Surface Anatomy and Clinical Correlation

Clavicular Fracture

• Occurs at the junction between the lateral and medial curvature of the clavicle

  • The weakest point of the clavicle

SYMPTOMS:

Muscle guarding wherein the

Commonly Caused:

Falling on outstretched hand: Wrist → radius → ulna (through the interosseous

membrane) → humerus → scapula → clavicle

Greenstick Fracture

Known as the partial break of the clavicle, wherein the bone cracks on one side but not all the way through

Common In Children (i.e shoulder dystocia in newborns) due to their softer bone

Scapular Fracture

Scapular Fracture

Brought upon by high-energy force such as blunt trauma to the scapula

Scaphoid Fracture

Can present as a complication of Prieser’s disease due to the avascular necrosis of the scaphoid

MRI

Best mode of radiographic imaging used for suspected avascular necrosis

Fracture of the surgical neck of the humerus

• Affected structures of the fracture:

  • Circumflex Humeral Artery can be compromised due to its location in the _______ ____, especially if the proximal region of the humerus

  • Can lead to avascular necrosis

• Axillary Nerve can be compromised since it passes through the posterior region of the _______ ____

Fracture of the Anatomical Neck of the Humerus

Injury to the ________ ___ can cause loss of blood

supply to the humeral head, and can cause rotting/necrosis

● Can also injure the circumflex humeral arteries

○ May result in:

■ Avascular Necrosis

■ Bone death

Humeral Shaft Fractures

Can damage structures related to the spiral groove

• Radial nerve

  • Characterized by wrist drop

  • Triceps may lose function

• Profunda brachii artery

  • torn/ruptured

Transverse Humeral Shaft Fracture

Oblique Humeral Shaft Fracture

Has a sharp edge which has the most potential to lacerate the radial nerve and profunda brachii artery

Spiral Humeral Shaft Fracture

Most common humeral shaft fracture

Comminuted Humeral Shaft Fracture

Segmental Humeral Shaft Fracture

Type I supracondylar fracture

A hairline crack in the supracondylar region of the humerus

Vasculatures affected:

○ Brachial artery

■ Absent pulse suggests possible brachial artery

damage.

■ Loss of strength may indicate the possibility that

the brachial artery is cut off.

○ Median nerve

■ Motor function test: “OK” Sign

● Normal: Patient can form a proper circle.

● Median/AIN damage: Flattened or “pinch” sign

instead of a circle

Type II supracondylar fracture

Fracture which demonstrates a slightly displaced anterior wall in the supracondylar region of the humerus

Vasculatures affected:

○ Brachial artery

■ Absent pulse suggests possible brachial artery

damage.

■ Loss of strength may indicate the possibility that

the brachial artery is cut off.

○ Median nerve

■ Motor function test: “OK” Sign

● Normal: Patient can form a proper circle.

● Median/AIN damage: Flattened or “pinch” sign

instead of a circle

Type III supracondylar fracture

Radial complete displacement( both anterior and posterior wall)

Vasculatures affected:

○ Brachial artery

■ Absent pulse suggests possible brachial artery

damage.

■ Loss of strength may indicate the possibility that

the brachial artery is cut off.

○ Median nerve

■ Motor function test: “OK” Sign

● Normal: Patient can form a proper circle.

● Median/AIN damage: Flattened or “pinch” sign

instead of a circle

Medial epicondylar fracture

Usually affects the ulnar nerve

● Common causes:

○ Direct trauma

○ FOOSH

○ Avulsion fracture

■ Occurs when a very forceful traction of muscles or

ligaments pulls on the bone, breaking it.

■ Avulsion fracture of the ___________ can

be attributed to the pull of the anterior compartment

muscles, most commonly the common flexor

origin as these muscles attach to the medial

epicondyle

Colles’ fracture, Smith’s fracture and Galeazzi fracture

Types of Radial Head Fractures

Colles’ fracture

Cause: FOOSH injury while wrist is extended

● A posterior/dorsal displacement fracture in the distal

radial segment towards the lister’s tubercle.

● Results in “Dinner fork” deformity

Smith’s Fracture

Also called “Reverse Colles’” or “Garden Spade”

● Cause: FOOSH injury while wrist is flexed

● An anterior/volar displacement fracture in the distal

radial segment near the wrist.

