Rebin I.

Hasan Hawler Medical University

Clinical Notes of The Upper Limb
Q1/ Median nerve is more liable to be injured in the lower part of
forearm than the upper part?
Ans: Because median nerve is superficial in the lower part and deep in
the upper part (between two heads of pronator teres muscle).
Q2/ Wrist drop after fracture of the mid-shaft of humerus?
Ans: In this type of fracture, radial nerve which has a direct relation with
humerus at (radial groove) will injury, then the extensor muscles which
are supplied by it will be paralyzed producing wrist drop.
Q3/Pus collection in the mid palmer space passes to forearm?
Ans: There is a space in the distal part of the forearm; the proximal
parts of the flexor synovial sheath protrude into that space. The space
may be infected by extension of synovial sheath infection.
Q4/Enlargement of axillary lymph nodes in infection of upper
abdominal wall?
Ans: Because axillary lymph nodes drain lymph not only from the upper
limb, but also from anterior and posterior body walls above the level of
umbilicus, therefore the infection gives rise to the enlargement of
axillary lymph nodes.
Q5/Dislocation of the carpal bones causes weakness of the thenar
muscles?
Ans: Because median nerve passes via carpal bones supplying thenar
muscles. Dislocation of the carpal bones will cause injury to median
nerve and then weakness of thenar muscles.
Q6/The lymphatic drainage of breast assumes great importance?
Ans: Because the malignant disease of the breast spreads mostly through
the lymphatics to the associated lymph nodes.
Q7/Intramuscularly injection in the lower half of deltoid (near to its
insertion) is not done?
Ans: To avoid injury to the axillary nerve and the posterior circumflex
humeral vessels.
Q8/Pressure below the acromion over deltoid with the arm causes the
pain when the arm is abducted?
Ans: Because the subacromial bursa disappears under the acromion in
this case.
Q9/Ape like hand in carpal bone dislocation?
Ans: Because median nerve is injured and the thenar muscles which
supplied by this nerve paralyzed, then the opposition of the thumb with
other fingers lost producing Ape-like hand.
Q10/We can put tourniquet in the upper part of the arm, but can not
put it in the forearm?
Ans: Because the arm composed of one bone (which is humerus) and one
artery (brachial artery), but the forearm is composed of two bones and
we can not ligate (block) the two arteries (ulnar & radial arteries) and
tourniquet is used for decreasing severe bleeding. Rebin I. Hasan Hawler
Medical University
Q11/ Numbness of little finger in fracture of medial epicondyle of
humerus?
Ans: The ulnar nerve which is directly related to the medial epicondyle is
injured in this fracture and the hypothenar muscles of the hand which
are supplied by this nerve are paralyzed and lose their action when
acting on the little finger.
Q12/Dislocation of finger joints easier than metacarpal joints?
Ans: Because the metacarpals help in the fixation (in which they have
the normal fixation) in the case of fracture, but fixation of fingers is
difficult.
Paralysis of the intrinsic muscles of the hand or any injury to the ulnar
nerve produces (claw hand).
Paralysis of the extensor muscles of the forearm produces wrist drop this
is usually due to example in the axilla and arm.
Progressive shortening and thickening of palmer aponeurosis produces a
condition known as Deuputyren's contraction. It usually affects the
medial part of the aponeurosis producing flexion of the little and ring
fingers and requires surgical division of the aponeurosis to straighten the
fingers.
Write short notes on:-
1- Injury of ulnar nerve at the flexor retinaculum?
2- Injury of median nerve at the wrist?
3- Injury of the radial nerve in the spiral groove?
Q13/The veins of the breast are important in spreading the
malignancy to the bone and nervous system?
Ans: Because they communicate with the vertebral plexus of veins,
through which malignancy can be spread to the bone and nervous system.
Q14/Uni-lateral malignancy may become bi-lateral?
Ans: Because the superficial lymphatic of the breast from one side
communicate with those of the other side.
Q15/ Axillary vein free to expand when blood flow increases?
Ans: Because there is no axillary sheath surrounding it. Rebin I. Hasan
Hawler Medical University
Q16/ Median cubital vein is an important vein for intravenous
injection, blood letting and cardiac catherzation?
Ans: Because it is easy to be fixed by perforator and does not slip away
from the needle as the other veins do.
Q17/ The adduction of the arm (loss of abduction) after the fracture
of the surgical neck of humerus?
