed Main ulnar nerve & its palmar cutaneous branch usually severed Posterior cutaneous branch unaffected 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 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. adductor pollicis 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. axillary nerve posterior circumflex humeral artery Compression of axillary nerve & posterior circumflex humeral quadrilateral space o Downward displacement of the humeral head in shoulder dislocations o Fractures of the surgical neck of the humerus Deltoidteres minor Deltoid & teres minor paralysis lower half of deltoid muscle Loss of skin sensation lower half of deltoid muscle Quadrangular Space Syndrome Excessive overhead activity of the upper limb may be the cause of tendinitis, although many cases appear spontaneously. Rotator Cuff Tendinitis Rotator Cuff Tendinitis Stabilizing the shoulder joint Common cause of pain in the shoulder 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. Rotator Cuff Tendinitis 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. 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. Communications Between Median & Ulnar Nerves Communications Between Median & Ulnar Nerves The common place: radial artery flexor carpi radialis brachioradialis tendons 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. Measuring Pulse Rate extensor pollicus longus brevis o Anatomical snuff box between extensor pollicus longus & brevis. For straightforward blood tests Median cubital vein Cephalic vein for short-term intravenous cannula Venipuncture 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 Abductor pollicis longus & Extensor pollicis brevis tendons Medial border Extensor pollicis longus tendon Floor extensor carpi radialis longus extensor carpi radialis brevis tendons Scaphoid & trapezium, distal ends of the extensor carpi radialis longus &extensor carpi radialis brevis tendons Radial artery scaphoid trapezium Radial artery passes via anatomical snuffbox, deep to extensor tendons of the thumb adjacent to scaphoid & trapezium Anatomical snuffbox Peripheral mono- neuropathy of the upper limb Compression of the median nerve as it passes through the carpal tunnel into wrist Lies immediately beneath palmaris longus tendon anterior to the flexor tendons Lies immediately beneath palmaris longus tendon and anterior to the flexor tendons Conditions Diabetes mellitus Rheumatoid arthritis AcromegalyHypothyroidismPregnancyTenosynovitis 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 excision- Simple 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 (