Galeazzi Fracture

Radius fracture with dislocation of the distal radioulnar

joint

Monteggia Fracture

Ulnar fracture with dislocation of the radial head

Lunate Fracture

Just like the scaphoid bone, the _______ is also at risk for

avascular necrosis called Kienbock’s Disease.

○ Rare condition where the _______ loses blood supply,

resulting in bone death.

○ Presents as a complication of the fracture

Hamate Fracture

Fractures can occur at the _______ due to its anterior projection.

● Causes:

○ FOOSH

○ Sports equipment handling injury (e.g., by baseball bats

or clubs)

■ May occur if the player hardly hits the incoming ball

as the tension or force is transmitted into the hook of

hamate

● Affects the ulnar artery and ulnar nerve that pass through

the Tunnel of Guyon

■ Pisohamate ligament which is found on the top of

the hook of hamate and pisiform forms the Tunnel

of Guyon or Guyon’s Canal

Boxer’s Fracture

Fracture of the neck of the 5th metacarpal

● Cause:

○ Striking an object with a closed fist (common in boxers)

● Symptoms:

○ Pain

○ Swelling

○ Depression of the knuckle

Bennett’s Fracture

Fracture at the base of the 1st metacarpal

● Often involves subluxation (partial dislocation) of the

carpometacarpal (CMC) joint

● Cause:

○ Axial force on a partially flexed/bent thumb (e.g., impact

from punching or a fall)

● Symptoms:

○ Pain, swelling, bruising at the base of the thumb

○ Difficulty or pain with gripping

○ Thumb misalignment

Rolando’s Fracture

Fracture at the base of the 1st metacarpal, with a Y- or

T-shaped pattern

● Multi-fragmented fracture

● Cause:

○ Axial force on a partially flexed/bent thumb (e.g., impact

from punching or a fall)

M. Phalangeal Fracture

Causes:

○ Acute trauma (e.g., finger caught in a car door)

○ Crush injuries

○ Forceful twisting or jamming of the fingers

○ Tumors may weaken the bone, making it more

susceptible to fracture

Dislocations

Characterized by total separation of joint components

Anterior Sternoclavicular Joint Dislocation

The separation of the sternum and the sternal/medial end of the clavicle

Common causes: Traumatic events such as collisions in

sports (e.g., rugby)

● The displacement can be anterior or posterior

○ Anterior dislocation: the clavicle moves forward

■ Most common

○ Posterior: the clavicle moves backward

■ a dangerous type of dislocation, since the clavicle can damage or lacerate structures posterior to the sternum (e.g., trachea, esophagus, subclavian artery)

Posterior Sternoclavicular Joint Dislocation

The separation of the sternum and the sternal/medial end of the clavicle

Common causes: Traumatic events such as collisions in

sports (e.g., rugby)

● The displacement can be anterior or posterior

○ Anterior dislocation: the clavicle moves forward

■ Most common

○ Posterior: the clavicle moves backward

■ a dangerous type of dislocation, since the clavicle can damage or lacerate structures posterior to the sternum (e.g., trachea, esophagus, subclavian artery)

Acromioclavicular Joint Dislocation

Displacement of the _________ joint:

○ If the coracoclavicular ligament is still intact, the dislocation is not that severe and undisplaced.

○ If the coracoclavicular ligament is torn, the _________ joint is displaced.

● The acromion and scapula are pulled downwards by the

weight of the upper limb, the clavicle displaced upward,

resulting in a step deformity.

Anterior Shoulder Joint Dislocation

The humeral head will move anterior to the scapula

Test always involve a screening for associated fractures; Patient is positioned to have a flattened shoulder, arm in slight abduction/flexed elbow

Posterior Shoulder Joint Dislocation

X-ray reveals that the humeral head is aligned with the acromion

Test always involve a screening for associated fractures; Patient is positioned to have a flattened shoulder, arm in slight abduction/flexed elbow

Normal shoulder joint alignment

The glenoid fossa is at the center of the Y line.