Ans: Because the fracture of the surgical neck of humerus will lead to
injury of the axillary nerve (which is directly related to the surgical neck
of the humerus) and this will paralyze deltoid muscle which is the main
abductor of the arm.
Q18/ Irritation of the diaphragm from any surrounding pathology
cause pain in shoulder?
Ans: Because the phrenic nerve and supraclavicular nerve have the same
root values (C3, C4).
The anterior surface of the breast is vascular (has an arterial supply)
while the posterior surface is the avascular (non-vascular).
Only three cords of the brachial plexus and their branches are contained
in axilla.
The breast may be fixed to the deep fascia.
Posterior primary rami of (C1) and lower two (C7, C8) and lower two
lumbar (L1, L6) nerves does not give any cutaneous branches.
Q19/ Injury to the radial nerve are more complex above the elbow
than below it?
Ans: Because above the elbow the nerve has direct contact with the
radial groove of humerus. The fracture of humerus at the radial groove
leads to the complex injury to the nerve ; and below the elbow the nerve
doesn't have any relation to the bone therefore injury is less common.
Q20/ Flexor muscles of the forearm are more bulky than extensor
muscles?
Ans: Because the flexors are anti-gravity muscles, and are also used for
powerful grip.
Q21/ Fracture at the upper and middle thirds of humerus show
delayed or non-union at all?
Ans: Because of the poor blood supplying to these regions. Rebin I. Hasan
Hawler Medical University
Q22/ at the wrist adduction is higher than abduction?
Ans: Because of the styloid process of radius projected 1cm lower than
the styloid process of ulna.
Q23/ The thumb unlike the other fingers are free in movement?
Ans: Because the palmer aponeurosis does not give any slip to the
thumb, but it gives slips to other fingers.
-Median nerve is the main motor nerve in the front of the forearm with
small share in the hand, while the ulnar nerve is the main motor nerve in
the hand with a small share in forearm.
-Radial nerve is the main motor nerve of the posterior compartment of
arm and forearm.
Q24/ Using a tourniquet in the arm, but not in the forearm in arterial
hemorrhage (bleeding) of the hand?
Ans: Because in the arm we use tourniquet to block brachial artery which
is the major arterial supply to the arm, forearm and hand, so the blood
flow stops, but in the forearm the brachial artery gives numerous
branches particularly radial and ulnar arteries which supply the forearm
and hand, and in this part of the body we must use more than one
tourniquet and the job will be complex.
Q25/ Fracture of upper end of ulna are less dangerous than the
fracture of the upper end of radius and humerus?
Ans: Because the upper end of ulna is not related to the nerves or
vessels, so fracture of it is less dangerous, while the upper end of the
radius and humerus are related to the nerves and vessels. Radius is
related to the deep branch of radial nerve and surgical neck of humerus
is related to the axillary nerve and posterior circumflex humeral vessels.
Q26/ Injury of spiral cord below C5 are less dangerous than above C3
segment?
Ans: Because injury to spinal cord above C3 may involve injury to phrenic
nerve (C2, C3 and C4) which is the sole (only) motor supply for
diaphragm, so paralysis at the diaphragm may lead to respiratory failure.
Q27/ Adduction of wrist joint are more adduction than that abduction
of it?
Ans: Because of styloid process.
Q28/ The diaphragm has relation to shoulder joint?
Ans: Because both of them are supplied by (C3, C4) nerves therefore any
effect on diaphragm will cause shoulder disability. Rebin I. Hasan Hawler
Medical University
Write reasons of following paralysis:
1- Drop hand
2- Ape like hand
3- Policeman's tip hand
4- Erb's paralysis
Joints
-joint:Elbow
Dislocation of the elbow joint by an effusion occurs posteriorly, because
here the capsule is weak and the covering deep fascia is thin.
A separating is done posteriorly on any side of olecranon process.
Elbow joint can be fractured in the olecranon process or in the medial
epicondyle of humerus .
Supination is stronger than pronation of the forearm , because other
muscles doing this action (supination) with the supinator muscle .
For example : Biceps and brachioradials muscles than that of the
pronation case.
-Wrist joint:
Adduction of the wrist joint is more active than that of abduction of it
because of the styloid process of the radius bone which is longer than
that of ulnar. Rebin I. Hasan Hawler Medical University
Clinical Notes Of The Thorax
-Notes:
· The mediastinum is a mobile position and not fixed, it extends from the
posterior surface of sternum to the vertebral column.

