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Cilinical Upper Limb
KLM & Snell
Dr M Idris Siddiqui
Witch’s Milk in the Newborn
While the fetus is in the uterus, the maternal and
placental hormones cross the placental barr...
Breast Examination
The breast is one of the common sites of cancer in women. It is also the site of
different types of ben...
Supernumerary and Retracted Nipples
Supernumerary nipples occasionally occur along a line
extending from the axilla to the...
The Importance of Fibrous Septa
The interior of the breast is divided into 15 to 20 compartments
that radiate from the nip...
Breast Abscess
An acute infection of the mammary gland may occur
during lactation. Pathogenic bacteria gain entrance to
th...
Carcinoma in the Male Breast
Carcinoma in the male breast
accounts for about 1% of all
Carcinomas of the breast.
This fact...
Breast Quadrants
For the anatomical location and
description of pathology (e.g., cysts
and tumors), the breast is divided ...
Changes in Breasts
Changes, such as branching of the lactiferous ducts, occur
in the breast tissues during the menstrual c...
Carcinoma of Breast
Carcinomas of the breast are malignant tumors, usually adenocarcinomas arising from the
epithelial cel...
Carcinoma of Breast
• Because most of the lymphatic drainage of the breast is to the axillary
lymph nodes, they are the mo...
Mammography
Mammography is a radiographic examination of
the breast used to detect breast masses.
• This technique is exte...
Surgical Incisions of Breast
Incisions are placed in the inferior breast quadrants when
possible because these quadrants a...
Mastectomy
Mastectomy (breast excision) is not as common as it once
was as a treatment for breast cancer.
In simple mastec...
Development of the Breasts
In the young embryo, a linear thickening of ectoderm appears
called the milk ridge, which exten...
Anomalies of breast
Polythelia:
Supernumerary nipples occasionally occur along a line corresponding to the position
of the...
Dislocation of the Acromioclavicular Joint
• Although its extrinsic coracoclavicular ligament is strong, the
AC joint itse...
Variations of the Clavicle
• The clavicle varies more in shape than most other
long bones.
• Occasionally, the clavicle is...
Fractures of the Clavicle
**It is the most commonly fractured bone in the body.
• After the fracture, the lateral fragment...
Fracture of the Clavicle
• Clavicular fractures are especially common in children and are often caused
by an indirect forc...
Fall on to an outstretched hand
(FOOSH)
Falls on the Outstretched Hand
In falls on the outstretched hand, forces are transmitted from the
scaphoid to the distal e...
Ossification of the Clavicle
• The clavicle is the first long bone to ossify (via intramembranous
ossification), beginning...
Compression of the Brachial Plexus, Subclavian
Artery, and Subclavian Vein by the Clavicle
The interval between the clavic...
Variations of the Brachial Plexus
• Variations in the formation of the brachial plexus
are common. In addition to the five...
Variations of the Brachial Plexus
• Variations may also occur in the formation of
trunks, divisions, and cords; in the ori...
Variations of the Brachial Plexus
• In some individuals, trunk divisions or cord formations may
be absent in one or other ...
Brachial Plexus Injuries
• Injuries to the brachial plexus affect movements and
cutaneous sensations in the upper limb. Di...
Brachial Plexus Injuries
• Injuries to superior parts of the brachial plexus (C5 and C6)
usually result from an excessive ...
Brachial Plexus Injuries
• As a result of injuries to the superior parts of the brachial
plexus (Erb-Duchenne palsy), para...
Brachial Plexus Injuries
• Acute brachial plexus neuritis (brachial plexus
neuropathy) is a neurologic disorder of unknown...
Brachial Plexus Injuries
• Compression of cords of the brachial plexus may result from prolonged
hyperabduction of the arm...
Brachial Plexus Block
• Injection of an anesthetic solution into or immediately
surrounding the axillary sheath interrupts...
Fractures of the Scapula
• Fractures of the scapula are usually the result
of severe trauma, such as occurs in run-over
ac...
Dropped Shoulder and Winged
Scapula
The position of the scapula on the posterior wall
of the Thorax is maintained by the t...
Fractures of the Proximal End of the Humerus
Humeral Head Fractures: Fractures of the humeral head can occur during the pr...
Fractures of the Humerus
• Most injuries of the proximal end of the humerus are fractures of
the surgical neck.
– These in...
Bicipital Myotatic Reflex
• The biceps reflex is one of several deep-tendon reflexes that
are routinely tested during phys...
Biceps Tendinitis
• The tendon of the long head of the biceps is
enclosed by a synovial sheath and moves back and
forth in...
Dislocation of the Tendon of the Long
Head of the Biceps
• The tendon of the long head of the biceps can be
partially or c...
Rupture of the Tendon of the Long
Head of the Biceps
• Rupture of the tendon usually results from wear and tear of
an infl...
Fracture of the shaft of the humerus
• A transverse fracture of the shaft of the humerus frequently results from a
direct ...
Fracture Dislocation of the Proximal
Humeral Epiphysis
• A direct blow or indirect injury of the shoulder of a
child or ad...
Fractures of the Shaft of the Humerus
Fractures of the humeral shaft are common; displacement of
the fragments depends on ...
Fracture of the Humeral Shaft
• A midhumeral fracture may injure the radial nerve in
the radial groove in the humeral shaf...
Fractures of the Distal End of the Humerus
Supracondylar fractures are common in children and occur when the
child falls o...
Absent Pectoralis Major
Occasionally, parts of the pectoralis
major muscle may be absent. The
sternocostal origin is the m...
Absence of the Pectoral Muscles
• Absence of part of the pectoralis major, usually its
sternocostal part, is uncommon, but...
Paralysis of the Serratus Anterior
• When the serratus anterior is paralyzed owing to injury to the long
thoracic nerve, t...
Triangle of Auscultation
• Near the inferior angle of the scapula is a small
triangular gap in the musculature. The superi...
Compression of the Axillary Artery
• The axillary artery can be palpated in the inferior
part of the lateral wall of the a...
Arterial Anastomoses around the
Scapula
• Many arterial anastomoses (communications between arteries) occur around the
sca...
Aneurysm of the Axillary Artery
• The first part of the axillary artery may enlarge
(aneurysm of the axillary artery) and
...
Spontaneous Thrombosis of the
Axillary Vein
Spontaneous thrombosis of the
axillary vein occasionally occurs
after excessiv...
Interruption of Blood Flow in the
Brachial Artery
• Stopping bleeding through manual or surgical control of blood flow is
...
Injuries to the Axillary Vein
• Wounds in the axilla often involve the axillary vein
because of its large size and exposed...
The Role of the Axillary Vein in
Subclavian Vein Puncture
• Subclavian vein puncture, in which a catheter is placed
into t...
The Axillary Sheath and a Brachial
Plexus Nerve Block
Because the axillary sheath encloses the axillary vessels and
the br...
Examination of the Axillary Lymph Nodes
With the patient standing or sitting, he or she is asked to place the hand of the ...
Rotator Cuff Tendinitis
The rotator cuff, consisting of the tendons of the subscapularis, supraspinatus, infraspinatus, an...
Rupture of the Supraspinatus Tendon
In advanced cases of rotator cuff tendinitis, the necrotic
supraspinatus tendon can be...
Axillary Nerve Injury
The axillary nerve can be
injured in dislocations of
the shoulder joint.
Axillary Nerve Injury
• The axillary nerve may be injured when the
glenohumeral joint dislocates because of its close
rela...
Injury to the Axillary Nerve
• The deltoid atrophies when the axillary nerve (C5 and C6) is
severely damaged. Because it p...
Rotator Cuff Injuries
• The musculotendinous rotator cuff is commonly injured during repetitive use of the upper
limb abov...
Rotator Cuff Injuries and the
Supraspinatus
• Injury or disease may damage the
musculotendinous rotator cuff, producing in...
Dislocation of the Glenohumeral Joint
• Because of its freedom of movement and instability, the glenohumeral joint is comm...
Glenoid Labrum Tears
• Tearing of the fibrocartilaginous glenoid labrum
commonly occurs in athletes who throw a baseball o...
Adhesive Capsulitis of the
Glenohumeral Joint
• Adhesive fibrosis and scarring between the inflamed joint
capsule of the g...
Accessory Nerve Injury
The accessory nerve can be injured as the result
of stab wounds to the neck.
Injury of the Accessory Nerve (CN XI)
• The primary clinical manifestation
of accessory nerve palsy is a
marked ipsilatera...
Injury of the Thoracodorsal Nerve
• Surgery in the inferior part of the axilla puts the thoracodorsal
nerve supplying the ...
Injury to the Dorsal Scapular Nerve
• Injury to the dorsal scapular nerve, the nerve
to the rhomboids, affects the actions...
Arterial Anastomosis and Ligation of
the Axillary Artery
The existence of the anastomosis
around the shoulder joint is vit...
