ARM, FOREARM

& HAND
Clinical
Anatomy
1. A 36 year old male presented with
wristdrop. This is due to pathology of which
nerve

A. radial
B. ulnar
C. median
D. musculocutaneous

Answer: A
2. Fracture of the medial epicondyle results
to injury of what nerve

A. radial C. ulnar
B. median D. musculocutaneous

Answer: C
To release pressure on the brachial artery when the elbow
is too swollen to avert impending Volkmann's ischaemia
(loss of blood supply to the forearm) this structure has to
be cut:

A. bicipital tendon insertion C. bicipital aponeurosis

B. medial intermuscular septum D. pronator teres belly

Answer C
A 24 year old male patient sustains a fracture at
the midshaft of the humerus. The patient may
sustain injury to a nerve which is likely to
produce:

A. claw hand deformity

B. winging of the scapula
C. wrist drop
D. carpal tunnel syndrome

ANSWER : C
 A 20-year old male fell twice in the course of a
basketball game and each time he used his right arm
to break his fall. He felt pain in the right shoulder the
following day. Physical examination revealed no
deformity. However, there was deep tenderness in the
acromion process. Abduction of the right arm was
painful. The injury is most likely a:

A. tear of the deltoid muscle

B. shoulder joint dislocation
C. fracture of the clavicle
D. rupture of the supraspinatus tendon

ANSWER:D
The supraspinatus located above the spine of the scapula, forms part of
the rotator cuff to help stabilize the shoulder joint. It initiates arm
abduction (the first 10deg-15deg) and this action is completed by
the deltoid muscle.
 Which of the following muscles will be paralyzed if
there is a lesion of the ulnar nerve?

A. medial two lumbricals and opponens pollicis

B. palmar interossei and adductor pollicis
C. dorsal interossei & lateral two lumbricals
D. medial and lateral lumbricals
ANSWER:B

The intrinsic muscles of the hand are innervated by the ulnar nerve except 5
muscles (3 thenar muscles and the first 2 lumbricals) which are
innervated by the median n. (B) palmar interossei and adductor pollicis
are supplied by the ulnar nerve.
Damage to the anatomic snuffbox
might be expected to injure the
A. ulnar nerve
B. median nerve
C. ulnar artery
D. radial artery

ANSWER D
 Damage to this nerve results in
“winged scapula

A. radialnerve
B. median nerve
C. ulnar nerve
D.long thoracic nerve

ANSWER D
 A drunkard falling asleep with one
arm over the back of the chair upon
Waking up had “ wrist drop”most
likely nerve involved?
A. radial nerve
B. axillary nerve
C. ulnar nerve
D. median nerve
ANSWER A
 Long Thoracic Nerve Lesion
(Nerve to Serratus Anterior)

 blows or pressure in the

posterior triangle of the
neck
 during a radical
mastectomy surgical
procedure

 SA pulls the medial border

of the scapula to the
posterior thoracic wall
and stabilizes it

 have a person push

against a wall or door
the medial border of the
scapula will be pushed
away from the thoracic
wall, and protrude like a
wing  'WINGED
SCAPULA'
Axillary Nerve

 Injured by the pressure

of a badly adjusted
crutch pressing upward
into the armpit
 Shoulder dislocation
 Fx of surgical neck
 Paralysis of deltoid &
teres minor
 Loss of skin sensation
lower half of deltoids
 RADIAL NERVE

Spiral groove
Radial Nerve Injury

 results will depend on where along

its path it is injured

 The most complete injury is one

that occurs in the axilla
- poor positioning of a crutch
- shoulder dislocation
- fractures of the upper part of the
humerus

 results in paralysis of the

– Triceps
– anconeus
– long extensors of the wrist
 The patient is unable to extend
the elbow joint, the wrist joint and
the fingers
 Unable to grip object

 "WRIST DROP"
 injured as it passes along the
spiral groove of the humerus
following fractures of the
humerus

 injured due to prolonged

pressure of the back of the
arm on the edge of an
operating table
 The branches to the triceps
are spared in this injury so
that extension of the elbow is
possible.
 The long extensors of the
forearm are paralyzed and this
will result in a "WRIST
DROP“
 .
 There is a small loss of
sensation over the dorsal
surface of the hand and the
dorsal surfaces of the roots of
the lateral three fingers.
 Radial nerve -
this is the
extensor nerve.
Failure to extend
the thumb
signify damage
to this nerve
Medial epicondyle
Ulnar Nerve Lesion
 a branch of the medial cord

 It passes into the anterior

compartment of the forearm after
passing behind the medial
epicondyle of the humerus.

– the nerve can be injured following

fractures of the medial epicondyle

 paralyzed are :
– flexor carpi ulnaris
– medial half of the flexor digitorum
profundus
– medial two lumbricals
– all interossei
– adductor pollicis
Ulnar Nerve Lesion

 The thumb is abducted and

extended with the distal phalanx
flexed.

 The first two fingers are fully

extended with a slight flexion of the
distal phalanges.

 The medial two fingers are

hyperextended at the
metacarpophalangeal joints but
flexed at the distal phalangeal
joints.

