DOCSLIB.ORG

Lecture 9: Forearm Bones and Muscles Remember, the Region Between the Shoulder and the Elbow = Brachium/Arm, Between Elbow and Wrist = Antebrachium/Forearm

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Lecture 9: Forearm Bones and Muscles Remember, the Region Between the Shoulder and the Elbow = Brachium/Arm, Between Elbow and Wrist = Antebrachium/Forearm Lecture 9: Forearm bones and muscles Remember, the region between the shoulder and the elbow = brachium/arm, between elbow and wrist = antebrachium/forearm. Forearm bones: ​ ● Humerus (distal ends) ● Radius ● Ulna Forearm regions: ● Cubital fossa ● anterior ­ flexor ● posterior ­ extensor On the humerus, the medial supracondylar ridge (which meets up with the medial epicondyle) and the lateral supracondylar ridge meets up with the lateral epicondyle. These two meet up with condyles, the capitulum (laterally) takes the head of the radius, and the trochlea (medial) takes the olecranon of the ulna. Just above the condyles, there are two fossae. The coronoid fossa and the radial fossa. During elbow flexion, the ulna sits in the coronoid fossa, and the radius sits in the radial fossa. During extension, the olecranon of the ulna sits in the olecranon fossa (a fossa above the condyles on the posterior surface). Ulna, radius and interosseous membrane: Ulna (medial) lies inline with the pinky finger. Starts of quite wide (proximally) and tapers to be quite narrow distally. Unusually, in the ulna, the distal end is the head (usually the proximal end is the head for bones). The proximal end has a curved shaped called the semilunar notch with two bony projections (superiorly the olecranon process & inferiorly the coronoid process). The C shaped notch between these two projections is the semilunar notch. On the lateral side of the ulna there is radial notch (which takes the head of the radius). Slightly inferior to that is the tuberosity of the ulna (which takes the brachialis muscle). Distally (the head), the bony projection is called the styloid process. The radius (is deeply placed in the forearm, harder to palpate than the ulna). The radius has a rounded head (proximal this time, c.f. the ulna) which sits in the radial notch of the ulna. There is a small constriction inferior to the head called the neck. Slightly inferior to the neck is the tuberosity of the radius which takes the biceps. At the distal end the radius widens (c.f. the narrowing of the ulna distally. in some ways they are opposites). There is another styloid process. Note, there are two styloid processes then, and we call them the styloid process of the radius and of the ulna separately. However, these two come together to form an arch shape where the wrist bones will sit. The interosseous membrane forms the syndesmosis joint between the radius and ulna. This allows for the transference of stress between the radius and ulna so that forces are shared. When someone falls on an outstretched hand, is it the radius that projects and takes the force, and will result in a fracture in the distal end of the radius. This is called a Colles’ fracture of the radius. It also results in the posterior displacement of the wrist and hand. Dislocation and fracture of the ulna: Falling on a flexed elbow can cause a fracture in the coronoid process of the ulna and breakaway. This may cause a dislocation of the elbow joint. This is very important because there are several major structures that pass through this region (the anterior side of the elbow = cubital fossa) e.g. median nerve which provides the nerve supply for the anterior anterior/flexor compartment. Also the brachial artery. If the muscles don’t get enough blood supply you can get Volkmann's ischaemia, where the muscles remain tightly flexed and degenerate. Fascial compartments: Muscles are enclosed in fascia. Helps separates functional groups of muscles and exert pressure within the muscle compartment. ● Fascia of the arm (brachial) and forearm (antebrachial) ­ tightly binds down muscles ● Significant rise in pressure (e.g. from bleeding or oedema, inflammation etc.) can lead to compression of contents which can be quite painful called a compartment syndrome (increased pressure within a fascial compartment) In a compartment syndrome, veins and lymphatics are likely to be first affected, then superficial nerves, then arteries, then deep nerves being compressed. Essentially, the vessels/vasculature that have the thinnest body walls will be first affected (hence veins and lymphatics first), then superficial nerves which lie subcutaneous tissue (superficial fascia) then arteries then deep nerves being compressed. At the arm (brachial fascia) you have brachial fascia that separates the flexor compartment from the extensor compartment. That same fascia when it reaches the forearm region is called the antebrachial fascia and separates the flexor