Chapter 6 Clinical Points An ulnar median collateral ligament injury in a sprain abnormal abduction of the forearm Radial lateral collateral ligament injury in a sprain abnormal adduction of forearm Colles fracture Falling on the hand with the arm extended Foot slides out in front person goes down slightly sideways and person lands on the heel of the extended hand Radius fractured with posterior displacement in its distal inch dinner fork shape to forearm known as silverfork deformity Fracture of the styloid process of ulna may or may not be present Associated complications injuries to median and ulnar nerves Fractures of the carpal bones Upper extremity fractures are among the most common fractures of the skeletal system Carpal bone fractures 18 of hand fractures Bones in proximal row are most commonly fractured Most commonly fractured bone scaphoid 70 of fractures in carpal group and 10 of all hand fractures Second most common triquetral fractures 14 of wrist injuries Rest of the bones comparatively low Carpal injury result of direct or indirect trauma Usually a result of high energy mechanisms Can result in disability if not treated Carpal Tunnel Syndrome pathologic condition of the anterior region of the wrist Characterized by pain and weakness of the hands Caused by compression of the median nerve in the carpal tunnel Most common cause repetitive movement of wrist like typing Also due to hypothyroidism rheumatoid arthritis pregnancy and amyloidosis Treatment courses of surgical and nonsurgical treatments o Early surgery when there is evidence of median nerve injury o Typically local steroid injection or splinting is suggested o Oral steroids or ultrasounds are other options o Carpal tunnel release o Surgical treatment of carpal tunnel retinaculum is recommended Describe the rotator cuff injury Involve supraspinatus infraspinatus teres minor and subscapularis maintain stability of shoulder joint Rotator cuff injury tendinopathy of the supraspinatus often occurs in athletes calcification pain tendon rupture and avulsion of the greater tubercle Many techniques and operative methods introduced Dupuytren s contracture progressive fibrosis Thickening and shortening of the palmar aponeurosis Leads to partial flexion of the ring and small finger What are the causes and signs symptoms of radial nerve injury Nerve injury proximal to the origin of the tricps o Elbow is flexed extension of the elbow may not be possible triceps reflex may be absent o Wrist drop all extensor muslces and the supinator are paralyzed and the thumb is flexed and abducted o Forearm might be pronated Sensory loss may be present o Dorsolateral lower brachial region o Posterior surface of the forearm o Dorsum of the hand o Radial side of the proximal phalanges Nerve injury in the radial groove in fractures of the humerus o Triceps muscle is usually functioning o Wrist drops and sensory loss in the dorsolateral aspect of the forearm may be notice Nerve injury to the forearm o Deep radial nerve is injured wrist drop o Extension of thumb and metacarpal joints disturbed o Sensation is typically preserved What are the causes and signs symptoms of median nerve injury Nerve injury above the elbow o Muscles in the arm are NOT affected by nerve injury above the elbow ONLY the muscles of the forearm and hand o ALL flexors of the wrist are paralyzed flexor carpi ulnaris and the ulnar part of the flexor digitorium profundus o Thumb flexors and other muscles on the thenar side are paralyzed but NOT the adductor ape hand o Flexion at the metacarpophalangeal joints may be possible interossei muscles are intact but fingers cannot be flexed at the interphalanged joints o First and second lumbricals lose function altogether inability to fully flex the index and middle fingers o Pronation of the forearm may be compromised and sensory loss at the median nerve area in the hand may be noticed Injury at the wrist joint o May lead to median nerve injury at wrist area o Short muscles of thumb may be paralyzed but NOT the adductor and the flexor pollicis longus o Thenar muscles atrophy Ape hand o Sensory loss over the median nerve sensory area o Percussion on the nerve in the wrist area may lead to heightened paraesthesia Tinel s sign in carpal tunnel syndrome What are the causes and signs symtoms of ulnar nerve injury Injury at the elbow o Paralysis of the flexor carpi ulnaris and the medial portion of the flexor digitorium profundus o Ulnar deviation at the wrist is weakened and hand is abducted and extended Injury at the wrist o Fingers are hyperextended at the metacarpophalangeal joints and flexed at the interphalangeal joints Paralysis of the interossei muscles and the two medial lumbrical muscles claw hand o Tendons of flexor digitorium profundus 2 medial muscles are paralyzed flexion of ring finger and ring finger not possible at distal phalangeal joints o Flexion at metacarpophalangeal joints is possible due to flexor digitorum superficials being intact o Small muscles of little finger are paralyzed o Abduction and adduction of the fingers are impaired paralysis of the interossei muscles no more writing or piano playing o Sensory loss of the hand in the ulnar nerve territory over the ulnar nerve area Brachial Plexus Syndromes Leads to motor sensory and automatic deficits T1 root involvement Horner s syndrome Upper brachial plexus lesion posterior cord lesion lower brachial plexus lesion and total brachial plexus lesion Upper brachial plexus lesion C5 C6 o Due to traction of the arm at birth Erb Duchenne paralysis or trauma to the shoulder Roots may even be pulled out of the spinal cord o Signs and symptoms paralysis of the deltoid and supraspinatus no arm abduction infraspinatus paralysis medial rotation of arm paralysis of the biceps and brachialis impaired elbow flexion biceps impaired supination adductors of shoulder pectoralis major and latissimus dorsi mildly affected Lower brachial plexus lesion C8 T1 o Causes sudden upward pull of the shoulder Injury to the C8 T1 roots following forced abduction of the shoulder at birth Klumpke s paralysis leads to paralysis of the intrinsic muscle of the hand and anesthesia o Not as common as upper o Signs symptoms atrophic paralysis of the forearm and small muscles of the hand claw hand Sympathetic palsy Horner s syndrome if T1 root is involved Chapter 8 Clinical Points Bell s Palsy temporary facial paralysis resulting from damage or trauma to the facial nerve CN VII nerves travels