· Left phrenic nerve is long in course than the right phrenic nerve
because of the dome of the diaphragm (the right dome of the diaphragm
is higher than the left dome).

· Main nerve supply of the diaphragm is via phrenic nerve.

· In the case of pneumothorax (air in the pleura cavity) the best area of
drain is the second intercostal space (upper intercostal space).

· Lymphatic drainage of the skin of thorax, note that levels of umbilicus

anteriorly and iliac crest posteriorly may be regarded as water sheds for
lymph flow.

· Lymphatic drainage of the skin of anterior chest wall passes to the

anterior axillary lymph nodes, that from posterior chest wall passes to
the posterior axillary lymph nodes.

· The plane of the inlet is directed downwards and forwards or the face
of the inlet is directed upwards.

· The superficial fascia of thorax is denser posteriorly than anteriorly.

· Kyphosis: Abnormal curvature for the back outwards (thoracic

vertebrae).

Scoliosis: Lateral abnormal flexion.

Lordosis: Backward increased curvature.
· The inspiration is active movement while the expiration is passive
movement.
Rebin I. Hasan Hawler Medical University
· Fracture may be directly or indirectly.

· The fracture in the shaft of the ribs is more probability than fracture in
other parts of the ribs.

· Diaphragm is attached to the pericardium then the pain in angina feel

in upper shoulder referred pain from the (C3 , C4 and C5) phrenic nerves
means the pain is not the region of it , but pain comes from the
diaphragm (C3 , C4 and C5) nerves and to shoulder.

· Floating rib gives more space of the cavity and moving thorax to
increasing space.

· Prone position causes the movement at diaphragm to upper side of the

body.

· Supine position causes the movement at diaphragm to lower side of the

body.

· Anterior in the lower space of the rib needle must pass through the 7th
intercostal space.

