Blue Box Stuff from Moore fourth and fifth fingers (paralysis of medial half of flexor

The Upper Limb digitorum profundus and hypothenar muscles).

The structure of the scapula: anterior – subscapular
fossa; posterior – supraspinatous and infraspinatous fossae; The median nerve pretty much runs as its name
articulates with the clavicle at the acromion; has a coracoid implies, passes through the two heads of the pronator teres
process where several muscles (coracobrachialis, pectoralis muscle, then dives in between the flexor digitorum
minor) attach. superficialis and the flexor digitorum profundum in the
forearm. Injury to this nerve results in loss of sensation to the
The structure of the humerus: the head goes into the lateral palmar side of the hand and paralysis of wrist and
glenoid fossa of the scapula, just inferior to the acromion. finger flexors, especially thenar muscles and the second and
There is the greater tubercle, which is lateral and serves as third digits. This is due to the fact that the median nerve
the attachment for the supraspinatus, infraspinatus, and innervates only the lateral half of the flexor digitorum
teres minor muscles. The lesser tubercle is anteromedial and profundus. It can also get trapped between the two heads of
is the attachment for the other muscle of the rotator cuff, the the pronator teres, causing pain in the proximal anterior
subscapularis. There are tuberosities, which serve as portion of the forearm.
attachments for the deltoid and brachialis muscles, more distal
on the anteromedial surface of the bone. At the distal end are Injuries to the brachial plexus are many and
the lateral and medial epicondyles. The humeroulnar and complex.
humeroradial joint facets are made up of the capitulum, on Injuries to the superior parts of the plexus usually
the radial / lateral side, and the trochlea, on the ulnar / medial result from separation of the neck and shoulder. The roots of
side. Posteriorly the olecranon fossa lies in-between C5 and C6 may be pulled out of the spinal cord. The
epicondyles. suprascapular, axillary, and musculocutaneous nerves do not
function. The supraspinatus and infraspinatus (lateral
The structure of the ulna: The coronoid process is on rotation of arm), deltoid and teres minor (abduction), and
the proximal, anterior surface, while the olecranon process biceps brachii and brachialis (flexion) are paralyzed. This
is on the proximal, posterior surface. It looks like a wrench, disorder, known as Erb’s palsy, results in a characteristic
sort of. Distally lies the styloid process of the ulna, which “waiter’s tip” presentation of the patient – pronated, medially
actually attaches on the medial surface of the radius (the rotated, and extended. The lateral aspect [lateral antebrachial
styloid process of the ulna articulates with the wrist). cutaneous] of the arm is numb.