Sternoclavicular Joint Injuries
The strong costoclavicular ligament firmly holds the medial end of the
clavicle to the 1st...
Acromioclavicular Joint Injuries
The plane of the articular surfaces of the acromioclavicular
joint passes downward and me...
Acromioclavicular Dislocation
A severe blow on the point of the shoulder, as is
incurred during blocking or tackling in fo...
Stability of the Shoulder Joint
The shallowness of the glenoid fossa of the scapula and the lack
of support provided by we...
Dislocations of the Shoulder Joint
The shoulder joint is the most commonly dislocated large joint.
Anterior Inferior Dislo...
Shoulder Pain
The synovial membrane, capsule, and ligaments of the shoulder joint
are innervated by the axillary nerve and...
Dermatomes and Cutaneous Nerves
It may be necessary for a physician to test the integrity of the spinal cord
segments of C...
High Division of the Brachial Artery
• Sometimes the brachial artery divides at
a more proximal level than usual. In this
...
Superficial Ulnar Artery
• In approximately 3% of people, the ulnar artery
descends superficial to the flexor muscles.
Pul...
Venipuncture and Blood Transfusion
The superficial veins are clinically important and are used for venipuncture,
transfusi...
Intravenous Transfusion and
Hypovolemic Shock
In extreme hypovolemic shock,
excessive venous tone may inhibit
venous blood...
Anatomy of Basilic and Cephalic Vein
Catheterization
The median basilic or basilic veins are the veins of choice for centr...
Measuring the Pulse Rate
• The common place for measuring the pulse rate is
where the radial artery lies on the anterior s...
Variations in the Origin of the Radial
Artery
• The origin of the radial artery may be more
proximal than usual; it may be...
Venipuncture in the Cubital Fossa
• The cubital fossa is the common site for sampling and transfusion
of blood and intrave...
Variation of Veins in the Cubital Fossa
• The pattern of veins in the cubital fossa varies greatly. In
approximately 20% o...
Dermatomes and Cutaneous Nerves
It may be necessary for a physician to test the integrity of the spinal cord segments of
C...
Lymphangitis
Infection of the lymph vessels (lymphangitis) of the arm is
common. Red streaks along the course of the lymph...
Lymphadenitis
Once the infection reaches the lymph nodes, they
become enlarged and tender, a condition known as
lymphadeni...
Enlargement of the Axillary Lymph
Nodes
• An infection in the upper limb can cause the axillary
nodes to enlarge and becom...
Dissection of the Axillary Lymph Nodes
• Excision and pathologic analysis of axillary lymph nodes are often necessary
for ...
Biceps Brachii and Osteoarthritis of
the Shoulder Joint
The tendon of the long head of biceps is
attached to the supraglen...
Fractures of the Radius and Ulna
Fractures of the head of the radius can occur from falls on the outstretched hand. As the...
Elbow Tendinitis or Lateral Epicondylitis
• Elbow tendinitis (tennis elbow) is a painful
musculoskeletal condition that ma...
Fracture of the Olecranon
• Fracture of the olecranon, called a “fractured
elbow―by laypersons, is common because the
...
Fractures of the Radius and Ulna
• Fractures of both the radius and the ulna are usually the result of severe injury. A di...
Bursitis of the Elbow
• The subcutaneous olecranon bursa is exposed to injury during falls on the
elbow and to infection f...
Avulsion of the Medial Epicondyle
• Avulsion of the medial epicondyle in children can result
from a fall that causes sever...
Dislocation of the Elbow Joint
• Posterior dislocation of the elbow joint may occur
when children fall on their hands with...
Wrist Fractures
• Fracture of the distal end of the radius (Colles fracture), the most
common fracture in people >50 years...
Subluxation and Dislocation of Radial Head
• Preschool children, particularly girls, are vulnerable to transient
subluxati...
Colles’ fracture
Colles’ fracture is a fracture of the distal end of the radius
resulting from a fall on the outstretched ...
Smith’s fracture
Smith’s fracture is a fracture of the
distal end of the radius and occurs from
a fall on the back of the ...
Olecranon Bursitis
A small subcutaneous bursa is present over the
olecranon process of the ulna, and repeated
trauma often...
Bull Rider's Thumb
• Bull rider's thumb refers to a sprain
of the radial collateral ligament and
an avulsion fracture of t...
Skier's Thumb
• Skier's thumb (historically, game-keeper's
thumb) refers to the rupture or chronic laxity
of the collatera...
Synovial Cyst of the Wrist
• Sometimes a non-tender cystic swelling appears on the hand, most
commonly on the dorsum of th...
Fracture of the Scaphoid
• The scaphoid is the most frequently fractured carpal bone. It
often results from a fall on the ...
Mallet or Baseball Finger
• Sudden severe tension on a long extensor tendon
may avulse part of its attachment to the phala...
Fracture of the scaphoid bone
Fracture of the scaphoid bone is common in young adults; unless
treated effectively, the fra...
Fracture of the Hamate
• Fracture of the hamate may result in non-
union of the fractured bony parts because of
the tracti...
Dislocation of the lunate bone
Dislocation of the lunate bone
occasionally occurs in young adults
who fall on the outstret...
Fractures of the metacarpal bones
Fractures of the metacarpal bones can occur as a
result of direct violence, such as the ...
Fracture of the Metacarpals
• The metacarpals (except the 1st) are closely bound
together; hence isolated fractures tend t...
Bennett’s fracture
Bennett’s fracture is a fracture of the base of
the metacarpal of the thumb causd when
violence is appl...
Fracture of the Phalanges
• Crushing injuries of the distal phalanges are common
(e.g., when a finger is caught in a car d...
Compartment Syndrome of the
Forearm
The forearm is enclosed in a sheath of deep fascia, which is attached to the periosteu...
Patterns of cutaneous innervation
occur in the upper limb
• (1) Segmental innervation (dermatomes) by spinal nerves
• (2) ...
Volkmann’s Ischemic Contracture
Volkmann’s ischemic contracture is a contracture of the muscles of the forearm that common...
Absent Palmaris Longus
The palmaris longus muscle may be absent
on one or both sides of the forearm in
about 10% of person...
Stenosing Synovitis of the Abductor Pollicis
Longus and Extensor Pollicis Brevis Tendons
As a result of repeated friction ...
Rupture of the Extensor Pollicis Longus
Tendon
Rupture of this tendon can occur after
fracture of the distal third of the ...
Anatomic Snuffbox”
The anatomic snuffbox is a term commonly used to
describe a triangular skin depression on the lateral
s...
Tennis Elbow
Tennis elbow is caused by a partial tearing or
degeneration of the origin of the superficial extensor
muscles...
Dupuytren’s Contracture
Dupuytren’s contracture is a localized thickening and contracture of the
palmar aponeurosis, which...
Dupuytren Contracture of Palmar Fascia
• Dupuytren contracture is a disease of the palmar fascia resulting in
progressive ...
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
Cilinical anatomy upper limb
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Cilinical anatomy upper limb

  1. 1. Cilinical Upper Limb KLM & Snell Dr M Idris Siddiqui
  2. 2. Witch’s Milk in the Newborn While the fetus is in the uterus, the maternal and placental hormones cross the placental barrier and cause proliferation of the duct epithelium and the surrounding connective tissue. This proliferation may cause swelling of the mammary glands in both sexes during the first week of life; in some cases a milky fluid, called witch’s milk, may be expressed from the mipples. The condition is resolved spontaneously as the maternal hormone levels in the child fall.
  3. 3. Breast Examination The breast is one of the common sites of cancer in women. It is also the site of different types of benign tumors and may be subject to acute inflammation and abscess formation. With the patient undressed to the waist and sitting upright, I. The breasts are first inspected for symmetry. Some degree of asymmetry is common and is the result of unequal breast development. II. Any swelling should be noted. A swelling can be caused by: a. an underlying tumor, b. a cyst, or c. abscess formation. III. The nipples should be carefully examined for evidence of retraction. A carcinoma within the breast substance can cause retraction of the nipple by pulling on the lactiferous ducts. The patient is then asked to lie down so that the breasts can be palpated against the underlying thoracic wall. IV. Finally, the patient is asked to sit up again and raise both arms above her head. With this maneuver, a carcinoma tethered to the skin, the suspensory ligaments, or the lactiferous ducts produces dimpling of the skin or retraction of the nipple.
  4. 4. Supernumerary and Retracted Nipples Supernumerary nipples occasionally occur along a line extending from the axilla to the groin; they may or may not be Associated with breast tissue. This minor congenital anomaly may result in a mistaken diagnosis of warts or moles. A long-standing retracted nipple is a congenital deformity caused by a failure in the complete development of the nipple. A retracted nipple of recent occurrence is usually caused by an underlying carcinoma pulling on the lactiferous ducts.