Q1/ Why breathing in infants is purely abdominal, while in adults

permits thoracic breathing?
Ans: Because in infants the shape of the ribs are horizontal and the
shape of the thorax is circular, while in the adult due to the oblique
shaped ribs and due to the oval shaped thorax.
Q2/ Enlargement of axillary lymph node in infection of upper
abdominal skin?
Ans: Because the axillary lymph node drains the lymph not only from the
upper limb, but from anterior and posterior body wall above the level of
umbilicus, therefore the infection rises to axillary lymph nodes.
Q3/ Children ribs fracture less that of the adult, why?
Ans: Because children's rib is more elastic.
Intercostal space
There are three types of muscles in thorax:
1- Muscles connecting the ribs e.g. intercostals muscles.
2- Muscles connecting the ribs to the sternum e.g. transversus thoracic
muscles. Rebin I. Hasan Hawler Medical University
3- Muscles connecting the ribs to the vertebra e.g. serratus posterior
muscles.
These muscles have respiratory action beside the diaphragm, which are
respiratory muscle acting only in inspiration.
* Intercotal muscles are not muscles of expiration.
Q1/ Passing a needle in the right lower intercostal space is better in
posterior than anterior end of the space, why?
Ans: To avoid injury to the liver.
Q2/ When fluid in pleura cavity must pass a needle in 5th-7th (7th is
better) intercostal space, why?
Ans: due to the collection of the fluid in this region (it means fluid is
heavy and descends down).
Q3/ Introducing a canal (puncture) through intercostal space is better
to be lateral to the angle of scapula posteriorly, why?
Ans: In order not to cause injury to posterior intercostal artery as it
passes and crosses the space obliquely from below upwards.
Q4/ Most needle pass above the upper border?********
Ans: Due to absence of any (vein, artery or nerve) in this region i.e.
(needle passes above the upper border) lower part of the space to avoid
injury to the principal neurovascular bundle.
Q5/ The right posterior intercostal arteries are longer than the left
posterior intercostal arteries, why?
Ans: Because it arises from the descending aorta which lies at the left
therefore the right posterior intercostal artery has to across the
vertebral column to reach the right side.
Pleura and lungs
Pleura cavity is close surrounding the root of the lungs.
Pulmonary ligament fixes root of the lung.
The lung is normally not filling pleura cavity except in deep respiration.
Rebin I. Hasan Hawler Medical University
At winding of esophageal opening sometimes stomach may enter to the
thorax and this is called hernia and this hernia is either (sliding
esophageal hernia) or (Para-esophageal hernia).
Q1/ Why the right lung is shorter than the left lung?
Ans: Because the dome of diaphragm (the right dome of diaphragm is
higher than the left dome).
Q2/ Why the inferior vena cava has a short course in the thorax?
Ans: Because the dome of diaphragm (the right dome of diaphragm is
higher than the left dome).
Q3/ Why the phrenic nerve is longer in its course than the right
phrenic nerve?
Ans: Because the dome of diaphragm (the right dome of diaphragm is
higher than the left dome).
Q4/ We can remove any of the lobes of the lungs without affecting
other, why?
Ans: Because each lobe has a special bronchus, blood supply and nerve
supply.
Q5/ Removing broncho pulmonary segment will not affect other
segments, why?
Ans: Because each broncho pulmonary segment is functionally and
structurally independing having its own nerve supply, blood supply and a
special bronchus.
Q6/ Broncho pulmonary segment is not bronchovascular segment,
why?
Ans: Because it does not have its own vein.
Q7/ The right dome of the diaphragm is higher than the left dome?
Ans: Because of the presence of the liver in the right side.
Q8/ Why fluids collect in the pleura cavity causes dysponea (difficult
breathing)?
Ans: Because these fluids will apply pressure upon the lung causing
discomfort respiration.
Q9/ Why lung abscesses are more common in the right side than the
left side? Rebin I. Hasan Hawler Medical University
Ans: Because right principal bronchus is shorter, wider and more in line
with trachea and for the same reason inhaled particle tend to pass and
more to right lung.
Q10/ Deep lymphatic of the lung flow to the superficial when the deep
vessels obstructed in lung or lymph node disease?
Ans: Because the peripheral parts the connection exist which can open
upward.
Pericardium and Heart
· Except for a part of the left branch of AV bundle (supplied by the left
coronary artery), whole of the conducting system is usually supplied by
the right coronary artery.

· Superficial cardiac plexus is smaller than deep cardiac plexus.

· Pericardium is a close sac.

· Oblique sinuses of pericardium permit pulsation of left atrium.

· Lingual covers parts of the pericardium.