The structure of the radius: The head of the radius Poorly fitting crutches may injure the posterior cord
articulates with the capitulum of the humerus, while its styloid of the plexus, damaging the radial nerve. The triceps and
process is attached to the wrist. extensors of the wrist are paralyzed, and unopposed flexion
causes characteristic “wrist drop.” Patient also cannot
The clavicle is most commonly fractured in the extend their elbow, wrist, or digits.
lateral third, medial to the coracoclavicular ligament. The
sternocleidomastoid contracts and elevates the medial Injury to the inferior roots of the plexus may occur if
fragment, while the latissimus dorsi and pectoralis contract an infant’s shoulder is pulled during birth or if someone grabs
and bring the lateral fragment medially. The arm sags because something to stop a fall. The inferior trunk is damaged, and
the trapezius supports all of its weight. Patients with broken the ulnar nerve loses function. This results in impaired
clavicles present with upper limb supported / in a sling. finger flexion, abduction, and thumb adduction. Also the
median brachial and antebrachial cutaneous nerves lose
Nerves function, resulting in numbness of the medial aspect of the
The radial nerve runs on the posterior aspect of the arm, forearm, and hand.
arm, runs anteriorly around the lateral epicondyle, then wraps
back posteriorly in the forearm, piercing the supinator, to Injury to the long thoracic nerve can result from a
become the posterior interosseous nerve. It branches into the stab wound, mastectomy, weight lifting, surgery, or carrying a
deep (motor) and superficial (sensory) radial nerves. Injury heavy object on the shoulder. The serratus anterior
results in anesthesia to the lateral half of the dorsum of the [protraction of scapula] loses function, resulting in wing
hand, and in loss of extension and abduction of wrist and scapula, where the medial edge of the scapula protrudes
extension of fingers  wrist drop. posteriorly, away from the thoracic wall. The patient cannot
abduct the arm above horizontal, nor can they push with
The ulnar nerve runs on the medial aspect of the their arm.
arm, wraps posteriorly around the medial epicondyle, where it
is liable to be bumped, then passes between the two heads of Injury to the axillary nerve can result from fracture
the flexor carpi ulnaris,. It too divides into superficial and of the humerus, or dislocation of the shoulder joint. The
deep branches. Injury results in impaired flexion and deltoid atrophies, leaving flatness on the lateral proximal side
adduction of the wrist, and loss of abduction / adduction of of the arm. The patient cannot abduct the arm.
the fingers, especially the fifth digit (hypothenar
compartment). Loss of sensation occurs to the hypothenar Injury to the thoracodorsal nerve can result from
compartment and the medial half of the dorsum of the hand. operations of the axilla. Injury results in paralysis of the
Patients presenting with ulnar nerve damage cannot flex their latissimus dorsi.
Arteries and veins spread distally through the wrist into the forearm. Infections of
The subclavian artery first sends off a vertebral a tendinous sheath of one finger will generally stay in that
branch superiorly, then a thyrocervical trunk superiorly and sheath unless neglected.
an internal thoracic artery inferiorly. Once it crosses the first
rib, it is named the axillary artery. The abductor pollicis brevis/ digiti minimi is most
The first branch of the axillary artery is the supreme lateral / medial (respectively) and superficial. Medial / lateral
intercostal [1st and 2nd intercostal spaces]. It is followed by the to that is the flexor pollicis brevis / digiti minimi, and deep to
thoracoacromial artery [deltoid, pectorales, and various other both is the opponens pollicis / digiti minimi. The lumbricals
areas.] The next branch is the lateral thoracic artery [lateral are innervated by either the median (II and III) or ulnar (IV
portion of the breast], then the subscapular artery [anterior and V) nerves, and flex the metacarpophalangeal joints /
surface of the scapula], and the posterior and anterior extend the interphalangeal joints. The interossei are
circumflex humeral arteries [head and neck of humerus]. innervated by the ulnar nerve and adduct (palmar) or abduct
*The posterior circumflex humeral and axillary nerve both (dorsal) the fingers about the middle finger.
enter the quadrangular space of the arm.
The axillary vein is large and lies anterior to the Carpal tunnel syndrome is characterized by
axillary artery. These two, along with the brachial plexus, are compression of the median nerve within the carpal tunnel.
enclosed in the axillary sheath. Patients present with tingling of the lateral aspect of their
hand, and a loss of coordination of the thumb due to weakness
Anastamosis: If the axillary artery is ligated in of the muscles of the thenar compartment. The second and
between the thyrocervical trunk and the subscapular, blood third fingers, too, may lose function the disorder is severe
can still flow distally through anastomoses. Blood flows from enough.
the dorsal scapular branches of the transverse cervical artery
[a branch of the thyrocervical trunk] into the first few The shoulder area
intercostal arteries, which anastomose with the circumflex The sternoclavicular joint is the only attachment of
scapular branch of the subscapular. Blood flows up through the upper limb to the axial skeleton. It is enclosed in an
the subscapular artery into the rest of the axillary. articular capsule, and like the temporomandibular joint,
contains an articular disc which gives it freedom of rotation. It
Laceration of the brachial artery can result from a is anchored to the first rib by the costoclavicular ligament
broken elbow. This is an emergency because the damage to the laterally and the sternoclavicular ligament medially. The
flexors of the fingers can be irreversible, resulting in joint is very sturdy and the clavicle will break before the joint
formation of scar tissue and permanent contracture of the dislocates.
digits. The brachial artery divides into the ulnar and radial
artery, with the ulnar artery branching into the ulnar and The acromioclavicular joint is also enclosed in an
common interosseous arteries. The common interosseous articular capsule. It is anchored by the coracoacromial,
artery branches further into anterior and posterior interosseous acromioclavicular, and coracoclavicular ligaments. When
arteries. these ligaments rupture from a hard fall on the shoulder, the
joint can dislocate. The shoulder will fall away from the
The hand clavicle due to the weight of the upper limb.
A fall on the hand may fracture the distal end of
the radius, resulting in a “Colle’s fracture.” The distal The shoulder joint is made up of the articular
fragment of the ulna is displaced posteriorly and the hand surface of the humerus and the glenoid fossa of the scapula.