  5. 5. The Importance of Fibrous Septa The interior of the breast is divided into 15 to 20 compartments that radiate from the nipple by fibrous septa that extend from The deep surface of the skin. Each compartment contains a lobe of the gland. Normally, the skin feels completely mobile over the breast substance. However, the fibrous septa become involved in a scirrhous carcinoma or in a disease such as a breast abscess, which results in the production of contracting fibrous tissue, the septa will be pulled on, causing dimpling of the skin. The fibrous septa are sometimes referred to as the Suspensory ligaments of the mammary gland.
  6. 6. Breast Abscess An acute infection of the mammary gland may occur during lactation. Pathogenic bacteria gain entrance to the breast tissue through a crack in the nipple. Because of the presence of the fibrous septa, the infection remains localized to one compartment or lobe to begin with. • Abscesses should be drained through a radial incision to avoid spreading of the infection into neighboring compartments; a radial incision also minimizes the damage to the radially arranged ducts
  7. 7. Carcinoma in the Male Breast Carcinoma in the male breast accounts for about 1% of all Carcinomas of the breast. This fact tends to be overlooked When examining the male patient.
  8. 8. Breast Quadrants For the anatomical location and description of pathology (e.g., cysts and tumors), the breast is divided into four quadrants. The axillary tail is an extension of the mammary gland of the superolateral quadrant.
  9. 9. Changes in Breasts Changes, such as branching of the lactiferous ducts, occur in the breast tissues during the menstrual cycle and pregnancy. Although mammary glands are prepared for secretion by midpregnancy, they do not produce milk until shortly after the baby is born. Colostrum, a creamy white to yellowish premilk fluid, may secrete from the nipples during the last trimester of pregnancy and during initial episodes of nursing. Colostrum is believed to be especially rich in protein, immune agents, and a growth factor affecting the infant's intestines. In multiparous women (those who have given birth two or more times), the breasts often become large and pendulous. The breasts in elderly women are usually small because of the decrease in fat and the atrophy of glandular tissue.
  10. 10. Carcinoma of Breast Carcinomas of the breast are malignant tumors, usually adenocarcinomas arising from the epithelial cells of the lactiferous ducts in the mammary gland lobules. Metastatic cancer cells that enter a lymphatic vessel usually pass through two or three groups of lymph nodes before entering the venous system. Breast cancer can spread via lymphatics and veins and as well as by direct invasion. Interference with the lymphatic drainage by cancer may cause lymphedema (edema, excess fluid in the subcutaneous tissue), which in turn may result in deviation of the nipple and a thickened, leatherlike appearance of the skin . Prominent or “puffy” skin between dimpled pores gives it an orange-peel appearance (peau d'orange sign). Larger dimples (fingertip size or bigger) result from cancerous invasion of the glandular tissue and fibrosis (fibrous degeneration), which causes shortening or places traction on the suspensory ligaments. Subareolar breast cancer may cause inversion of the nipple by a similar mechanism involving the lactiferous ducts. Abundant communications among lymphatic pathways and among axillary, cervical, and parasternal nodes may also cause metastases from the breast to develop in the supraclavicular lymph nodes, the opposite breast, or the abdomen.
  11. 11. Carcinoma of Breast • Because most of the lymphatic drainage of the breast is to the axillary lymph nodes, they are the most common site of metastasis from a breast cancer. Enlargement of these palpable nodes suggests the possibility of breast cancer and may be key to early detection. • However, the absence of enlarged axillary lymph nodes is no guarantee that metastasis from a breast cancer has not occurred because the malignant cells may have passed to other nodes, such as the infraclavicular and supraclavicular lymph nodes. • Nodal metastatic breast cancer can be difficult to manage because of the complex system of lymphatic drainage. The posterior intercostal veins drain into the azygos/hemiazygos system of veins alongside the bodies of the vertebrae and communicate with the internal vertebral venous plexus surrounding the spinal cord. • Cancer cells can also spread from the breast by these venous routes to the vertebrae and from there to the cranium and brain. Cancer also spreads by contiguity (invasion of adjacent tissue). When breast cancer cells invade the retromammary space, attach to or invade the pectoral fascia overlying the pectoralis major, or metastasize to the interpectoral nodes, the breast elevates when the muscle contracts. This movement is a clinical sign of advanced cancer of the breast.
  12. 12. Mammography Mammography is a radiographic examination of the breast used to detect breast masses. • This technique is extensively used for screening the breasts for benign and malignant tumors and cysts. • Extremely low doses of x-rays are used so that the dangers are minimal, and the examination can be repeated often. • Its success is based on the fact that a lesion measuring only a few millimeters in diameter can be detected long before it is felt by clinical examination.
  13. 13. Surgical Incisions of Breast Incisions are placed in the inferior breast quadrants when possible because these quadrants are less vascular than the superior ones. The transition between the thoracic wall and breast is most abrupt inferiorly, producing a line, crease, or deep skin fold—the inferior cutaneous crease. Incisions made along this crease will be least evident and may actually be hidden by overlap of the breast. • Incisions that must be made near the areola or on the breast itself are usually directed radially to either side of the nipple (Langer tension lines run transversely here or circumferentially).
  14. 14. Mastectomy Mastectomy (breast excision) is not as common as it once was as a treatment for breast cancer. In simple mastectomy, the breast is removed down to the retromammary space. Radical mastectomy, a more extensive surgical procedure, involves removal of the breast, pectoral muscles, fat, fascia, and as many lymph nodes as possible in the axilla and pectoral region. In current practice, often only the tumor and surrounding tissues are removed—a lumpectomy or quadrantectomy (known as breast-conserving surgery, a wide local excision)— followed by radiation therapy
  15. 15. Development of the Breasts In the young embryo, a linear thickening of ectoderm appears called the milk ridge, which extends from the axilla obliquely to the inguinal region. In animals, several mammary glands are formed along this ridge. In the human, the ridge disappears except or a small part in the pectoral region. This localized area thickens, becomes slightly depressed, and sends off 15 to 20 solid cords, which grow into the underlying mesenchyme. Meanwhile, the underlying mesenchyme proliferates, and the depressed ectodermal thickening becomes raised to form the nipple. At the fifth month, the areola is recognized as a circular pigmented area of skin around the future nipple.
  16. 16. Anomalies of breast Polythelia: Supernumerary nipples occasionally occur along a line corresponding to the position of the milk ridge. They are liable to be mistaken for moles. Retracted Nipple or Inverted Nipple: Retracted nipple is a failure in the development of the nipple during its later stages. It is portant clinically, because normal suckling of an infant cannot take place, and the nipple is prone to infection. Micromastia: An excessively small breast on one side occasionally occurs, resulting from lack of development. Macromastia: Diffuse hypertrophy of one or both breasts occasionally occurs at puberty in otherwise normal girls. Gynecomastia: Unilateral or bilateral enlargement of the male breast occasionally occurs, usually at puberty. The cause is unknown, but the condition is probably related to some form of hormonal imbalance.
  17. 17. Dislocation of the Acromioclavicular Joint • Although its extrinsic coracoclavicular ligament is strong, the AC joint itself is weak and easily injured by a direct blow. • In contact sports such as football, soccer, hockey, or the martial arts, it is not uncommon for dislocation of the AC joint to result from a hard fall on the shoulder or on the outstretched upper limb. • Dislocation of the AC joint can also occur when a hockey player is driven into the boards or when a person receives a severe blow to the superolateral part of the back. An AC joint dislocation, often called a shoulder separation, is severe when both the AC and the coracoclavicular ligaments are torn. When the coracoclavicular ligament tears, the shoulder separates from the clavicle and falls because of the weight of the upper limb. Dislocation of the AC joint makes the acromion more prominent, and the clavicle may move superior to this process.
  18. 18. Variations of the Clavicle • The clavicle varies more in shape than most other long bones. • Occasionally, the clavicle is pierced by a branch of the supraclavicular nerve. • The clavicle is thicker and more curved in manual workers, and the sites of muscular attachments are more marked. • The right clavicle is usually stronger and shorter than the left clavicle.
  19. 19. Fractures of the Clavicle **It is the most commonly fractured bone in the body. • After the fracture, the lateral fragment is Depressed by the weight of the arm, and it is pulled medially and forward by the strong adductor muscles of the shoulder joint, especially the pectoralis major. The medial end is tilted upward by the sternocleidomastoid muscle. • The close relationship of the supraclavicular nerves to the clavicle may result in their involvement in callus formation after fracture of the bone. This may be the cause of persistent pain over the side of the neck. • The slender clavicles of newborn infants may be fractured during delivery if the neonates are broad shouldered; however, the bones usually heal quickly. A fracture of the clavicle is often incomplete in younger children that is, it is a greenstick fracture, in which one side of a bone is broken and the other is bent. – This fracture was so named because the parts of the bone do not separate; the bone resembles a tree branch (greenstick) that has been sharply bent but not disconnected
  20. 20. Fracture of the Clavicle • Clavicular fractures are especially common in children and are often caused by an indirect force transmitted from an outstretched hand through the bones of the forearm and arm to the shoulder during a fall. • A fracture may also result from a fall directly on the shoulder. • The weakest part of the clavicle is the junction of its middle and lateral thirds. • After fracture of the clavicle, the sternocleidomastoid muscle elevates the medial fragment of bone. Because of the subcutaneous position of the clavicles, the end of the superiorly directed fragment is prominent readily palpable and/or apparent. The trapezius muscle is unable to hold the lateral fragment up owing to the weight of the upper limb, and thus the shoulder drops. • The strong coracoclavicular ligament usually prevents dislocation of the AC joint. • People with fractured clavicles support the sagging limb with the other limb. In addition to being depressed, the lateral fragment of the clavicle may be pulled medially by the adductor muscles of the arm, such as the pectoralis major. • Overriding of the bone fragments shortens the clavicle.