Q1/ Why ventricular contraction follows arterial contraction of the

heart?
Ans: Because first contraction indicated in the SA nodes which is situated
in the upper of terminal in the right atrium, than the pulse is transmitted
to AV node then by AV bundle to the ventricle.
Q2/ Why reaching the pericardium is better in the fifth intercostals
space in the left side?
Ans: Due to the presence of the cardiac notch in this space, in the left
side. Rebin I. Hasan Hawler Medical University
Trachea
Q1/ Incomplete cartilaginous tiny in the wall of the trachea, why?
Ans: Because when the food passes via esophagus, which lies behind the
trachea causing decreasing the lumen of trachea, but this incomplete
ring will keep the lumen open.
Q2/ Why foreign body in trachea passes mostly to right bronchus?
Ans: Because right bronchus is wider than the left which is more oblique
than the right.
Q3/ During swallowing when larynx elevate the trachea bifurcation is
fixed, why?
Ans: Because the trachea bifurcation is not permitted to move by aortic
arch.
Q4/ In removing fluid from pericardial cavity we have to introduce a
needle to the left of xiphoid process in an upward and backward
direction, why?
Ans: To avoid damage to lunge and pleura due to the presence of cardiac
notch in the process.
Blood supply of the thorax
-Each intercostal space contains two small anterior intercostal arteries
and a large single posterior intercostal artery.
A – Anterior intercostal artery:
1- Upper anterior six spaces supplied by internal thoracic artery by two
branches.
2- Lower anterior three spaces supplied by musculophrenic artery by
two branches.
3- The lower two spaces have no anterior branch.
B – Posterior intercostal artery:
1- Upper two spaces supplied by costocervical trunk (superior
intercostal artery) by one branch.
2- Lower nine spaces supplied by descending thoracic aorta by one
branch.
-Intercostal nerve
1- Upper six intercostal nerve supply only chest (Intercostal muscle, skin,
periosteum, parietal pleura).
2- Lower five intercostal nerve supply the abdominal wall. Rebin I. Hasan
Hawler Medical University
• Clinical Notes Of The Lower Limb
Q1/ Varicosity of the superficial veins of the legs?
Ans: Because of the common infection of valves of the perforating
branches from superficial to the deep veins.
Q2/ Lateral planter nerve is more liable to injury than medial planter
nerve?
Ans: Because lateral planter nerve crosses the sole of the foot from
medial to the lateral side and its branches are more distributed.
Q3/ Lateral planter nerve is more dangerous to injury than medial
planter nerve?
Ans: Because it supplied more muscles in the sole of foot.
Q4/ A stab wound in the lower third of leg is dangerous?
Ans: Because in the lower third of leg some nerves and vessels that
supply the leg and foot lie superficial and a stab to this region leads to
paralysis of some muscles and bleeding of blood from the vessels such as:
1- Anterior and posterior tibial artery.
2- Superficial peroneal nerve.
3- Sural nerve.
4- Tibial nerve.
Q5/ Lateral and medial planter arteries are marginal in the foot?
Ans: Because of the higher division of posterior tibial artery than that of
tibial artery.
Q6/ Common peroneal nerve (common fibular nerve) is more liable to
injury than tibial nerve?
Ans: Because common peroneal nerve is in direct contact to the neck of
fibula, which is the liable site to fracture, then injury occurs to common
peroneal nerve while tibial nerve is in indirect contact to the neck of
fibula.
Q7/ The veins of lower limb and all the body are clearer in males than
in females?
Ans: Because the presence of fatty tissue in males is less than that in
females.
Q8/ Femoral artery is more liable to injury below the inguinal
ligament than other parts (adductor canal)?
Ans: Because it lies superficial in the region below inguinal ligament,
while in the adductor canal lies deep.
Q9/ Popliteal artery is more liable to injury in the middle of the fossa?
Ans: Because it lies superficial in the middle of popliteal fossa.
Q10/ Foot drop and paralysis of the muscles of lower limb after gluteal
intramuscular injection?
Ans: Because in this case, there will be injury to the sciatic nerve which
is the main nerve supplying most muscles of the lower limb especially in
