MSK Clinical Correlates

Erb's Palsy
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Terms in this set (127)
Erb's Palsy
- Upper Brachial Plexus (C5, C6, C7) roots and/or trunks injury
- arm adducted and internally rotated, forearm extended and pronated
- Nerves involved:
1) Suprascapular: inability to initiate aBduction and loss of external rotation)
2) Axillary: loss of aBduction to 90 deg. and external rotation
3) Musculocutaneous: loss of forearm flexion and weakened forearm supination

Sensory loss: sergeant badge area, lateral aspect of arm/forearm/thumb
Image: Erb's Palsy
Klumpke's Palsy
- Lower brachial plexus (C8, T1) trunks of medial cord
- loss of flexor carpi ulnaris and medial 1/2 of flexor digitorum profundus
- loss of all intrinsic hand muscles (both ulnar and median)

Sensory loss: medial aspect of arm/forearm/hand
Image: Klumpke's Palsy
Mid-shaft Fracture of the Humerus
- radial nerve and deep brachial artery injury due to lying in radial groove
- retain ability to extend elbow joint (distal to innervation of triceps)
- loss of wrist extensors: wrist drop and impaired grip strength

Sensory loss: variable in arm, posterior forearm, dorsum of hand, proximal part of lateral 2.5 digits
Image: Mid-shaft Fracture of the Humerus
Saturday Night Palsy
- injury in axilla
- loss of ability to extend elbow joint
- loss of wrist extensors: wrist drop, impaired grip strength

Sensory loss: posterior and lower lateral arm, posterior forearm, dorsum of hand and proximal part of lateral 2.5 digits
Image: Saturday Night Palsy
Common Median Nerve Injuries
1) At/above the elbow (e.g. supracondylar fracture)
2) Injury to anterior interosseous nerve only (e.g. entrapment of nerve between 2 heads of pronator teres)
3) At the level of the wrist (e.g. carpal tunnel syndrome, lunate dislocation, suicide attempt)
4) Injury to the palm (e.g. laceration to base of thumb)
Image: Common Median Nerve Injuries
Common Radial Nerve Injuries
1) Injury in the axilla (e.g. Saturday night palsy)
2) Injury in the arm (e.g. midshaft fracture of the humerus)
3) Injury in the forearm (e.g. posterior interosseous nerve syndrome --> motor only)
Image: Common Radial Nerve Injuries
Lunate Dislocation
median nerve injury in the carpal tunnel
Image: Lunate Dislocation
Median Nerve Injury at/or above the elbow
Elbow: loss of pronation

Wrist: weakened wrist flexion, ulnar deviation

Hand: loss of flexion of index and middle fingers at DIP/PIP joints, paralysis of 1st and 2nd lumbricals, OAF thumb muscles are paralyzed, loss of opposition/flexion of thumb, weakened aBduction go thumb

Sensory loss: lateral palmar 3.5 digits to DIP on dorsal aspect and associated surface of hand
Image: Median Nerve Injury at/or above the elbow
Benediction Hand
- medial nerve injury test
- occurs when patient tries to make a fist
Image: Benediction Hand
Median nerve injury at the wrist
Elbow and Wrist: forearm pronation and wrist flexion intact, no ulnar deviation

Hand: FDP and FDS intact (no Benediction hand), paralysis of 1st and 2nd lumbricals, OAF muscles of thumb are paralyzed, loss of opposition of thumb, weakened flexion and aBduction of thumb