  21. 21. Fall on to an outstretched hand (FOOSH)
  22. 22. Falls on the Outstretched Hand In falls on the outstretched hand, forces are transmitted from the scaphoid to the distal end of the radius, from the radius across the interosseous membrane to the ulna, and from the ulna to the humerus; thence, through the glenoid fossa of the scapula to the coracoclavicular ligament and the clavicle; and finally, to the sternum. • If the forces are excessive, different parts of the upper limb give way under the strain. The area affected seems to be related to age. • In a young child, for example, there may be a posterior displacement of the distal radial epiphysis; in the teenager the clavicle might fracture; in the young adult the scaphoid is commonly fractured; and in the elderly the distal end of the radius is fractured about 1 in. (2.5 cm) proximal to the wrist joint (Colles’ fracture).
  23. 23. Ossification of the Clavicle • The clavicle is the first long bone to ossify (via intramembranous ossification), beginning during the 5th and 6th embryonic weeks from medial and lateral primary centers that are close together in the shaft of the clavicle. • aThe ends of the clavicle later pass through a cartilaginous phase (endochondral ossification); the cartilages form growth zones similar to those of other long bones. A secondary ossification center appears at the sternal end and forms a scale-like epiphysis that begins to fuse with the shaft (diaphysis) between 18 and 25 years of age and is completely fused to it between 25 and 31 years of age. • This is the last of the epiphyses of long bones to fuse. An even smaller scale-like epiphysis may be present at the acromial end of the clavicle; it must not be mistaken for a fracture. • Sometimes fusion of the two ossification centers of the clavicle fails to occur; as a result, a bony defect forms between the lateral and the medial thirds of the clavicle. Awareness of this possible congenital defect should prevent diagnosis of a fracture in an otherwise normal clavicle. When doubt exists, both clavicles are radiographed because this defect is usually bilateral
  24. 24. Compression of the Brachial Plexus, Subclavian Artery, and Subclavian Vein by the Clavicle The interval between the clavicle and the first rib in some patients may become narrowed and thus is responsible for compression of nerves and blood vessels.
  25. 25. Variations of the Brachial Plexus • Variations in the formation of the brachial plexus are common. In addition to the five anterior rami (C5-C8 and T1) that form the roots of the brachial plexus, small contributions may be made by the anterior rami of C4 or T2. When the superiormost root (anterior ramus) of the plexus is C4 and the inferiormost root is C8, it is a prefixed brachial plexus. Alternately, when the superior root is C6 and the inferior root is T2, it is a postfixed brachial plexus.
  26. 26. Variations of the Brachial Plexus • Variations may also occur in the formation of trunks, divisions, and cords; in the origin and/or combination of branches; and in the relationship to the axillary artery and scalene muscles. • For example, the lateral or medial cords may receive fibers from anterior rami inferior or superior to the usual levels, respectively.
  27. 27. Variations of the Brachial Plexus • In some individuals, trunk divisions or cord formations may be absent in one or other parts of the plexus; however, the makeup of the terminal branches is unchanged. • Because each peripheral nerve is a collection of nerve fibers bound together by connective tissue, it is understandable that the median nerve, for instance, may have two medial roots instead of one (i.e., the nerve fibers are simply grouped differently). This results from the fibers of the medial cord of the brachial plexus dividing into three branches, two forming the median nerve and the third forming the ulnar nerve. • Sometimes it may be more confusing when the two medial roots are completely separate; however, understand that although the median nerve may have two medial roots, the components of the nerve are the same (i.e., the impulses arise from the same place and reach the same destination whether they go through one or two roots).
  28. 28. Brachial Plexus Injuries • Injuries to the brachial plexus affect movements and cutaneous sensations in the upper limb. Disease, stretching, and wounds in the lateral cervical region (posterior triangle) of the neck or in the axilla may produce brachial plexus injuries. Signs and symptoms depend on the part of the plexus involved. Injuries to the brachial plexus result in paralysis and anesthesia. • In complete paralysis, no movement is detectable. In incomplete paralysis, not all muscles are paralyzed; therefore, the person can move, but the movements are weak compared with those on the normal side. • Determining the ability of the person to feel pain (e.g., from a pinprick of the skin) tests the degree of anesthesia.
  29. 29. Brachial Plexus Injuries • Injuries to superior parts of the brachial plexus (C5 and C6) usually result from an excessive increase in the angle between the neck and the shoulder. These injuries can occur in a person who is thrown from a motorcycle or a horse and lands on the shoulder in a way that widely separates the neck and shoulder . When thrown, the person's shoulder often hits something (e.g., a tree or the ground) and stops, but the head and trunk continue to move. This stretches or ruptures superior parts of the brachial plexus or avulses (tears) the roots of the plexus from the spinal cord. • Injury to the superior trunk of the plexus is apparent by the characteristic position of the limb (waiter's tip position•), in which the limb hangs by the side in medial rotation . Upper brachial plexus injuries can also occur in a newborn when excessive stretching of the neck occurs during delivery .
  30. 30. Brachial Plexus Injuries • As a result of injuries to the superior parts of the brachial plexus (Erb-Duchenne palsy), paralysis of the muscles of the shoulder and arm supplied by the C5 and C6 spinal nerves occurs: deltoid, biceps, brachialis, and brachioradialis. • The usual clinical appearance is an upper limb with an adducted shoulder, medially rotated arm, and extended elbow. The lateral aspect of the upper limb also experiences loss of sensation. Chronic microtrauma to the superior trunk of the brachial plexus from carrying a heavy backpack can produce motor and sensory deficits in the distribution of the musculocutaneous and radial nerves. A superior brachial plexus injury may produce muscle spasms and a severe disability in hikers (backpacker's palsy) who carry heavy backpacks for long periods.
  31. 31. Brachial Plexus Injuries • Acute brachial plexus neuritis (brachial plexus neuropathy) is a neurologic disorder of unknown cause that is characterized by the sudden onset of severe pain, usually around the shoulder. Typically, the pain begins at night and is followed by muscle weakness and sometimes muscular atrophy (neurologic amyotrophy). • Inflammation of the brachial plexus (brachial neuritis) is often preceded by some event (e.g., upper respiratory infection, vaccination, or non-specific trauma). The nerve fibers involved are usually derived from the superior trunk of the brachial plexus.
  32. 32. Brachial Plexus Injuries • Compression of cords of the brachial plexus may result from prolonged hyperabduction of the arm during performance of manual tasks over the head, such as painting a ceiling. The cords are impinged or compressed between the coracoid process of the scapula and the pectoralis minor tendon. Common neurologic symptoms are pain radiating down the arm, numbness, paresthesia (tingling), erythema (redness of the skin caused by capillary dilation), and weakness of the hands. Compression of the axillary artery and vein causes ischemia of the upper limb and distension of the superficial veins. These signs and symptoms of hyperabduction syndrome result from compression of the axillary vessels and nerves. • Injuries to inferior parts of the brachial plexus (Klumpke paralysis) are much less common. Inferior brachial plexus injuries may occur when the upper limb is suddenly pulled superiorlyfor example, when a person grasps something to break a fall or a baby's upper limb is pulled excessively during delivery . These events injure the inferior trunk of the brachial plexus (C8 and T1) and may avulse the roots of the spinal nerves from the spinal cord. The short muscles of the hand are affected, and a claw hand results
  33. 33. Brachial Plexus Block • Injection of an anesthetic solution into or immediately surrounding the axillary sheath interrupts nerve impulses and produces anesthesia of the structures supplied by the branches of the cords of the plexus Sensation is blocked in all deep structures of the upper limb and the skin distal to the middle of the arm. Combined with an occlusive tourniquet technique to retain the anesthetic agent, this procedure enables surgeons to operate on the upper limb without using a general anesthetic. • The brachial plexus can be anesthetized using a number of approaches, including an interscalene, supraclavicular, and axillary approach or block
  34. 34. Fractures of the Scapula • Fractures of the scapula are usually the result of severe trauma, such as occurs in run-over accident victims or in occupants of automobiles involved in crashes. • Injuries are usually associated with fractured ribs. • Most fractures of the scapula require little treatment because the muscles on the anterior and posterior surfaces adequately splint the fragments.