muscles of the forearm from the extensor muscles. However, when the same fascia reaches the wrist (palmar and dorsal aspect) the fascia becomes thicker and forms a retinaculum (one flexor and one extensor). These two retinaculum are important because most of the tendons which travel into the hand go through windows formed in the retinaculum. Cubital fossa: The cubital fossa is between the medial and lateral epicondyles of the humerus (so imagine we draw a horizontal line, dotted line in above picture), pronator teres (medially) and brachioradialis (laterally). Sitting on top of the cubital fossa is the bicipital aponeurosis (the roof). Deeply (i.e. the floor) there is the brachialis muscle and supinator muscle (deeper). Several structures lie in this space, which when disrupted can cause damage to the nerve and blood innervation in the antebrachial region (i.e. Volkmann's ischaemia). Superficial veins (cephalic vein laterally, and basilic vein medially) meet in the cubital fossa to form the median cubital vein. This is where blood samples are typically drawn from. These are very much in the skin region (roof) of cubital fossa. On either side of the veins we have the lateral and medial cutaneous nerves of the forearm. These are also in the roof. Deeper, we have the brachial artery which divides distally into the radial and ulnar artery. Along with this, the main nerve supply (median) nerve runs. On the lateral side, going into the supinator muscle we have the radial nerve, on the medial side we have the ulnar nerve. Muscles of the forearm: ● Flexors are more powerful than extensors ● Skin overlying the flexor muscles is more sensitive than that over extensors i.e. more nerve endings running to the skin on the flexor side than extensor side ● Supplied by 3 nerves: median, ulnar and radial. Anterior flexor compartment: Organised into 3 layers (8 muscles): ­ Superficial (‘PFPF’) (4 muscle) ­ Intermediate (FDS) (1 muscle) ­ Deep (FPL, FDP, PQ) (3) 1. Superficial layer (medially to laterally): ­ pronator teres (PT) (does not cross the wrist, ulnar to radius, important in pronation, and has two heads which the median nerve travels between) (so repetitive action of pronation can compress the median nerve) ­ flexor carpi radialis (FCR) (inserts on base of first metacarpal, therefore crosses wrist joint) (important because laterally to the tendon is the radial artery, useful for getting a pulse at the wrist) ­ palmaris longus (PL) (this is the one that is absent in a large percentage of population) (starts from CFO and inserts on palmar aponeurosis, functionally not as important) (sits right on top of the median nerve, meaning in those without the PL the median nerve is slightly exposed) ­ flexor carpi ulnaris (FCU) (ulnar side, inserts on 5th metacarpal) (innervated entirely by the ulnar nerve) (the ulnar artery runs medially, the lateral side is the radial artery, pulse of the ulnar artery is not as well felt because it is deeper) All arise from common flexor origin (CFO) on the medial epicondyle. 2. Intermediate layer ­ Flexor digitorum superficialis (FDS) (this has a long sweeping origin, from CFO and shaft of radius) (median nerve goes deep to the muscle) (travels all the way the medial four digits ­ 4 separate tendons) (each of the 4 digit tendons then split into two and insert on the base of the middle phalanges) (allows for flexion of proximal phalanges and metacarpophalangeal joint) from CFO, radius and ulna 3. Deep layer ­ flexor pollicis longus (FPL) (lateral side, shaft of the radius, inserts on the distal tips of the phalanges of the thumb) (thumb flexion) ­ flexor digitorum profundus (FDP) (travels through carpal tunnel) (distal tendons then travel between and under the space formed by the flexor digitorum superficialis at the phalanges. the tendons then continue to insert on the distal phalanges of the medial 4 digits) (digit flexion, particular of the distal phalanges) ­ pronator quadratus (PQ) (doesn’t cross wrist joint) (between ulnar and radius) (allows for pronation along with pronator teres) all from radius, ulna and/or IO membrane Pronators and supinators: ­ pronator teres ­ pronator quadratus Together these pronate the forearm. Supinators (posterior compartment, so not a flexor): supination is the more powerful action, also produced by the biceps. The radius moves relative to the ulna. That is, during pronation (i.e. from supination to pronation), the radius moves over the ulna, and the ulna stays relatively still. Posterior (extensor) compartment: 11 muscles in the extensor compartment ​ 2 layers: superficial (6) and deep (5) 1. Superficial layer ­ Brachioradialis (it is the exception because whereas most of the muscle start from the common extensor region CEO, the brachioradialis starts from the supracondylar ridge, lateral side) (it doesn’t cross the wrist joint, it goes to the distal end of the radius) (despite the fact that it is a muscle of the posterior compartment ­ and so it is innervated by the nerve of the posterior compartment, the radial nerve, functionally, it