Elbow Joint Dislocation

Separation of the radius and ulna from the distal humerus

• the Collateral ligament tears possibly with the valgus force

Pulled Lebow/ Nursemaid’s elbow

Common injury in children less than 5 years old when the radial head slips out of the annular ligament.

Characterized by the annular ligament slipping over the radius bone

Symptoms:

• Pain the elbow, leading to elbow guarding

• Reluctance to use the arm

Wrist Join Dislocation

• Rare

• Collateral ligaments can be damaged

• The radiocarpal joint is displaced

• Anterior or Posterior Displacement

Lunate Bone Dislocation

Lunate bone is dislocated

Lunate is aligned with 3rd metacarpal

• Murphy’s Sign: The patient is asked to make a fist. If the 3rd metacarpal is aligned with the 2nd and 4th metacarpal, a lunate dislocation is suspected(+)

Metacarpophalangeal/Interphalangeal Joint/Finger dislocation

Seen in Murphy’s sign

Can occur anteriorly or posteriorly

Can rupture the collateral ligaments surrounding the joints

Joints must be repositioned in extended position

• Collateral ligaments are loose in extended position & taut in flexed position

Frozen shoulder/ Adhesive Capsulitis

Commonly occurs in the elderly

Usually idiopathic or occurs after trauma/immobilization

Progression: Capsular inflammation > adhesion > stiffness

Analgesia + early PT intervention

Management for adhesive capsulitis

Stage 1/Pre-freezing of Adhesive Capsulitis

Stage of adhesive capsulitis which occurs 1-3 months and pain is first noticed in the shoulder region

Stage 2/Freezing phase of Adhesive Capsulitis

Stage of adhesive capsulitis which lasts from 10 weeks to 8 months and is known to be the most painful phases. Movement is also restricted

Stage 3/Frozen Phase of Adhesive Capsulitis

Stage of adhesive capsulitis which lasts from 4-12 months and the shoulder is notably stiff

Stage 4/Thawing phase of adhesive capsulitis

Stage of adhesive capsulitis which lasts from 5 months to 2 years and the shoulder joint has become stiff but gradually loosens

Tommy John Injury

A sprain or tear of the ulnar collateral ligament on the medial side of the elbow

Can also present a tingling sensation along the ulnar nerve distribution in the hand

Can be torn especially during elbow-joint dislocation or other sport injuries

Skier’s Thumb

A sprain or torn ulnar collateral ligament on the medial side of the thumb

Commonly observed in skiers after a bad fall while still holding the ski poles

Rotator Cuff Injury

Tear of the rotator cuff muscles or irritation of the ligaments that are attached to the humerus (holds the shoulder in place)

• Causes pain, weakness, limited movement(ex. abduction or lifting above the head)

• Can lead to frozen shoulder if not addressed

• Common in sports like baseball and tennis

• Diagnostic imaging: MRI

Bicipital Tendonitis

The long head of the biceps tendon will pass through the bicipital groove or intertubercular groove

• Covered by the bicipital ligament or transverse humeral ligament

Inflammation of the tendon of the long head of the biceps brachii

• Continuous use of the biceps brachii will rub its tendon against the ligament surface. This repeated friction irritates the tendon and can lead to tendonitis

Biceps Brachii Tendon Rupture

Tear of the biceps brachii tendon

• May occur at the distal or proximal end

Symptom:
(+) Popeye’s deformity: bulging of biceps brachii

May present with bruising

Golder’s Elbow/ Medial Epicondylitis

Affects the common flexor tendon origin

Common with golfers when they swing the golf club

Excessive use led to inflammation of the common flexor tendon origin

Tennis Elbow/ Lateral Epicondylitis

Affects the common extensor tendon originating from the lateral epicondyle

Posterior muscles in the forearm are affected which can cause small tears and inflammation in the tendon

Common in racket-related sports like tennis, badminton and pickleball

Medial epicondylitis test

Special tests for medial epicondylitis

Cozen’s Tests and Mill’s Test

Special tests Lateral Epicondylitis

De Quervain’s Tenosynovitis

Also called stenosing tenosynovitis

Inflammation of the lareal tendons formed by the abductor Pollicis longus(APOL) and Extensor Pollicis Brevis, which share a common tendon sheath and contribute to the anatomical snuffbox