the foot (via lateral and medial planter nerves) which then leads to the
paralysis of the muscles of food producing "Foot Drop". Rebin I. Hasan
Hawler Medical University
Q11/ Tear of the spring ligament cause "flat foot"? "Or" Flat foot after
rapture of spring ligament?
Disease of the hip may referred as a pain in the knee and their cutaneous
innervations, because of the both nerve by obturator and femoral nerve
to the hip and knee joint.
Perforating branch of peroneal artery may replace dorsalis pedis artery.
Calf muscles (soleus) sometime called (peripheral heart) because during
contraction it pumps the blood from sinuses into the deep vein and
during relaxation the blood sucked from the superficial vein and the
sinuses are refilled.
Unidirectional blood flow is maintained by the valves in the perforating
veins and for the same reason the calf is necessary for venous drainage.
Injury to the cruciate ligament is common, and the injury to the anterior
cruciate is more common than posterior cruciate.
Lymphatics from anterior compartment of the leg pass to the superficial
inguinal lymph node and some lymph of leg and from its upper lateral
side of anterior surface pass to the popliteal nodes.
Lateral planter artery is longer than medial planter artery, because of its
continuation from the sole (planter arch).
A stab wound at the apex of femoral triangle is more dangerous than the
base of triangle.
Tibial nerve is rarely injured, because of its deep and protected position.
Qa/ Wasting of the intrinsic muscles of hand following fracture of
medial epicondyle of humerus?
Ans: Because ulnar nerve passes behind the medial epicondyle of
humerus and supplies intrinsic muscles of the hand, so the fracture
causes injury to ulnar nerve and paralysis of intrinsic muscles.
Qb/ The radial nerve is more liable to injury than the median nerve in
the arm?
Ans: Because the radial nerve has a direct relation to radial groove of
humerus which is more liable to fracture leads to injury of the radial
nerve whereas the median nerve related to the brachial artery in the
arm.
Qc/ Dislocation of the shoulder joint is more common than dislocation
of the hip joint?
An: Because head of humerus is much greater (several lines) than glenoid
cavity of copula articular surface.
Qd/ Generally the veins are clearer in males than females?
Ans: Because the presence of fatty tissue in males is less than that in
females. Rebin I. Hasan Hawler Medical University
Qe/ Infection of common synovial sheath of flexor tendon passes to
the little finger earlier than other fingers?
Ans: Because the continuity of the common synovial sheath with that of
the little finger and some times with that of the thumb allows the
infection to spread rapidly from these situations to the carpal tunnel
(which is continuous with little finger, but interrupted with other
fingers).
Qf/ A stab wound in the lower part of the forearm is more dangerous
than in its upper part?
Ans: Because the nerves in the lower part (median nerve and ulnar
nerve) are superficial, but in the upper part are deep.
Qg/ Pronation of the forearm in Erb's paralysis?
Ans: In the case of Erb's paralysis the upper trunk is injured together
with C5 and C6 nerves which supinator and biceps muscles are paralyzed,
because they are supplied by C5 and C6 nerves, and they lose their
action (supination of forearm); therefore for position of forearm will be
in pronation.
Qh/ Adduction of the arm in Erb's paralysis?
Ans: Because in this case C5 and C6 nerves are injured, then the deltoid
muscle is paralyzed which supplied by C5 and C6 nerves and lose its
action which is the abduction of the arm, therefore the arm is adducted.
There is compression of the median nerve in the carpal tunnel a case is
produced is called "Carpal tunnel syndrome". Cause of injury is
dislocation of lunate.
Posterior dislocation of hip joint is easier than anterior dislocation while
anterior dislocation of shoulder joint is easier than posterior dislocation.
When there is a blockage of one lobe of the breast other lobes will not
be affected.
When there is a blockage in one lactiferous of breast there will be
enlargement in size and swelling and the treatment is a surgical
operation.
If there is abscess, we must open the area of abscess in a radial position
to avoid cutting others.