Load more

Recommended publications
  • Gross Anatomy
    www.BookOfLinks.com THE BIG PICTURE GROSS ANATOMY www.BookOfLinks.com Notice Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required. The authors and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contained in this work. Readers are encouraged to confirm the infor- mation contained herein with other sources. For example and in particular, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this work is accurate and that changes have not been made in the recommended dose or in the contraindications for administration. This recommendation is of particular importance in connection with new or infrequently used drugs. www.BookOfLinks.com THE BIG PICTURE GROSS ANATOMY David A. Morton, PhD Associate Professor Anatomy Director Department of Neurobiology and Anatomy University of Utah School of Medicine Salt Lake City, Utah K. Bo Foreman, PhD, PT Assistant Professor Anatomy Director University of Utah College of Health Salt Lake City, Utah Kurt H.
    [Show full text]
  • Anatomical Snuffbox
    Anatomical snuffbox • Depression seen on the lateral aspect of the wrist immediately distal to the radial styloid process. • Bounded: laterally by tendons of the abductor pollicis longus, extensor pollicis brevis. Medially by tendon of the extensor pollicis longus. floor: scaphoid and trapezium bones Its clinical importance lies in the fact that the scaphoid bone is most easily palpated here and that the pulsations of the radial artery can be felt here Anatomical snuffbox Anatomical snuffbox • Contents: 2) Origin of the 1) The radial artery cephalic vein pass subcutaneously over the snuffbox. 3) Superficial branch of the radial nerve pass subcutaneously over the snuffbox. Blood supply of the hand Anastomoses occur between the radial and ulnar arteries via the superficial and deep palmar arches The Deep palmar arch is formed mainly by the radial artery while the superficial palmar arch is formed mainly by the ulnar artery 3-On entering the palm, it curves laterally behind (deep) the palmar 4-The arch is aponeurosis and in front completed on (superficial) of the long flexor the lateral side tendons forming by the the superficial palmar arch superficial branch of the radial artery. 2-Then it gives off its deep branch of which runs in front of the FR , and joins the radial artery to complete the deep palmar arch 1-Enters the hand anterior (superficial) to the Superficial flexor retinaculum palmar branch of radial artery through Guyon’s canal Radial artery 5-The superficial palmar arch gives off digital arteries from its convexity which pass to the fingers and supply them Superficial palmar arch Deep palmar branch of ulnar artery Superficial palmar branch of radial artery Ulnar artery Radial artery Radial Artery first dorsal interosseous muscle 1-From the floor of the anatomical snuff-box the radial artery leaves the dorsum of the hand by turning forward between the two heads of the first dorsal interosseous muscle.
    [Show full text]
  • Distal Radial Approach Through the Anatomical Snuff Box for Coronary Angiography and Percutaneous Coronary Intervention
    Korean Circ J. 2018 Dec;48(12):1131-1134 https://doi.org/10.4070/kcj.2018.0293 pISSN 1738-5520·eISSN 1738-5555 Editorial Distal Radial Approach through the Anatomical Snuff Box for Coronary Angiography and Percutaneous Coronary Intervention Jae-Hyung Roh, MD, PhD, and Jae-Hwan Lee , MD, PhD Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea ► See the article “Feasibility of Coronary Angiography and Percutaneous Coronary Intervention via Left Snuffbox Approach” in volume 48 on page 1120. Received: Aug 27, 2018 The anatomical snuffbox, also known as the radial fossa, is a triangular-shaped depression Accepted: Sep 17, 2018 on the radial, dorsal aspect of the hand at the level of the carpal bones. It is clearly observed Figure 1 1)2) Correspondence to when the thumb is extended ( ). The bottom of the snuffbox is supported by carpal Jae-Hwan Lee, MD, PhD bones composed of the scaphoid and trapezium. The medial and lateral borders are bounded Division of Cardiology, Department of Internal by tendons of the extensor pollicis longus and the extensor pollicis brevis, respectively. The Medicine, Chungnam National University proximal border is formed by the styloid process of the radius. Within this narrow triangular Hospital, Chungnam National University space, various structures are located, including the distal radial artery (RA), a branch of the School of Medicine, 282, Munhwa-ro, Jung-gu, radial nerve, and the cephalic vein. Daejeon 35015, Korea. E-mail: [email protected] The anatomy of the hand arteries is illustrated in Figure 2.