Common among those who write frequently

Mallet Finger/ Baseball Finger

Tear to the tendon that extends the DIP joint resulting in a flexed position

The extensor digitorum tendon pulls a piece of bone due to sudden force of impact hitting a stretched finger

Avulsion fracture, torn extensor tendon

Boutenniere deformity

• Bending of the proximal interphalangeal joint posteriorly, affected by the torn central slip extensor tendon

• Rupture to the extensor tendon of the proximal interphalangeal joint

• Distal joint will extend due to the pull of the tendon

Jersey Finger

• Results from an avulsion injury of the flexor digitorum profundus form the insertion at the base of the distal phalanx’

  • Hyperextension of the DIP joint

  • Unable to bend the DIP joint due to FDP being unable to act onit

  • Special test: Sweater finger

Trigger Finger

Delayed finger snapping
Common in elderly where nodules can form on the tendon of the FDP/S

The nodules can get stuck by these flexor sheaths which prevents the smooth glidingg of tendons through the sheath

Management: Steroid injection to reduce the nodule or surgical release of the tendon if conservative treatment fails

Olecranon Bursitis

Inflammation of the olecranon bursa

Commonly known as student’s elbow

Thoracic Outlet Syndrome

Hypertrophy of the muscles obstructs or compresses the subclavian artery and other blood vessels

The pulse is used to determine compression

Compression of subclavian artery will lead to decreased blood flow in upper limb

Volkmann’s Ischemic contracture

Severe permanent flexion deformity of the hand and fingers caused by muscle damage from ischemia

The fracture compresses nerves and blood vessels which leads to claw hand deformity and complications of the supracondylar fracture

Lymphatic Edema

Compression of the clavicular and pectoral lymph nodes which can result in reduced lymphatic drainage and swelling of the upper limb

Spinal Accessory nerve

Can be damaged due to acute injuries

Affects sternocleidomastoid and trapezius muscle—leading of lack of head movement and shoulder joint elevation

Winged Scapula

Characterized by a prominent vertebral border of the scapula

Test: ask patient to press palm on wall> prominence of vertebral border of scapula

Caused by long thoracic nerve injury—affecting the serratus anterior which is responsible for pulling near the rib or chest wall

Typically caused by trauma or latrogenic(doctor-induced injuries)

Thoracodorsal Nerve Affectation

Paralyzes latissimus dorsi—affecting the arm extension, adduction and internal rotation

Dorsal Scapular Nerve

Affects the levator scapulae, rhomboid major and rhomboid minor—resulting to difficulty in retracting the scapula

Suprascapular nerve

Affects the supraspinatus and infraspinatus—disables the ability of the arm to abduct (supra—) & externally rotate(infra—)
Leads to atrophy of supra and infra due to lack of movement

Subscapular nerve

Affects the subscapularis and teres major

Difficulty in internal rotation of the shoulder

Plexopathy

Injuries are common and are usually caused by traction, pressure or a stab would

Defined as a form of peripheral neuropathy involving damage or dysfunction of a nerve plexus, which is a complex network of nerves branching from the spinal cord to various parts of the body

Brachial plexopathy

affects the arm, shoulder, and upper chest, often caused by trauma, compression, or inflammation

Damage to the brachial plexus

Erb-Duchenne palsy

• Affects C5 and C6 upper ventral rami

• Injury to the upper trunk of the brachial plexus

• Results from excessive displacement of the head to the opposite side and depression of the shoulder

• Common in babies who are difficult to push out during labor

CHARACTERIZED By:

• Waiter’s position

  • Shoulder: adducted(loss of deltoid & supraspinatus function) and medially rotated(unopposed ppectoralis major)

  • Elbow: Extended(loss of biceps)

  • Forearm: Pronated(Loss of biceps function)

  • Fingers and Wrist: Flexed

Klumpke’s Palsy

Traction injury due to excessive arm abduction

• When a person falls and clutches an object to save them

• Injury to lower trunk of the brachial plexus

  • Typically involves tearing of the C8 & T1 lower ventral rami

    • Affected nerves:

      • Ulnar nerve

      • Median nerve

    • Affected muscles

      • Small muscles of the hand(d/t damage to ulnar and median nerve fibers)