Sensory loss: lateral palmar 3.5 digits to DIP on dorsal aspect and associated surface of hand
Image: Median nerve injury at the wrist
Carpal Tunnel Syndrome- median nerve compressed by increased pressure in carpal tunnel - loss of function of median nerve hand muscles (LLOAF) - paresthesia in median nerve distribution of handTinel SignTest for carpal tunnel syndromePhalen maneuverTest for carpal tunnel syndromeMedian Nerve Injury in Proximal Palm- recurrent branch: motor only nerve, no sensory lossFracture of hook of hamate- ulnar nerve and artery injury in Guyon's canalCommon Ulnar Nerve Injuries1) At the wrist (e.g. suicide attempt, fracture of hamate hook, entrapment of Guyon's canal) 2) At the elbow (e.g. cubital tunnel syndrome, medial epicondyle fracture)Ulnar Nerve Injury at/or Above ElbowWrist: paralysis of FCU and ulnar half of FDP, weakened wrist flexion, wrist deviates laterally (aBducts) on flexion Hand: lose flexion of ring and little finger at DIP, paralysis of hypothenar muscles (POAF), paralysis of 3rd and 4th lumbricals, paralysis of all interosseous muscles (loss of aBduction and aDduction of digits), paralysis of aDductor pollicis (loss of aDduction of thumb) Sensory: medial palmar and dorsal 1.5 fingers and associated surface of handUlnar nerve injury at wristWrist: flexion in tact, no lateral deviation Hand: paralysis of hypothenar muscles, paralysis of 3rd and 4th lumbricals, paralysis of all interosseous muscles (loss of aBduction and aDduction of digits), paralysis of aDductor pollicis (loss of aDduction of thumb) Sensory loss: medial palmar and dorsal 1.5 fingers and associated surface of handFroment's TestTests ulnar n. motor loss, patient asked to hold piece of paper between thumb/index finger, positive test results in weakness of adductor pollicis muscle allowing flexion at IP jointFracture of surgical neck of humerus- axillary nerve and posterior humeral circumflex artery injurySigns of Axillary Nerve Injury- decreased lateral rotation - decreased aBduction - loss of sensation to lateral shoulderHerpes Zoster/Shingles- chickenpox virus remains dormant in sensory ganglia (dorsal root, trigeminal, geniculate) - eruption of vesicles similar to chickenpox on the skin along dermatome of affected nerve - usually unilateralPolymastia- ectopic mammary gland on milk line - fully functionalPolytheliaextra nipples along milk line (more common in males)Peau d' orange- pitted appearance around breast - due to blockage of lymphatic channels leading to lymphedema in the skin - more advanced stage: cancerous cells invade suspensory ligaments and nipple retractsMammogram- Specific for viewing the breast - irregular opaque "lumps" can indicate cancer --> confirm with lymph/sentinel node biopsy - non-malignant lumps: fibroadenomas, fibroadenosis, breast cystsRadical Mastectomy- surgical resection of entire breast - includes removal of axillary tail and associated lymph nodes (extent determined by axillary clearance) - Nerves commonly damaged: 1) long thoracic 2) thoracodorsal 3) intercostobrachialLymphedema- can be consequence of mastectomy or radiation therapy - removal of or damage to axillary lymph nodes leads to decreased lymphatic drainage of upper limb - accumulation of interstitial fluidLateral Thoracic x-ray- right ribs are larger due to magnification - spine appears darker caudallyAnterior Thoracic x-rayInspiration: - posterior ribs are used for counting - anterior ribs are faint due to costal cartilagesRib Fractures X-rayFlail Chest- multipoint fracture of consecutive ribs - fractured segments move in opposite direction from remainder of chest when patient breathesPleurisy/Pleuritis-Inflammation of pleura -Inflamed pleural layers rub against each other every time lungs expand -Sharp pain during respiration -Localized pain due to somatic nerves -May radiate to shoulder due to phrenic nerve innervation to central diaphragmatic pleura -Pleural friction rub (scratching) evident on auscultationThoracocentesis- "pleural tap" to sample fluid from pleural space - needle inserted superior to rib - 9th intercostal space --> midaxillary line during expiration VAN - vein, artery, nerveSurface Landmarks for pleuraLymphatic Drainage of Breast- Sentinel node: first node into which lymph drains from any of the breast quadrants - Axillary nodes: receives from anterior normally (pectoral), posterior (subscapular), or lateral (humeral) into central and eventually apical