  35. 35. Dropped Shoulder and Winged Scapula The position of the scapula on the posterior wall of the Thorax is maintained by the tone and balance of the Muscles attached to it. If one of these muscles is paralyzed, the balance is upset, as in dropped shoulder, which occurs with paralysis of the trapezius, or winged scapula, caused by paralysis of the serratus anterior. Such imbalance can be detected by careful physical examination.
  36. 36. Fractures of the Proximal End of the Humerus Humeral Head Fractures: Fractures of the humeral head can occur during the process of anterior and posterior dislocations of the shoulder joint. The fibrocartilaginous glenoid labrum of the scapula produces the fracture, and the labrum can become jammed in the defect, making reduction of the shoulder joint difficult. Greater Tuberosity Fractures: The greater tuberosity of the humerus can be fractured by direct trauma, displaced by the glenoid labrum during dislocation of the shoulder joint, or avulsed by violent contractions of the supraspinatus muscle. The bone fragment will have the attachments of the supraspinatus, teres minor, and infraspinatus muscles, whose tendons form part of the rotator cuff. When associated with a shoulder dislocation, severe tearing of the cuff with the fracture can result in the greater tuberosity remaining displaced posteriorly after the shoulder joint has been reduced. In this situation, open reduction of the fracture is necessary to attach the rotator cuff back into place. Lesser Tuberosity Fractures : Occasionally, a lesser tuberosity fracture accompanies posterior dislocation of the shoulder joint. The bone fragment receives the insertion of the subscapularis tendon , a part of the rotator cuff. Surgical Neck Fractures: The surgical neck of the humerus, which lies immediately distal to the lesser tuberosity, can be fractured by a direct blow on the lateral aspect of the shoulder or in an indirect manner by falling on the outstretched hand.
  37. 37. Fractures of the Humerus • Most injuries of the proximal end of the humerus are fractures of the surgical neck. – These injuries are especially common in elderly people with osteoporosis, whose demineralized bones are brittle. • Humeral fractures are often result in one fragment being driven into the spongy bone of the other fragment (impacted fracture). – The injuries usually result from a minor fall on the hand, with the force being transmitted up the forearm bones of the extended limb. Because of impaction of the fragments, the fracture site is sometimes stable and the person is able to move the arm passively with little pain. • An avulsion fracture of the greater tubercle of the humerus (pulling the tubercle away from the humeral head) is seen most commonly in middle-aged and elderly people. The fracture usually results from a fall on the acromion, the point of the shoulder. • In younger people, an avulsion fracture of the greater tubercle usually results from a fall on the hand when the arm is abducted. Muscles (especially the subscapularis) that remain attached to the humerus pull the limb into medial rotation.
  38. 38. Bicipital Myotatic Reflex • The biceps reflex is one of several deep-tendon reflexes that are routinely tested during physical examination. The relaxed limb is passively pronated and partially extended at the elbow. The examiner's thumb is firmly placed on the biceps tendon, and the reflex hammer is briskly tapped at the base of the nail bed of the examiner's thumb. A normal (positive) response is an involuntary contraction of the biceps, felt as a momentarily tensed tendon, usually with a brief jerk-like flexion of the elbow. • A positive response confirms the integrity of the musculocutaneous nerve and the C5 and C6 spinal cord segments. Excessive, diminished, or prolonged (hung) responses may indicate central or peripheral nervous system disease or metabolic disorders (e.g., thyroid disease).
  39. 39. Biceps Tendinitis • The tendon of the long head of the biceps is enclosed by a synovial sheath and moves back and forth in the inter-tubercular groove of the humerus. Wear and tear of this mechanism can cause shoulder pain. Inflammation of the tendon (biceps tendinitis), usually the result of repetitive microtrauma, is common in sports involving throwing (e.g., baseball and cricket) and use of a racquet (e.g., tennis). A tight, narrow, and/or rough intertubercular groove may irritate and inflame the tendon, producing tenderness and crepitus (a crackling sound).
  40. 40. Dislocation of the Tendon of the Long Head of the Biceps • The tendon of the long head of the biceps can be partially or completely dislocated from the intertubercular groove in the humerus. • This painful condition may occur in young persons during traumatic separation of the proximal epiphysis of the humerus. • The injury also occurs in older persons with a history of biceps tendinitis. Usually a sensation of popping or catching is felt during arm rotation.
  41. 41. Rupture of the Tendon of the Long Head of the Biceps • Rupture of the tendon usually results from wear and tear of an inflamed tendon as it moves back and forth in the intertubercular groove of the humerus. This injury usually occurs in individuals > 35 years of age. Typically, the tendon is torn from its attachment to the supraglenoid tubercle of the scapula. The rupture is commonly dramatic and is associated with a snap or pop. The detached muscle belly forms a ball near the center of the distal part of the anterior aspect of the arm (Popeye deformity). Rupture of the biceps tendon may result from forceful flexion of the arm against excessive resistance, as occurs in weight lifters. However, the tendon ruptures more often as the result of prolonged tendinitis that weakens it. The rupture results from repetitive overhead motions, such as occurs in swimmers and baseball pitchers, which tear the weakened tendon where it passes through the intertubercular groove.
  42. 42. Fracture of the shaft of the humerus • A transverse fracture of the shaft of the humerus frequently results from a direct blow to the arm. The pull of the deltoid muscle carries the proximal fragment laterally . Indirect injury resulting from a fall on the outstretched hand may produce a spiral fracture of the humeral shaft. Overriding of the oblique ends of the fractured bone may result in foreshortening. Because the humerus is surrounded by muscles and has a well-developed periosteum, the bone fragments usually unite well. An intercondylar fracture of the humerus results from a severe fall on the flexed elbow. The olecranon of the ulna is driven like a wedge between the medial and lateral parts of the condyle, separating one or both parts from the humeral shaft. • The following parts of the humerus are in direct contact with the indicated nerves: 1. Surgical neck: axillary nerve. 2. Radial groove: radial nerve. 3. Distal end of humerus: median nerve. 4. Medial epicondyle: ulnar nerve.
  43. 43. Fracture Dislocation of the Proximal Humeral Epiphysis • A direct blow or indirect injury of the shoulder of a child or adolescent may produce a fracture dislocation of the proximal humeral epiphysis because the joint capsule of the glenohumeral joint, reinforced by the rotator cuff (tendons of the SITS muscles), is stronger than the epiphysial plate. In severe fractures, the shaft of the humerus is markedly displaced, but the humeral head retains its normal relationship with the glenoid cavity of the scapula
  44. 44. Fractures of the Shaft of the Humerus Fractures of the humeral shaft are common; displacement of the fragments depends on the relation of the site of fracture to the insertion of the deltoid muscle. When the fracture line is proximal to the deltoid insertion, the proximal fragment is adducted by the pectoralis major, latissimus dorsi, and teres major muscles; the distal fragment is pulled proximally by the deltoid, biceps, and triceps. When the fracture is distal to the deltoid insertion, the proximal fragment is abducted by the deltoid, and the distal fragment is pulled proximally by the Biceps and triceps. The radial nerve can be damaged where it lies in the spiral groove on the posterior surface of the humerus Under cover of the triceps muscle.
  45. 45. Fracture of the Humeral Shaft • A midhumeral fracture may injure the radial nerve in the radial groove in the humeral shaft. When this nerve is damaged, the fracture is not likely to paralyze the triceps because of the high origin of the nerves to two of its three heads. A fracture of the distal part of the humerus, near the supraepicondylar ridges, is called a supraepicondylar fracture. The distal bone fragment may be displaced anteriorly or posteriorly. The actions of the brachialis and triceps tend to pull the distal fragment over the proximal fragment, shortening the limb. Any of the nerves or branches of the brachial vessels related to the humerus may be injured by a displaced bone fragment.
  46. 46. Fractures of the Distal End of the Humerus Supracondylar fractures are common in children and occur when the child falls on the outstretched hand with the elbow partially flexed. Injuries to the median, radial, and ulnar nerves are not uncommon, although function usually Quickly returns after reduction of the fracture. Damage to or pressure on the brachial artery can occur at the time of the fracture or from swelling of the surrounding tissues; the circulation to the forearm may be interfered with, leading to Volkmann’s ischemic contracture . The medial epicondyle can be avulsed by the medial collateral ligament of the elbow joint if the forearm is forcibly abducted. The ulnar nerve can be injured at the time of the fracture, can become involved later in the repair process of the fracture (in the callus), or can undergo irritation on the irregular bony surface after the bone fragments are areunited.
  47. 47. Absent Pectoralis Major Occasionally, parts of the pectoralis major muscle may be absent. The sternocostal origin is the most commonly missing part, and this causes weakness in adduction and medial rotation of the shoulder joint.