 CLAW HAND
 Ulnarnerve - if
damaged, the
patient can not
approximate the 4
medial fingers ("4-
fingered cone").
MEDIAN NERVE lesions
 Injured most commonly above the
retinaculum

 Thenar muscle  paralyzed & atrophies

 Thumb laterally rotated &adducted

 Hands look apelike

 Opposition movement of thumb is

impossible

 1st 2 lumbricals are paralyzed with

lagging of index & middle finger when
making a fist
 Median nerve - inability to
approximate the 5 fingers ("5-
fingered cone").
Carpal Tunnel Syndrome
Lateral Epicondylitis/ TENNIS
ELBOW
 Partial tearing or
degeneration of
origin of superficial
extensor muscles

 Pain & tenderness

with radiation to
lateral side of
forearm
Hand Injuries  Boutonniere
Deformity
– Injury to extensor
tendon proximal to
its insertion into the
base of the middle
phalanx
– Direct trauma to the
finger, over the back
of proximal
interphalangeal joint
or laceration of
dorsum of finger
 Mallet Finger (Flexion
Hand Injuries deformity)
• Avulsion of the
insertion of one of the
extensor tendons into
the distal phalanges
• Occur if the distal
phalanx is forcibly
flexed when the
extendor tendon is taut
• Last 20 degree of
active extension is lost
 UPPER EXTREMITY EDEMA:
– relatively common finding in the lower extremity, rare in
the arms and hands.

– Lower extremities exposed to greater hydrostatic

pressure due to their dependent position

– Upper extremity edema, when present, usually occurs

focally over an area of local inflammation (e.g. cellulitis).

– Diffuse arm edema can occur if drainage is

compromised, as when the lymphatics are disrupted
following axillary lymph node surgery for staging and
treatment of breast cancer.

– Upper extremity venous obstruction can also cause

edema, though blood clots in this region are much less
common then in the lower extremity.
Pulses:

1 subclavian artery in
the neck just as it
passes over the first rib
2 the terminal part of the
axillary artery as it
crosses teres major
muscle
3 the brachial artery at
the elbow just medial to
the tendon of the
biceps brachii muscle
4 the radial artery at the
wrist
5 the ulnar artery at the
wrist
 RADIAL ARTERY- from level
of neck of the radius to a
point in front of the styloid
process of the radius.
 Pulsations - may be felt
between the radial styloid
process and the tendon of
the flexor pollicis longus.

 ULNAR ARTERY- line drawn

with slight concavity
outwards, from the middle
of the cubital fossa to the
junction of the upper and
middle thirds of a line
joining the medial
epicondyle to the radial side
of the pisiform bone.
 Ulnar nerve - follows the
same line.
Anatomy of Basilic and Cephalic Vein
Catheterization
 The median basilic or basilic veins are the veins of
choice for central venous catheterization, because
from the cubital fossa until the basilic vein reaches
the axillary vein, the basilic vein increases in
diameter and is in direct line with the axillary vein

 The valves in the axillary vein may be troublesome,

but abduction of the shoulder joint may permit the
catheter to move past the obstruction.
Anatomy of Basilic and Cephalic Vein
Catheterization

 The cephalic vein

– does not increase in size as it ascends the arm

– it frequently divides into small branches as it lies within the

deltopectoral triangle

– One or more of these branches may ascend over the clavicle

and join the external jugular vein.

– In its usual method of termination, the cephalic vein joins the

axillary vein at a right angle. It may be difficult to maneuver
the catheter around this angle.
Superficial veins - used
for venipuncture,
transfusion, and
catheterization.
 median cubital vein (2)
 cephalic vein (1) just
posterior to the styloid
process of the radius
at the wrist.
Site most often used for a
cut down in the upper
limb.
 frequently, the
cephalic and basilic
veins (3) can be seen
on either side of the
elbow where the
medial cubital vein is
located.
Lymphangitis
 Infection of the lymph vessels iss common.
 Red streaks along the course of the lymph vessels
– The lymph vessels from the thumb and index finger
and the lateral part of the hand follow the cephalic vein to
the infraclavicular group of axillary nodes
– those from the middle, ring, and little fingers and from the
medial part of the hand follow the basilic vein to the
supratrochlear node, which lies in the superficial fascia just
above the medial epicondyle of the humerus, and thence to
the lateral group of axillary nodes.
Lymphadenitis
 lymph nodes become enlarged and tender

 Most of the lymph vessels from the fingers

and palm pass to the dorsum of the hand
before passing up into the forearm

 This explains the frequency of inflammatory

edema, or even abscess formation, which
may occur on the dorsum of the hand after
infection of the fingers or palm
ALLEN’S TEST

 To test for ulnar & radial artery

 Let hand rest on the
lap,compress radial arteries
against the anterior surface of
each radius and ask the px to
tightly clench fists.
 Open hand, if it turns pink ulnar
artery is patent
Common Nail Pathology

Nicotine Staining Onychomycosis

Onycholysis Paronychia
 CLUBBING
• Bulbous appearance of the distal
phalanges of all fingers along with
concurrent loss of the normal angle
between the nail base and adjacent skin

• chronic hypoxemia (e.g. severe

emphysema).