    [Show full text]
  • Ultrasound-Guided Access of the Distal Radial Artery at the Anatomical Snuffbox for Catheter-Based Vascular Interventions: a Technical Guide
    Title: Ultrasound-guided access of the distal radial artery at the anatomical snuffbox for catheter-based vascular interventions: A technical guide. Authors: Anastasia Hadjivassiliou, MBBS, BSc; Ferdinand Kiemeneij, M.D, PhD; Sandeep Nathan, M.D, MSc; Darren Klass, M.D, PhD DOI: 10.4244/EIJ-D-19-00555 Citation: Hadjivassiliou A, Kiemeneij F, Nathan S, Klass D. Ultrasound-guided access of the distal radial artery at the anatomical snuffbox for catheter-based vascular interventions: A technical guide. EuroIntervention 2019; Jaa-625 2019, doi: 10.4244/EIJ-D-19-00555 Manuscript submission date: 10 June 2019 Revisions received: 24 July 2019 Accepted date: 01 August 2019 Online publication date: 06 August 2019 Disclaimer: This is a PDF file of a "Just accepted article". This PDF has been published online early without copy editing/typesetting as a service to the Journal's readership (having early access to this data). Copy editing/typesetting will commence shortly. Unforeseen errors may arise during the proofing process and as such Europa Digital & Publishing exercise their legal rights concerning these potential circumstances. Ultrasound-guided access of the distal radial artery at the anatomical snuffbox for catheter-based vascular interventions: A technical guide Anastasia Hadjivassiliou, MBBS, BSc1; Ferdinand Kiemeneij, MD, PhD2; Sandeep Nathan, MD, MSc3; Darren Klass, MD, PhD1 1. Department of Interventional Radiology, Vancouver General Hospital, University of British Columbia, Canada 2. Department of Cardiology, Tergooi Hospital, Blaricum, the Netherlands 3. University of Chicago Medicine, Chicago, IL, USA Short title: Ultrasound guided distal radial artery access at the anatomical snuffbox Corresponding author: Dr Darren Klass Department of Radiology, Vancouver General Hospital 899 West 12th Avenue, V5Z 1M9, Vancouver, BC, Canada Email address: [email protected] Disclaimer : As a public service to our readership, this article -- peer reviewed by the Editors of EuroIntervention - has been published immediately upon acceptance as it was received.
    [Show full text]
  • Ultrasonograpic Assessment of Relationship Between the Palmaris Longus Tendon and the Flexor Retinacular Ligament and the Palmar Aponeurosis of the Hand
    Original Article Ultrasonograpic Assessment of Relationship Between the Palmaris Longus Tendon and the Flexor Retinacular Ligament and the Palmar Aponeurosis of the Hand Kadir Ertem1, Ahmet Sığırcı2, Salih Karaca1, Aykut Sığırcı3, Yunus Karakoç4, Saim Yoloğlu5 İnonu University, Faculty of Medicine, ABSTRACT Departments of Orthopedics and Trauma- tology1, Radioloy2, Physiology4 and Biosta- Aim: This study aimed to evaluate the presence of the Palmaris Longus tistics5, Malatya, Turkey Tendon (PLT) and the relationship between the Flexor Retinacular Ligament (FRL) and the Palmar Aponeurosis (PA) of the hand. 319 Mayıs University, Faculty of Medicine, Departments of Orthopaedics and Trauma- Method: 62 voluntary subjects (31 female, 31 male students and per- tology, Samsun, Turkey sonnel from the Inonu University, at the average age 28.38 ± 6.86 years ranging from 19 to 48 years) took part in this study using ultrasound. Eur J Gen Med 2010;7(2):161-166 Received: 16.05.2009 Result: Significant differences were found in the PA p-m-d diameters of subjects between with and without PLT bilaterally, on the right Accepted: 06.07.2009 and the left hand (p<0.05), whereas there was no meaningful differ- ence considering FRL diameters (p>0.05). Furthermore, this ultraso- nographic assessment revealed the continuity of collagen bunches of the PL tendon up to FRL, but not PA. Conclusion: Although not demonstrated by ultrasonography here, the increased thickness of the PA in subjects with a PLT supports the find- ings in the literature in which the structural
    [Show full text]
  • Carpal Box and Open Cup Radiography