  48. 48. Absence of the Pectoral Muscles • Absence of part of the pectoralis major, usually its sternocostal part, is uncommon, but when it occurs, no disability usually results. However, the anterior axillary fold, formed by the skin and fascia overlying the inferior border of the pectoralis major, is absent on the affected side, and the nipple is more inferior than usual. In Poland syndrome, both the pectoralis major and minor are absent; breast hypoplasia and absence of two to four rib segments are also seen.
  49. 49. Paralysis of the Serratus Anterior • When the serratus anterior is paralyzed owing to injury to the long thoracic nerve, the medial border of the scapula moves laterally and posteriorly away from the thoracic wall, giving the scapula the appearance of a wing, especially when the person leans on a hand or presses the upper limb against a wall. When the arm is raised, the medial border and inferior angle of the scapula pull markedly away from the posterior thoracic wall, a deformation known as a winged scapula. • In addition, the upper limb cannot be abducted above the horizontal position because the serratus anterior is unable to rotate the glenoid cavity superiorly to allow complete abduction of the limb. Although protected when the limbs are at one's sides, the long thoracic nerve is exceptional in that it courses on the superficial aspect of the serratus anterior, which it supplies. Thus when the limbs are elevated, as in a knife fight, the nerve is especially vulnerable. Weapons, including bullets directed toward the thorax, are a common source ofinjury.
  50. 50. Triangle of Auscultation • Near the inferior angle of the scapula is a small triangular gap in the musculature. The superior horizontal border of the latissimus dorsi, the medial border of the scapula, and the inferolateral border of the trapezius form a triangle of auscultation. • This gap in the thick back musculature is a good place to examine posterior segments of the lungs with a stethoscope. When the scapulae are drawn anteriorly by folding the arms across the chest and the trunk is flexed, the auscultatory triangle enlarges and parts of the 6th and 7th ribs and 6th intercostal space are subcutaneous.
  51. 51. Compression of the Axillary Artery • The axillary artery can be palpated in the inferior part of the lateral wall of the axilla. Compression of the third part of this artery against the humerus may be necessary when profuse bleeding occurs (e.g., resulting from a stab or bullet wound in the axilla). If compression is required at a more proximal site, the axillary artery can be compressed at its origin (as the subclavian artery crosses the 1st rib) by exerting downward pressure in the angle between the clavicle and the inferior attachment of the sternocleidomastoid.
  52. 52. Arterial Anastomoses around the Scapula • Many arterial anastomoses (communications between arteries) occur around the scapula. Several vessels join to form networks on the anterior and posterior surfaces of the scapula: the dorsal scapular, suprascapular, and (via the circumflex scapular) subscapular arteries. The importance of the collateral circulation made possible by these anastomoses becomes apparent when ligation of a lacerated subclavian or axillary artery is necessary. For example, the axillary artery may have to be ligated between the 1st rib and subscapular artery; in other cases, vascular stenosis (narrowing) of the axillary artery may result from an atherosclerotic lesion that causes reduced blood flow. In either case, the direction of blood flow in the subscapular artery is reversed, enabling blood to reach the third part of the axillary artery. Note that the subscapular artery receives blood through several anastomoses with the suprascapular artery, transverse cervical artery, and intercostal arteries. • Slow occlusion of the axillary artery (e.g., resulting from disease or trauma) often enables sufficient collateral circulation to develop, preventing ischemia. Sudden occlusion usually does not allow sufficient time for adequate collateral circulation to develop; as a result, there is an inadequate supply of blood to the arm, forearm, and hand. While potential collateral pathways (periarticular anastomoses) exist around the shoulder joint proximally and the elbow joint distally, surgical ligation of the axillary artery between the origins of the subscapular artery and the deep artery of the arm will cut off the blood supply to the arm because the collateral circulation is inadequate.
  53. 53. Aneurysm of the Axillary Artery • The first part of the axillary artery may enlarge (aneurysm of the axillary artery) and compress the trunks of the brachial plexus, causing pain and anesthesia (loss of sensation) in the areas of the skin supplied by the affected nerves. Aneurysm of the axillary artery may occur in baseball pitchers because of their rapid and forceful arm movements
  54. 54. Spontaneous Thrombosis of the Axillary Vein Spontaneous thrombosis of the axillary vein occasionally occurs after excessive and unaccustomed movements of the arm at the shoalder joint.
  55. 55. Interruption of Blood Flow in the Brachial Artery • Stopping bleeding through manual or surgical control of blood flow is hemostasis. The best place to compress the brachial artery to control hemorrhage is medial to the humerus near the middle of the arm . Because the arterial anastomoses around the elbow provide a functionally and surgically important collateral circulation, the brachial artery may be clamped distal to the origin of the deep artery of the arm without producing tissue damage. The anatomical basis for this procedure is that the ulnar and radial arteries will still receive sufficient blood through the anastomoses around the elbow. Although collateral pathways confer some protection against gradual temporary and partial occlusion, sudden complete occlusion or laceration of the brachial artery creates a surgical emergency because paralysis of muscles results from ischemia of the elbow and forearm within a few hours. Muscles and nerves can tolerate up to 6 hours of ischemia; after this, fibrous scar tissue replaces necrotic tissue and causes the involved muscles to shorten permanently, producing a flexion deformity, the ischemic compartment syndrome (Volkmann or ischemic contracture). Contraction of the fingers and sometimes the wrist results in loss of hand power as a result of irreversible necrosis of the forearm flexor muscles.
  56. 56. Injuries to the Axillary Vein • Wounds in the axilla often involve the axillary vein because of its large size and exposed position. When the arm is fully abducted, the axillary vein overlaps the axillary artery anteriorly. • A wound in the proximal part of the axillary vein is particularly dangerous, not only because of profuse bleeding but also because of the risk of air entering it and producing air emboli (air bubbles) in the blood.
  57. 57. The Role of the Axillary Vein in Subclavian Vein Puncture • Subclavian vein puncture, in which a catheter is placed into the subclavian vein, has become a common clinical procedure . The axillary vein becomes the subclavian vein as the first rib is crossed. Because the needle is advanced medially to enter the vein as it crosses the rib, the vein actually punctured (the point of entry) in subclavian vein puncture is the terminal part of the axillary vein. However, the needle tip proceeds into the lumen of the subclavian vein almost immediately. Thus it is clinically significant that the axillary vein lies anterior and inferior (i.e., superficial) to the axillary artery and the parts of the brachial plexus that begin to surround the artery at this point.
  58. 58. The Axillary Sheath and a Brachial Plexus Nerve Block Because the axillary sheath encloses the axillary vessels and the brachial plexus, a brachial plexus nerve block can easily be obtained. The distal part of the sheath is closed with finger pressure, and a syringe needle is inserted into the proximal part of the sheath. The anesthetic solution is then injected into the sheath, and the solution is massaged along the sheath to produce the nerve block. The position of the sheath can be verified by feeling the pulsations of the third part of the axillary artery.
  59. 59. Examination of the Axillary Lymph Nodes With the patient standing or sitting, he or she is asked to place the hand of the side to be examined on the hip and push hard medially. This action of adduction of the shoulder joint causes the pectoralis major muscle to contract maximally so that it becomes hard like a board. The examiner then palpates the axillary nodes as follows: ■■ The anterior (pectoral) nodes may be palpated by pressing forward against the posterior surface of the pectoralis major muscle on the anterior wall of the axilla. ■■ The posterior (subscapular) nodes may be palpated by pressing backward against the anterior surface of the subscapularis muscle on the posterior wall of the axilla. ■■ The lateral nodes may be palpated against the medial side of the axillary vein. The xaminer’s fingers are pressed laterally against the subclavian vein and the pulsating axillary artery. ■■ The central nodes may be palpated in the center of the axilla between the pectoralis major (anterior wall) and the subscapularis (posterior wall). ■■ For the apical nodes, the patient is asked to relax the shoulder muscles and let the upper limb hang down at the side. The examiner then gently places the tips of the fingers of the examining hand high up in the axilla to the outer border of the first rib. If the nodes are enlarged, they can be felt. The examination of the axillary lymph nodes always forms part of the clinical examination of the breast.
  60. 60. Rotator Cuff Tendinitis The rotator cuff, consisting of the tendons of the subscapularis, supraspinatus, infraspinatus, and teres minor muscles, which are fused to the underlying capsule of the shoulder joint, plays an important role in stabilizing the shoulder joint. The rotator cuff presses the humeral head into the glenoid cavity. Lesions of the cuff are a common cause of pain in the shoulder region. Failure of the cuff is due to either wear or tear. Wear is age related. Excessive overhead activity of the upper limb may be the cause of tendinitis, although many cases appear spontaneously. During abduction of the shoulder joint, the supraspinatus tendon is exposed to friction against the acromion . Under normal conditions, the amount of friction is reduced to a minimum by the large subacromial bursa, which extends laterally beneath the deltoid. Degenerative changes in the bursa are followed by degenerative changes in the underlying supraspinatus tendon, and these may extend into the other tendons of the rotator cuff. Clinically, the condition is known as subacromial bursitis, supraspinatus tendinitis, or pericapsulitis. It is characterized by the presence of a spasm of pain in the middle range of abduction, when the diseased area impinges on the acromion. Extensive acute traumatic tears are best repaired surgically as soon as possible. Small chronic cuff injuries are best managed without surgery using nonsteroidal anti-inflammatory drugs and muscle exercises.