nodes - Parasternal nodes: receives 25% lymph - joins venous system by left or right main ductMcBurney's Point- 2/3 distance from umbilicus to anterior superior iliac spine - incision spot for appendectomyAbdominal IncisionsHasselbach's TriangleInguinal HerniasDirect: - medial to inferior epigastric vessels - only through superficial inguinal ring - acquired: strain Indirect: - lateral to inferior epigastric vessels - passes through both deep and superficial inguinal rings - congenital: patent processus vaginalis - does not transilluminateHydrocele- transillumination may reveal it is fluid - collection of fluid in tunica vaginalisKyphosisthoracic spine curvature (hunchback)Lordosis- cervical and lumbar spine curvature - anterior tilting of pelvisScoliosislateral curvature of spineHerniated DiscNucleus pulposus breaks through anulus fibrosus Presses on spinal cord or nervesLumbar Puncture- obtain CSF - not performed in patients w/ increased intracranial pressure - supracristal line: line between top of iliac crests - between L3/4 or L4/5 for adults, L4/5 for children - pops through ligaments flavum then pops when penetrating dura mater to enter lumbar cisternTriangle of AuscultationBoundaries: ā€¢Inferior - superior border of Latissimus Dorsi ā€¢Superior - lateral border of Trapezius ā€¢Lateral - medial border of scapulaTriangle of PetitBoundaries: Inferior: iliac crest Anterior: external abdominal oblique Posterior: latissimus dorsi floor: internal abdominal oblique and transversus abdominus Clinical significance: Petit's hernia (lumbar triangle hernia)Odontoid FractureFracture of dens of C2 (axis) vertebraeHangman's Fracture- fracture in the pars inter-articularis - traumatic spondylolysis of C2 (axis) - usually due to her-extension of head/neckJefferson Fracture- burst fracture of C1 (atlas) - caused by compression from above - fracture of one or both of anterior/posterior archesWedge/Compression Fracture- vertebral compression fracture occurring anteriorly and/or laterally - more commonly found in thoracic spine (T11-L1) - flexion and extension become limitedBurst Spinal Fracture- vertebral body is severely compressed - margins of vertebral body spread out in all directionsSpondylolysis- fracture of the column bones connecting the superior and inferior articular processes (pars interarticularis) - "dog with a collar"Spondylolisthesis- when a vertebra is slipping anteriorly upon its inferior counterpartSpinal Stenosis- vertebral column narrowingLumbar Epidural Anesthesia- epidural steroid injection into epidural spaceSacral/Caudal Epidural Anesthesia- into sacral hiatus - for operations which involve low lumbar and sacral dermatomesWinged Scapula- long thoracic nerve injury (serrates anterior)Fractured Clavicle- shoulder depressed with arm medially rotated and aDducted - SCM pulls medial fragment of clavicle upwards - Pectoralis major pulls lateral fragment medially - Latissimus dorsi pulls lateral fragment downwardsShoulder Separation"step deformity" - tearing of the acromioclavicular joint/ligament with or without coracoclavicular ligamentRotator Cuff Injury- inflammation of the rotator cuff in the shoulder caused by overuse - calcification of coracoacromial ligament, swelling of supraspinatus, or bony subacromial spurs commonly seenShoulder Dislocation- decreased ability to laterally rotate the arm - loss of aBduction from 15 to 90 deg. - sensory loss: upper lateral part of arm - axillary nerve and posterior humeral circumflex arteryNursemaid's Elbow- radial head slips out of annular ligament - occurs when arm of young children is pulled forciblySupracondylar fracture of the humerus- median nerve and brachial artery injuryVolkmann's Ischemic Contracture- consequence of supracondylar fracture if not treated - brachial artery injury leads to ischemic flexor contracture of anterior compartment musclesPosterior dislocation of elbow joint- ulnar and median nerve and brachial artery injury - FOOSHFracture of radial head- signs of elbow effusion (lifting of fat pads) - sail signEpicondylitis- inflammation of common tendons - Tennis elbow: lateral epicondylitis (extensor origin) - Golfer's elbow: medial epicondylitis (flexor origin)Colle's Fracture- fracture of distal radius - FOOSH - "dinner fork" deformity from fracture fragment displaced posteriorly - injury to median and/or ulnar nerves or acute carpal tunnel syndromeSmith's Fracture- fracture of distal radius - FOOSH - reverse Colle's fracture - "garden spade" deformity of distal forearm due to anterior displacement of fragment - jury to median and/or ulnar nerves or acute carpal tunnel syndromeScaphoid Fracture- pain in anatomical snuff box - FOOSH - avascular necrosis due to non-union of proximal fragmentBoxers Fracture- impaction fracture of neck of 5th metacarpalDupuytren's Contracture- flexion contracture of the hand - thickening of palmar aponeurosis (nodule formation) - unable to extend fingers Treatment: - needle aponeurotomy - surgeryInflammation of synovial sheathsTrigger finger (Stenosing Tenosynovitis)- fibrosis and tightening of tendon sheath at level of metocarpophalageal joint - inflammation and nodule formation in flexor tendons - excessive force is required to flexAllen Test- testing blood supply of the hand - erythema: normal test - pallor: badSpina bifida occulta- neural tube defect - no bulge over bony defect - tuft of hair or skin dimple present - failure of fusion of neural arch during 4th weekSpina bifida cystica meningocele- neural tube defect - bulge seen over bony defect (typically lumbar) - contains meninges & CSF in subarachnoid spaceSpina bifida cystica meningomyelocele- neural tube defect - bulge is seen over bony defect (typically lumbar) - contains meninges, spinal cord and nerves - neurological defects commonSpina bifida cystica with myeloschisis- neural tube defect - skin and bony defect with "open" spinal cordMeroencephaly- failure of rostral neuropore to close - absence of large part of brain and skull - either miscarriage or do not live longer than a few daysHirschsprungs Disease- congenital "megacolon" in infants - due to absence of autonomic ganglia in a segment of smooth muscle that normally stimulates peristalsisSacrococcygeal Teratoma- most common tumors in newborns (more common in females) - persistence of remnants of pluripotent "primitive streak" in caudal region of embryo - derivatives from all 3 germ layers (teeth, hair, muscle, glands, etc.)Right Phrenic Nerve Palsy- right dome of diaphragm higher than left - apical lung mass is likely causing damage to the phrenic nerve (C3-5)Cremasteric Reflex- testing the cremaster muscle - lightly touching skin over medial side of upper thigh invokes cremasteric reflex: testis pulled upward - efferent pathway: genital branch of genitofemoral nerve (L1-2) - afferent pathway: ilioinguinal nerve (L1)Obstructed blood flow in the IVC- venous drainage from abdominal and pelvic walls and organs is via inferior vena cava - obstructing can lead to alternate drainage pathways increasing size of vessels becoming visible under the skinEpisiotomy- to prevent excessive tearing during childbirth and reduced damage to perineal body (central tendon of perineum) - muscles are cut obliquely to reduce damage of external anal sphincterPudendal nerve block- ischial spine can be palpated via vaginal canal and used as a landmark for pudendal nerve blockArterial Occlusive Disease of the Leg- femoral artery can be passed by perforating branches of the deep femoral artery, descending branch of lateral femoral circumflex and articularAnterior-Posterior Compression Pelvic Fracture- most commonly from head-on motor vehicle collisions - pubic symphysis is disrupted - hemipelvis is externally rotated (opened like a book)Lateral Compression Pelvic Fracture- side impact collisions - sacrum "buckles" and pubic rami fracture - hemipelvis is rotated internallyUnhappy Triad- excessive force to the lateral side of the knee - valgus pressure: bone distal to joint AWAY from midline 3 C's: Cartilage (medial meniscus) Cruciate (anterior) Collateral (medial)Tibial Nerve Injury in Popliteal Fossa- paralysis of muscles in posterior compartment of leg and intrinsic muscles of sole of foot - unable to plantarflex, decreased inversion - loss of sensation on posterior lateral leg and sole of footTibial Nerve Injury at Tarsal Tunnel- plantarflex and inversion NOT affected - intrinsic muscles on sole of feet will be lost - loss of sensation on sole of footCommon Fibular Nerve Injury- affects lateral and anterior compartments - foot drop (loss of dorsiflexion) and decreased inversion of foot - to compensate for foot drop: high stepping gait and swing out the leg - loss of sensation on inferior-anterior leg and dorsal of footAnterior Compartment Syndrome- compression of deep fibular nerve and anterior tibial vessels - weakened dorsiflexion (foot drop) and