    .............................................................................................................. ON THE JOB Carpal Box and Open Cup Radiography Dan L. Hobbs, M.S.R.S., Scaphoid fractures of the wrist are will include a discussion of the blood R.T.(R)(CT)(MR), is an asso- common and account for 71% of all car- supply to this bone. Next, there will be ciate professor in the depart- pal bone fractures. In the United States, a brief discussion of the mechanism of ment of radiographic science approximately 345 000 new scaphoid frac- injury, and the article will conclude with at Idaho State University in tures occur each year.1 Additionally, sta- a review of 3 positioning techniques that Pocatello. tistics have shown that scaphoid fractures can be employed to help diagnose scaph- account for 2% to 7% of all orthopedic oid fractures. Acknowledgement: Joshua fractures; they are the most commonly Howard , a student in the undiagnosed fracture.2 If an undiag- Anatomy radiographic science program nosed fracture is left without proper The scaphoid is located on the radial at Idaho State University, con- immobilization, a portion of the scaphoid side of the wrist in the anatomical snuff tributed valuable research to may die; therefore, it is imperative that box, which is located between the extensor this article. proper diagnosis, radiographic evalua- pollicis brevis and extensor pollicis longus tion and therapeutic treatment begin as tendons. (See Fig. 1.) It is the largest bone soon as possible. in the proximal row of carpals and can be The purpose of this article is to described as being complex because of its acquaint the radiographer with a few non- twisted shape; some describe it as being traditional methods used to image this boat-shaped.3 It articulates with the radius, fracture.
    [Show full text]
  • Abdominal Wall Anterior 98-108 Posterior 109-11 Abductor Digiti
    Index Cambridge University Press 978-0-521-72809-6 - Atlas of Musculoskeletal Ultrasound Anatomy: Second Edition Dr Mike Bradley and Dr Paul O’Donnell Index More information Index abdominal wall brachialis 42 echogenicity xi anterior 98–108 – – brachioradialis 49 elbow 49 64 posterior 109 11 anterior 53–8 calcaneo-fibular – abductor digiti minimi 70, 87 ligament 193 lateral 49 52 abductor pollicis brevis 87 medial 60 calf 178–86 posterior 62–4 abductor pollicis longus 79 antero-lateral compartment – extensor carpi radialis brevis acromioclavicular joint 26–7 179 80 lateral compartment 181–2 49, 79 adductor brevis 134 posterior compartment extensor carpi radialis longus – adductor canal 151 183 6 49, 79 adductor longus 134 capsule echogenicity xi extensor carpi ulnaris 79 – adductor magnus 134, 137 carpal tunnel 70 3 extensor digiti minimi 79 air echogenicity xi cartilage echogenicity extensor digitorum 79 costal cartilage xi – extensor digitorum longus 178 anatomical snuffbox 76 7 fibrocartilage xi anisotropy ix hyaline cartilage xi extensor hallucis longus 178, 205, 218–19 ankle 187–205 chest wall 13–21 anterior 202–5 anterior 13 extensor indicis 79 – lateral 193–6 costal cartilages 13 16 extensor pollicis brevis 79 medial 197–201 lateral 17 posterior 187–92 posterior 18–21 extensor pollicis longus 79 ribs 13–16 annular ligament 52 extensor retinaculum 202 collateral ligament anterior cruciate ligament fascia echogenicity xi lateral 167 (ACL) 153–7 fat echogenicity xi medial 165 antero-lateral pelvis 127–30 ulnar (UCL) 61 femoral neck
    [Show full text]
  • Hand Surgery: a Guide for Medical Students
    Hand Surgery: A Guide for Medical Students Trevor Carroll and Margaret Jain MD Table of Contents Trigger Finger 3 Carpal Tunnel Syndrome 13 Basal Joint Arthritis 23 Ganglion Cyst 36 Scaphoid Fracture 43 Cubital Tunnel Syndrome 54 Low Ulnar Nerve Injury 64 Trigger Finger (stenosing tenosynovitis) • Anatomy and Mechanism of Injury • Risk Factors • Symptoms • Physical Exam • Classification • Treatments Trigger Finger: Anatomy and MOI (Thompson and Netter, p191) • The flexor tendons run within the synovial tendinous sheath in the finger • During flexion, the tendons contract, running underneath the pulley system • Overtime, the flexor tendons and/or the A1 pulley can get inflamed during finger flexion. • Occassionally, the flexor tendons and/or the A1 pulley abnormally thicken. This decreases the normal space between these structures necessary for the tendon to smoothly glide • In more severe cases, patients can have their fingers momentarily or permanently locked in flexion usually at the PIP joint (Trigger Finger‐OrthoInfo ) Trigger Finger: Risk Factors • Age: 40‐60 • Female > Male • Repetitive tasks may be related – Computers, machinery • Gout • Rheumatoid arthritis • Diabetes (poor prognostic sign) • Carpal tunnel syndrome (often concurrently) Trigger Finger: Subjective • C/O focal distal palm pain • Pain can radiate proximally in the palm and distally in finger • C/O finger locking, clicking, sticking—often worse during sleep or in the early morning • Sometimes “snapping” during flexion • Can improve throughout the day Trigger Finger:
    [Show full text]
  • Anatomical Considerations of Fascial Release in Ulnar Nerve Transposition: a Concept Revisited
    LABORATORY INVESTIGATION J Neurosurg 123:1216–1222, 2015 Anatomical considerations of fascial release in ulnar nerve transposition: a concept revisited Mark A. Mahan, MD,1 Jaime Gasco, MD,2 David B. Mokhtee, MD,3 and Justin M. Brown, MD4 1Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona; 2Division of Neurological Surgery, University of Texas Medical Branch, Galveston, Texas; 3Tulsa Bone and Joint Associates, Tulsa, Oklahoma; and 4Division of Neurosurgery, University of California, San Diego, La Jolla, California OBJECT Surgical transposition of the ulnar nerve to alleviate entrapment may cause otherwise normal structures to become new sources of nerve compression. Recurrent or persistent neuropathy after anterior transposition is commonly attributable to a new distal compression. The authors sought to clarify the anatomical relationship of the ulnar nerve to the common aponeurosis of the humeral head of the flexor carpi ulnaris (FCU) and flexor digitorum superficialis (FDS) muscles following anterior transposition of the nerve. METHODS The intermuscular septa of the proximal forearm were explored in 26 fresh cadaveric specimens. The fibrous septa and common aponeurotic insertions of the flexor-pronator muscle mass were evaluated in relation to the ulnar nerve, with particular attention to the effect of transposition upon the nerve in this region. RESULTS An intermuscular aponeurosis associated with the FCU and FDS muscles was present in all specimens. Transposition consistently resulted in angulation of the nerve during elbow flexion when this fascial septum was not released. The proximal site at which the nerve began to traverse this fascial structure was found to be an average of 3.9 cm (SD 0.7 cm) from the medial epicondyle.
    [Show full text]
  • Causes and Assessment of Subacute and Chronic Wrist Pain
    Singapore Med J 2013; 54(10): 592-598 P ictorial E ssay doi:10.11622/smedj.2013205 CMEARTICLE Causes and assessment of subacute and chronic wrist pain Janice Chin-Yi Liao1, MBBS, MRCS, Alphonsus Khin Sze Chong1,2, MBBS, FAMS, David Meng Kiat Tan1 , MBBS, MMed ABSTRACT Wrist pain is a common presentation to the general practitioner and emergency department. Most cases are simple to treat, and pain frequently resolves with conservative treatment. However, there are certain conditions, such as scaphoid nonunion and Kienböck’s disease, where delayed diagnosis and treatment can result in long-term deformity or disability. This article covers the various causes of wrist pain, recommendations on how wrist pain should be assessed, as well as details some of the common conditions that warrant specialist referral. Keywords: chronic wrist pain, physical examination, wrist injuries, wrist pain INTRODUCTION in the scapholunate interval or ulnar fossa may indicate Wrist pain is a common clinical problem.(1) Many acute cases scapholunate ligament injuries or triangular fibrocartilage are sprains or contusions following a minor injury, or tendinitis complex (TFCC) injuries, respectively. The wrist should following an episode of overuse. These problems generally then be assessed through passive and active range of motion resolve within weeks with rest, temporary immobilisation and exercises. Special tests (e.g. Finkelstein’s and Watson’s tests) symptomatic pain relief. to differentiate specific wrist conditions are described in Wrist pain that does not resolve after six weeks to three later sections. Ideally, patients with persistent swelling and months is a frequent diagnostic challenge to primary care tenderness, or a recent or remote history of trauma, should physicians.