  61. 61. Rupture of the Supraspinatus Tendon In advanced cases of rotator cuff tendinitis, the necrotic supraspinatus tendon can become calcified or rupture. Rupture of the tendon seriously interferes with the normal abduction movement of the shoulder joint. It will be remembered that the main function of the supraspinatus muscle is to hold the head of the humerus in the glenoid fossa at the commencement of abduction. The patient with a ruptured supraspinatus tendon is unable to initiate abduction of the arm. However, if the arm is passively assisted for the first 15° of abduction, the deltoid can then take over and complete the movement to a right angle.
  62. 62. Axillary Nerve Injury The axillary nerve can be injured in dislocations of the shoulder joint.
  63. 63. Axillary Nerve Injury • The axillary nerve may be injured when the glenohumeral joint dislocates because of its close relation to the inferior part of the joint capsule of this joint. The subglenoid displacement of the head of the humerus into the quadrangular space damages the axillary nerve. Axillary nerve injury is indicated by paralysis of the deltoid (manifest as an inability to abduct the arm to or above the horizontal level) and loss of sensation in a small area of skin covering the central part of the deltoid.
  64. 64. Injury to the Axillary Nerve • The deltoid atrophies when the axillary nerve (C5 and C6) is severely damaged. Because it passes inferior to the humeral head and winds around the surgical neck of the humerus, the axillary nerve is usually injured during fracture of this part of the humerus. It may also be damaged during dislocation of the glenohumeral joint and by compression from the incorrect use of crutches. As the deltoid atrophies, the rounded contour of the shoulder disappears. This gives the shoulder a flattened appearance and produces a slight hollow inferior to the acromion. In addition to atrophy of the deltoid, a loss of sensation may occur over the lateral side of the proximal part of the arm, the area supplied by the superior lateral cutaneous nerve of the arm. • The deltoid is a common site for the intramuscular injection of drugs. The axillary nerve runs transversely under cover of the deltoid at the level of the surgical neck of the humerus. Awareness of its location avoids injury to it during surgical approaches to the shoulder.
  65. 65. Rotator Cuff Injuries • The musculotendinous rotator cuff is commonly injured during repetitive use of the upper limb above the horizontal (e.g., during throwing and racquet sports, swimming, and weightlifting). Recurrent inflammation of the rotator cuff, especially the relatively avascular area of the supraspinatus tendon, is a common cause of shoulder pain and results in tears of the musculotendinous rotator cuff. Repetitive use of the rotator cuff muscles (e.g., by baseball pitchers) may allow the humeral head and rotator cuff to impinge on the coracoacromial arch, producing irritation of the arch and inflammation of the rotator cuff. As a result, degenerative tendonitis of the rotator cuff develops. Attrition of the supraspinatus tendon also occurs. • To test for degenerative tendonitis of the rotator cuff, the person is asked to lower the fully abducted limb slowly and smoothly. From approximately 90° abduction, the limb will suddenly drop to the side in an uncontrolled manner if the rotator cuff (especially the supraspinatus part) is diseased and/or torn. • Rotator cuff injuries can also occur during a sudden strain of the muscles, for example, when an older person strains to lift something, such as a window sash that is stuck, a previously degenerated musculotendinous rotator cuff may rupture. A fall on the shoulder may also tear a previously degenerated rotator cuff. Often the intracapsular part of the tendon of the long head of the biceps brachii becomes frayed (even worn away) leaving it adherent to the intertubercular groove. As a result, shoulder stiffness occurs. Because they fuse, the integrity of the fibrous layer of the joint capsule of the glenohumeral joint is usually compromised when the rotator cuff is injured. As a result, the articular cavity communicates with the subacromial bursa. Because the supraspinatus muscle is no longer functional with a complete tear of the rotator cuff, the person cannot initiate abduction of the upper limb. If the arm is passively abducted 15° or more, the person can usually maintain or continue the abduction using the deltoid.
  66. 66. Rotator Cuff Injuries and the Supraspinatus • Injury or disease may damage the musculotendinous rotator cuff, producing instability of the glenohumeral joint. Trauma may tear or rupture one or more of the tendons of the SITS muscles; that of the supraspinatus is most commonly involved. • Degenerative tendonitis of the rotator cuff is common, especially in older people. These syndromes are discussed in detail (later in this chapter) in relationship to the glenohumeral joint.
  67. 67. Dislocation of the Glenohumeral Joint • Because of its freedom of movement and instability, the glenohumeral joint is commonly dislocated by direct or indirect injury. Because the presence of the coracoacromial arch and the support of the rotator cuff are effective in preventing upward dislocation, most dislocations of the humeral head occur in the downward (inferior) direction. However, they are described clinically as anterior or (more rarely) posterior dislocations, indicating whether the humeral head has descended anterior or posterior to the infraglenoid tubercle and the long head of the triceps. The head ends up lying anterior or posterior to the glenoid cavity. • Anterior dislocation of the glenohumeral joint occurs most often in young adults, particularly athletes. It is usually caused by excessive extension and lateral rotation of the humerus . • The head of the humerus is driven inferoanteriorly, and the fibrous layer of the joint capsule and glenoid labrum may be stripped from the anterior aspect of the glenoid cavity in the process. A hard blow to the humerus when the glenohumeral joint is fully abducted tilts the head of the humerus inferiorly onto the inferior weak part of the joint capsule. This may tear the capsule and dislocate the shoulder so that the humeral head comes to lie inferior to the glenoid cavity and anterior to the infraglenoid tubercle. The strong flexor and adductor muscles of the glenohumeral joint usually subsequently pull the humeral head anterosuperiorly into a subcoracoid position. Unable to use the arm, the person commonly supports it with the other hand. Inferior dislocation of the glenohumeral joint often occurs after an avulsion fracture of the greater tubercle, owing to the absence of the upward and medial pull produced by the muscles attaching to the tubercle.
  68. 68. Glenoid Labrum Tears • Tearing of the fibrocartilaginous glenoid labrum commonly occurs in athletes who throw a baseball or football and in those who have shoulder instability and subluxation (partial dislocation) of the glenohumeral joint. The tear often results from sudden contraction of the biceps or forceful subluxation of the humeral head over the glenoid labrum. Usually a tear occurs in the anterosuperior part of the labrum. The typical symptom is pain while throwing, especially during the acceleration phase, but a sense of popping or snapping may be felt in the glenohumeral joint during abduction and lateral rotation of the arm.
  69. 69. Adhesive Capsulitis of the Glenohumeral Joint • Adhesive fibrosis and scarring between the inflamed joint capsule of the glenohumeral joint, rotator cuff, subacromial bursa, and deltoid usually cause adhesive capsulitis , a condition seen in individuals 60 years of age. A person with this condition has difficulty abducting the arm and can obtain an apparent abduction of up to 45° by elevating and rotating the scapula. Because of the lack of movement of the glenohumeral joint, strain is placed on the AC joint, which may be painful during other movements (e.g., elevation, or shrugging, of the shoulder). Injuries that may initiate acute capsulitis are glenohumeral dislocations, calcific supraspinatus tendinitis, partial tearing of the rotator cuff, and bicipital tendinitis
  70. 70. Accessory Nerve Injury The accessory nerve can be injured as the result of stab wounds to the neck.
  71. 71. Injury of the Accessory Nerve (CN XI) • The primary clinical manifestation of accessory nerve palsy is a marked ipsilateral weakness when the shoulders are elevated (shrugged) against resistance.
  72. 72. Injury of the Thoracodorsal Nerve • Surgery in the inferior part of the axilla puts the thoracodorsal nerve supplying the latissimus dorsi at risk of injury. This nerve passes inferiorly along the posterior wall of the axilla and enters the medial surface of the latissimus dorsi close to where it becomes tendinous . The nerve is also vulnerable to injury during surgery on scapular lymph nodes because its terminal part lies anterior to them and the subscapular artery. The latissimus dorsi and the inferior part of the pectoralis major form an aanteroposterior muscular sling between the trunk and the arm; however, the latissimus dorsi forms the more powerful part of the sling. With paralysis of the latissimus dorsi, the person is unable to raise the trunk with the upper limbs, as occurs during climbing. Furthermore, the person cannot use an axillary crutch because the shoulder is pushed superiorly by it. These are the primary activities for which active depression of the scapula is required; the passive depression provided by gravity is adequate for most activities.
  73. 73. Injury to the Dorsal Scapular Nerve • Injury to the dorsal scapular nerve, the nerve to the rhomboids, affects the actions of these muscles. If the rhomboids on one side are paralyzed, the scapula on the affected side is located farther from the midline than that on the normal side.