digital extension - loss of sensation in 1st pedal webspace - treatment: release pressure by incising deep fascia within compartment6 P's of Acute Limb IschemiaPain Pallor Paresthesia Pulselessness Poikilothermia (cold) Paresis (weakness/paralysis)Impacted Femoral Neck FractureNondisplaced Femoral neck FracturePartially Displaced Complete Femoral neck FractureFully Displaced Complete Femoral Neck FractureAvascular Necrosis of Femoral Head- flattening of weight bearing upper portion against acetabulum and sclerosis - increased density: necrosis and calcificationInter-Trochanteric Fracture- treated with dynamic hip screwOsteoarthritis- degenerative joint disease - decreased proteoglycan content resulting in reduction in intercellular water content in cartilage matrix - loss of articular cartilageSyndactylyCutaneous syndactyly: webbing of digits - failure of webs to degenerate between 2 or more digits Osseous syndactyly: fusion of bones - failure of development of notches between digital raysPolydactyly- supernumerary digits - disruption of anteroposterior patternClub Foot (Congenital Talipes)- Talipes equinovarus - twice more frequently in males than females - sole of foot is turned medially and foot is inverted - multifactorial inheritance patternAmelia & MeromeliaAmelia: - complete absence of limbs - suppression of limb bud development in the 4th week Meromelia: - partial absence of limbs - disturbance of limb development during 5th weekCleft Hand & Cleft Foot (Ectrodactyly)ā€¢ Absence of one or more central digits - Failure of development of one or more digital rays ā€¢ Remaining digits are partially or completely fused ā€¢ Rare anomaly - Lobster-claw deformitiesAmniotic Band Syndrome- tears in amnion result in amniotic bands - bands may encircle fetal limbs and digits - ring constrictions and/or amputationsVACTERL SyndromeVertebral defects Anal atresia Cardiovascular anomalies Tracheo-esophageal fistula Esophageal atresia Renal anomalies Limb anomaliesAxial Control in the Developing LimbVaricose Veins- Superficial veins and perforation branches with insufficient valves - continuous excess flow through superficial veins (from deep) leads to pressure in superficial veinsChronic Venous Insufficiency- can be caused from continuous varicose veins - mechanical injury to small vessels, inflammation and fibrosis, and venous ulcersHallux Valgus and VarusValgus: lateral deviation Varus: medial deviationFoot inversion injuryanterior talofibular and calcaneofibular most commonly tornPrepatella Bursitis- Housemaid's knee - subcutaneous pre patella bursa inflammationKnee Effusion- suprapatellar bursa > 5mm - patella liftingCalcitonin- peptide hormone secreted by thyroid gland - inhibits osteoclast activity (decrease bone resorption) - reduces plasma calcium, opposing the effects of PTHVitamin D DeficiencyRickets: in children - demineralization of bone - bow-leg deformity - overgrowth at costochondral junction: rachitic rosary - pigeon chest deformity - front bossing Osteomalacia: in adults - weakening of bones: frequent fracturesVitamin D Resistant Rickets- similar symptoms as classical rickets and alopecia - plasma levels of 1,25(OH)2D are elevated - caused by mutation in the gene encoding vitamin D receptor in intestine: decrease calcium absorption from dietHypervitaminosis D- Vitamin D toxicity - non specific symptoms like loss of appetite, nausea, thirst, and stupor - enhanced calcium absorption and bone resorption results in hypercalcemia --> deposition of calcium --> soft tissue calcificationHypocalcemia- hypocalcemia tetany (carpopedal spasm) - cardiac arrhythmias - low 25 hydroxyvitamin D levels - low 1,25 dihydroxyvitamin D levels - low PTH levels caused by: - hypoparathyroidism - secondary hyperparathyroidismHypercalcemia- non specific signs and symptoms like lethargy, renal calculi, anorexia/nausea, peptic ulceration, depression caused by: - excessive PTH production - hypervitaminosis - excessive vitamin D production - excesive calcium intake "bones, moans, stones, and abdominal groans"Hypophosphatemia- nerve, bone, red/white blood cells, membrane and muscle functional problems caused by: - inadequate intestinal phosphate absorption (vitamin D deficiency) - excessive renal phosphate excretion (excess PTH)Hyperphosphatemia- calcification soft-tissue, organs - tetany - seizures caused by: - decreased renal excretion - hypoparathyroidism - excessive release of phosphate into ECF