    [Show full text]
  • Section 1 Upper Limb Anatomy 1) with Regard to the Pectoral Girdle
    Section 1 Upper Limb Anatomy 1) With regard to the pectoral girdle: a) contains three joints, the sternoclavicular, the acromioclavicular and the glenohumeral b) serratus anterior, the rhomboids and subclavius attach the scapula to the axial skeleton c) pectoralis major and deltoid are the only muscular attachments between the clavicle and the upper limb d) teres major provides attachment between the axial skeleton and the girdle 2) Choose the odd muscle out as regards insertion/origin: a) supraspinatus b) subscapularis c) biceps d) teres minor e) deltoid 3) Which muscle does not insert in or next to the intertubecular groove of the upper humerus? a) pectoralis major b) pectoralis minor c) latissimus dorsi d) teres major 4) Identify the incorrect pairing for testing muscles: a) latissimus dorsi – abduct to 60° and adduct against resistance b) trapezius – shrug shoulders against resistance c) rhomboids – place hands on hips and draw elbows back and scapulae together d) serratus anterior – push with arms outstretched against a wall 5) Identify the incorrect innervation: a) subclavius – own nerve from the brachial plexus b) serratus anterior – long thoracic nerve c) clavicular head of pectoralis major – medial pectoral nerve d) latissimus dorsi – dorsal scapular nerve e) trapezius – accessory nerve 6) Which muscle does not extend from the posterior surface of the scapula to the greater tubercle of the humerus? a) teres major b) infraspinatus c) supraspinatus d) teres minor 7) With regard to action, which muscle is the odd one out? a) teres
    [Show full text]
  • Supplemental Methods
    Supplemental Methods: Patients: Inclusion criteria were patients 18 years of age and older with a lower trunk or C8-T1 pattern of brachial plexus injury and a minimum of 6 months postoperative follow-up. The indication for brachialis to FDP muscle transfer was a lack of active finger flexion in patients with a history of lower trunk or C8-T1 pattern of brachial plexus injury at greater than 9 months from injury with no sign of nerve recovery on clinical exam as well as electromyogram. Additionally, triceps motor function of BRMC grade 2+ or greater was required to provide significant antagonist force to balance the elbow flexion force generated with firing of the brachialis muscle transfer. Patients were excluded if they were younger than 18 years of age, had a triceps of grade 2 or less, or sustained other injuries which precluded the use of the brachialis or FDP for tendon transfers. Patient demographic data including age, sex, BMI, smoking status, age at time of injury, mechanism of injury, co-morbidities, and history of previous reconstructive surgery. Patients were follow-up at regular intervals following surgery for functional assessment until their functional level had plateaued. Patients initially received a full evaluation for motor strength by the three senior authors (AYS, ATB, RJS), including but not limited to trapezius, supraspinatus, infraspinatus, deltoid, biceps, triceps, pronator teres, flexor digitorum profundus, extensor digitorum communis, extensor carpi radialis longus and brevis, and first dorsal interosseous motor strength. Motor strength was graded using a modified British Medical Research Council Grade (BMRC) 2,15. BMRC grading is reported as follows: M0 – no contraction, no joint motion, and no EMG reinnervation; M1 – EMG reinnervation, but no joint motion; M2 – perceptible joint motion, however insufficient power to act against gravity; M3 – muscle act against gravity; M4 – muscle acts against resistance; and M5 – muscle acts against strong resistance.
    [Show full text]