    • Results in claw hand deformity

      • Hyperextension of the MCP joints and flexion of the IP joints

    • Sensory loss along the medial side of the arm

Musculocutaneous nerve

Paralyzed muscles of the anterior fascial compartment due to MC nerve injury

• The musculocutaneous nerve rises from the lateral cord of the brachial plexus

• The nerve pierces through the coracobrachialis and is covered by the biceps brachii

• Its terminal end supplies the lateral skin

Damage results to weak elbow flexion

Weakness of forearm supination

Numbness in the anterolateral surface of the forearm

Common causes are penetrating injury as the biceps brachii covers the nerve

Axillary Nerve

Presentation: Decreased roundness and flattening of shoulder

Common causes: Fractures of the surgical neck of the humerus

• Downward displacement of the humeral head in glenohumeral (shoulder) dislocations

Median Nerve

Extends from origin in the brachial plexus until wrist and hand

• Rises from the lateral half of the lateral cord and half of the medial cord

• No role in brachium but has a role in anterior forearm, thenar eminence, and lumbricals 1-2

• Anywhere from its origin can damage the median nerve but differs in its presentation

Proximal Median Nerve Injury

Upper arm, elbow or anterior forearm is affected

All manifestations pertaining to median nerve will be present

Median nerve oppression due to supracondylar fracture

Proximal affectation:

• Oppression of the ______ nerve due to a supracondylar fracture

Pronator Teres Syndrome

Compression of the median nerve due to pronator teres

Usually happens for profession that require frequent pronation/supination

Presents with pain on top of the pronator teres

Manifests with hypesthesia

• Decrease in sensation of the distribution of median nerve

• Presents with papal benediction sign

  • Only the lateral 2 fingers supplied by ulnar nerve will move

High Median Nerve Injury

Does not supply the FDS and FDP

• The terminal branch supplies the thenar eminence which will result in its atrophy due to wasting of muscles

• Decreased sensation on area being supplied by the median nerve

Presentation: Ape hand deformity, papal benediction

Distal Median Nerve Injury

Lesion at the distal side affects of the FDS and FDP

• If the median nerve is compressed, specifically in the carpal tunnel, both FDS and FDP will still be functional

  • No papal benediction

• However, thenar eminence will not be innervated = ape hand deformity

Carpal Tunnel Syndrome

Compression of the median nerve within the carpal tunnel at the anterior wrist

• Causes:

  • Occupation or activities that require prolonged use of the FDP and FDS such as frequent typing and frequent writing

  • Repetitive use of the flexor tendons can lead to hypertrophy(thickening) of these tendons which can compress the median nerve within the carpal tunnel

Affected Muscles:

• Thenar eminence

• Lumbricals 1 & 2

• Sign: Ape hand deformity

Provocative tests for Carpal Tunnel Syndrome:

• Phalen Test

  • Compressing further the median nerve

  • Tingling sensation will increase in area

  • Inverted praying hand position

• Tinel Test

  • Tapping on the area of carpal tunnel

  • Median nerve is irritated and will present tingling sensation as well

Anterior Interosseus Syndrome

Affects the anterior interosseus nerve

Test:

• O sign test

  • Intact muscle = Negative O sign

  • Weak FPL and FDP = O sign collapse > Positive O sign

Radial Nerve

Comes from posterior division of trunk

Divides into superficial nerve and the posterior interosseus nerve

Proximal radial nerve injury

At distal humerus

Affects all posterior skin being supplied will be affected

Problem with elbow extension

• Triceps is still functional

• No sensation at posterior forearm and dorsum of hand

• Both proximal and distal injuries present with affectation of posterior forearm muscles

  • (+) wrist drop

  • Causes: Improper use of axillary crutch

    • Radial nerve is compressed

Saturday Night Palsy

Pressing up into the arm

Common in people who fall asleep with one arm over the back of the chair

Spiral Groove Fracture

Results: Claw hand deformity due to atrophy of adductor pollicis, guttering or depression in between the metacarpals occupied by interossei muscles

• Clawing due to pull of extensor digitorum

• Loss of function of the structures moved by the medial half of the flexor digitorum profundus and the flexor carpi ulnaris

Test: Froment Test