looks sort of like a fork. The scaphoid bone is also often The fossa is very shallow but is deepened somewhat by a rim
fractured breaking a fall, and results in tenderness of the base of fibrocartilage named the glenoid labrum. The four rotator
of the anatomical snuff box. The “anatomical snuff box:” cuff muscles provide most of the stability for this joint, which
bounded by the tendons of the extensor pollicis longus is prone to dislocation and other injuries due to its degree of
superiorly, extensor pollicis brevis and abductor pollicis mobility. There are many bursae in the region but Moore
longs inferiorly. Within it are contained the radial artery and especially mentions the subacromial bursa, which lies in
the superficial radial nerve. between the acromion and the tendon of the supraspinatus on
the superior aspect of the joint. Inflammation of this bursa
Tendinitis of the common flexor tendon can result (bursitis) causes pain only when the arm is abducted – the
from repetitive use of the flexors, and pain is experienced on tendon is in contact with the acromion only then.
the anteromedial side of the elbow, where the flexor tendon is
located. Patients will have trouble flexing their fingers against Anterior dislocation of the shoulder joint is caused
resistance. Tendinitis of the common extensor tendon, by excessive extension and lateral rotation of the humerus.
located on the posterolateral aspect of the elbow, results in The head of the humerus is driven anteriorly and the joint
pain when supinating and extending the digits. Patients will capsule and glenoid labrum are torn off the fossa.
have difficulty extending their fingers against resistance. Quarterbacks who are hit forcefully on the arm as
. they are about to release the ball; i.e. when their shoulder is
Infections in the hand are limited to the compartment fully abducted, will tear the joint capsule so that the humeral
they begin in, unless they break through intercompartmental head will lie inferior to the glenoid cavity. Patients will
septa. Thus, most are localized to the thenar, hypothenar, or present with the injured arm rotated anterosuperiorly
adductor compartments of the hand. They can, however, (forward, medially rotated) under the coracoid process,
holding the nonfunctional arm with their other arm. One would probably also have lack of finger abduction strength
must suspect damage to the axillary nerve in a shoulder (dorsal interossei), impaired flexion of digits IV and V (medial
dislocation because it lies very close to the inferior aspect of flexor digitorum profundus), and impaired wrist flexion and
the joint capsule. abduction (flexor carpi ulnaris). Prognosis for recovery is
good, as the nerve was not severed.
The elbow joint
This joint is not stable in children due to incomplete 6-4: Wrist-drop and lack of sensation to the lateral
ossification. Separation of humeral, ulnar, or radial epiphyses half of the dorsum of the hand is screaming “Radial nerve
can occur when a child falls on his / her elbow. Dislocations damage!!” Elbow flexion would be impaired if the forearm
tend to occur posteriorly because the humerus is pushed was midway between supination and pronation, as the
through the weaker anterior portion of the humeroradial / brachioradialis (“hand shake muscle”) is responsible for elbow
humeroulnar joint capsule [think this one through]. flexion in this situation; it is innervated by the radial nerve.
The medial epicondyle of the humerus also ossifies The humerus is shortened because the biceps, brachialis, and
late, and can be avulsed in a fall. It will be pulled distally due triceps contract to immobilize the ends of the broken bone.
to traction of the ulnar collateral ligament. Since the ulnar The radial nerve is prone to injury at the lateral aspect of the
nerve passes through this region, avulsion of the medial arm, midway down, because it lies right next to the humerus
epicondyle can also stretch this nerve and cause difficulties
flexing digits IV and V and adducting the wrist. 6-5: The trapezium and scaphoid lie in the floor of
If someone is holding a child’s hand and suddenly the snuff box, along with the distal end of the radius. The
tugs it, an injury known as subluxation is likely to occur. The scaphoid was most probably fractured.
sudden force on the forearm tears the distal attachment of the
annular ligament of the radius. The head of the radius is 6-6: The tendon of the palmaris longus was probably
then pulled distally, out of the torn ligament. The poor child severed, as well as the flexor carpi radialis. Her median nerve
will present with his / her elbow flexed and forearm was definitely severed; the lack of thumb opposition, fine
pronated. control of digits II and III, and lack of sensation over the
lateral half of the palm demonstrate deficits in median nerve
The wrist and hand function [opponens pollicis, the first two lumbricals, and
I have no good mnemonic for the eight carpals. I tend sensory innervation to the lateral palm are provided by the
to remember starting from the “Thumb Side” – the most median n.] Her superficial radial artery was probably severed;
lateral carpals are the Trapezium and the Scaphoid. wrist flexion would be affected a bit by the severing of her
Proceeding medially from the trapezium are the trapezoid, palmaris longus, which attaches to the palmar aponeurosis.
capitate, and hamate. Doing the same from the scaphoid are Her wrist will probably adduct when she flexes it, due to the
the lunate, triquetrum, and the pisiform. I guess you can also unopposed action of the flexor carpi ulnaris.
remember that the Pisiform is on the Pinky side of the hand. I
dunno, whatever works best for you. 6-7: The lady’s ulna styloid process was probably
fractured, and with muscle contraction, brought to the same
A broken scaphoid bone results in tenderness of level as the radial styloid process, which makes the wrist look
the anatomical snuff box. like a fork (Colle’s fracture). The scaphoid, again, was
probably fractured in this fall.
With the exception of the thumb, digits have one
metacarpal and three phalanges. The metacarpophalangeal
joints are capable of flexion / extension, ab / adduction, and
rotation. The interphalangeal joints can only flex / extend. The
carpometacarpal joint in the thumb is the joint capable of fl /
ex, ab / ad, and rotation, while the metacarpophalangeal and
interphalangeal joint fl / ex.

Sudden tension on an extensor tendon may avulse

part of its attachment. Patient will present being unable to
extend the distal interphalangeal joint.

Case Studies
6-1 … Check the description of injuries of the
brachial plexus.
6-2 … Check the description of a dislocated
acromioclavicular joint.

6-3: The lack of response to pinprick on digit V and

medial border of palm indicates that the ulnar nerve, which
supplies sensation to this area, is damaged. This is
corroborated by the lack of finger adduction strength in the
boy’s hand (caused by impaired palmar interossei). The boy