  74. 74. Arterial Anastomosis and Ligation of the Axillary Artery The existence of the anastomosis around the shoulder joint is vital to preserving the upper limb should it be necessary to ligate the axillary artery.
  75. 75. Sternoclavicular Joint Injuries The strong costoclavicular ligament firmly holds the medial end of the clavicle to the 1st costal cartilage. Violent forces directed along the long axis of the clavicle usually result in fracture of that bone, but dislocation of the sternoclavicular joint takes place occasionally. Anterior dislocation results in the medial end of the clavicle projecting forward beneath the skin; it may also be pulled upward by the sternocleidomastoid muscle. Posterior dislocation usually follows direct trauma applied to the front of the joint that drives the clavicle backward. This type is the more serious one because the displaced clavicle may press on the trachea, the esophagus, and major blood vessels in the root of the neck. If the costoclavicular ligament ruptures completely, it is difficult to maintain the normal position of the clavicle once reduction has been accomplished.
  76. 76. Acromioclavicular Joint Injuries The plane of the articular surfaces of the acromioclavicular joint passes downward and medially so that there is a tendency for the lateral end of the clavicle to ride up over the upper surface of the acromion. The strength of the joint depends on the strong racoclavicular ligament, which binds the coracoid process to the ndersurface of the lateral part of the clavicle. The greater part of the weight of the upper limb is transmitted to the clavicle through this ligament, and rotary movements of the scapula occur at this important ligament.
  77. 77. Acromioclavicular Dislocation A severe blow on the point of the shoulder, as is incurred during blocking or tackling in football or any severe fall, can result in the acromion being thrust beneath the lateral end of the clavicle, tearing the coracoclavicular ligament. This condition is known as shoulder separation. The displaced outer end of the clavicle is easily palpable. As in the case of the sternoclavicular joint, the dislocation is easily reduced, but withdrawal of support results in immediate redislocation.
  78. 78. Stability of the Shoulder Joint The shallowness of the glenoid fossa of the scapula and the lack of support provided by weak ligaments make this joint an unstable structure. Its strength almost entirely depends on the tone of the short muscles that bind the upper end of the humerus to the scapula—namely, the subscapularis in front, the supraspinatus above, and the infraspinatus and teres minor behind. The tendons of these muscles are fused to the underlying capsule of the shoulder joint. Together, these tendons form the rotator cuff. The least supported part of the joint lies in the inferior location, where it is unprotected by muscles.
  79. 79. Dislocations of the Shoulder Joint The shoulder joint is the most commonly dislocated large joint. Anterior Inferior Dislocation Sudden violence applied to the humerus with the joint fully abducted tilts the humeral head downward onto the inferior weak part of the capsule, which tears, and the humeral head comes to lie inferior to the glenoid fossa. During this movement, the acromion has acted as a fulcrum. The strong flexors and adductors of the shoulder joint now usually pull the humeral head forward and upward into the subcoracoid position. Posterior Dislocations Posterior dislocations are rare and are usually caused by direct violence to the front of the joint. On inspection of the patient with shoulder dislocation, the rounded appearance of the shoulder is seen to be lost because the greater tuberosity of the humerus is no longer bulging laterally beneath the deltoid muscle. A subglenoid displacement of the head of the humerus into the quadrangular space can cause damage to the axillary nerve, as indicated by paralysis of the deltoid muscle and loss of skin sensation over the lower half of the deltoid. Downward displacement of the humerus can also stretch and damage the radial nerve.
  80. 80. Shoulder Pain The synovial membrane, capsule, and ligaments of the shoulder joint are innervated by the axillary nerve and the suprascapular nerve. The joint is sensitive to pain, pressure, excessive traction, and distention. The muscles surrounding the joint undergo reflex spasm in response to pain originating in the joint, which in turn serves to immobilize the joint and thus reduce the pain. Injury to the shoulder joint is followed by pain, limitation of movement, and muscle atrophy owing to disuse. It is important to appreciate that pain in the shoulder region can be caused by disease elsewhere and that the shoulder joint may be normal; for example, diseases of the spinal cord and vertebral column and the pressure of a cervical rib (see page XXX) can cause shoulder pain. Irritation of the diaphragmatic pleura or peritoneum can produce referred pain via the phrenic and supraclavicular nerves.
  81. 81. Dermatomes and Cutaneous Nerves It may be necessary for a physician to test the integrity of the spinal cord segments of C3 through T1. The diagrams in Figures 1.23 and 1.24 show the arrangement of the dermatomes of the upper limb. It is seen that the dermatomes for the upper cervical segments C3 to 6 are located along the lateral margin of the upper limb; the C7 dermatome is situated on the middle finger; and the dermatomes for C8, T1, and T2 are along the medial margin of the limb. The nerve fibers from a particular segment of the spinal cord, although they exit from the cord in a spinal nerve of the same segment, pass to the skin in two or more different cutaneous nerves. The skin over the point of the shoulder and halfway down the lateral surface of the deltoid muscle is supplied by the supraclavicular nerves (C3 and 4). Pain may be referred to this region as a result of inflammatory lesions involving the diaphragmatic pleura or peritoneum. The afferent stimuli reach the spinal cord via the phrenic nerves (C3, 4, and 5). Pleurisy, peritonitis, subphrenic abscess, or gallbladder disease may therefore be responsible for shoulder pain.
  82. 82. High Division of the Brachial Artery • Sometimes the brachial artery divides at a more proximal level than usual. In this case, the ulnar and radial arteries begin in the superior or middle part of the arm, and the median nerve passes between them
  83. 83. Superficial Ulnar Artery • In approximately 3% of people, the ulnar artery descends superficial to the flexor muscles. Pulsations of a superficial ulnar artery can be felt and may be visible. This variation must be kept in mind when performing venesections for withdrawing blood or making intravenous injections. If an aberrant ulnar artery is mistaken for a vein, it may be damaged and produce bleeding. If certain drugs are injected into the aberrant artery, the result could be fatal
  84. 84. Venipuncture and Blood Transfusion The superficial veins are clinically important and are used for venipuncture, transfusion, and cardiac catheterization. Every clinical professional, in an emergency, should know where to obtain blood from the arm. When a patient is in a state of shock, the superficial veins are not always visible. The cephalic vein lies fairly constantly in the superficial fascia, immediately posterior to the styloid process of the radius. In the cubital fossa, the median cubital vein is separated from the underlying brachial artery by the bicipital aponeurosis. This is important because it protects the artery from the mistaken introduction into its lumen of irritating drugs that should have been injected into the vein. The cephalic vein, in the deltopectoral triangle, frequently communicates with the external jugular vein by a small vein that crosses in front of the clavicle. Fracture of the clavicle can result in rupture of this communicating vein, with the formation of a large hematoma.
  85. 85. Intravenous Transfusion and Hypovolemic Shock In extreme hypovolemic shock, excessive venous tone may inhibit venous blood flow and thus delay the introduction of intravenous blood into the vascular system.
  86. 86. 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. The cephalic vein does not increase in size as it ascends the arm, and 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.
  87. 87. Measuring the Pulse Rate • The common place for measuring the pulse rate is where the radial artery lies on the anterior surface of the distal end of the radius, lateral to the tendon of the FCR. Here the artery is covered by only fascia and skin. The artery can be compressed against the distal end of the radius, where it lies between the tendons of the FCR and APL. When measuring the radial pulse rate, the pulp of the thumb should not be used because it has its own pulse, which could obscure the patient's pulse. If a pulse cannot be felt, try the other wrist because an aberrant radial artery on one side may make the pulse difficult to palpate. A radial pulse may also be felt by pressing lightly in the anatomical snuff box.
  88. 88. Variations in the Origin of the Radial Artery • The origin of the radial artery may be more proximal than usual; it may be a branch of the axillary artery or the brachial artery. • Sometimes the radial artery is superficial to the deep fascia instead of deep to it. When a superficial vessel is pulsating near the wrist, it is probably a superficial radial artery. The aberrant vessel is vulnerable to laceration
  89. 89. Venipuncture in the Cubital Fossa • The cubital fossa is the common site for sampling and transfusion of blood and intravenous injections because of the prominence and accessibility of veins. Usually, the median cubital vein or basilic vein is selected. The median cubital vein lies directly on the deep fascia, crossing the bicipital aponeurosis, which separates it from the underlying brachial artery and median nerve and provides some protection to the latter. Historically, during the days of bloodletting, the bicipital aponeurosis was known as the grace Deux (Fr. grace of God) tendon, by the grace of which arterial hemorrhage was usually avoided. A tourniquet is placed around the midarm to distend the veins in the cubital fossa. Once the vein is punctured, the tourniquet is removed so that when the needle is removed the vein will not bleed extensively. The cubital veins are also a site for the introduction of cardiac catheters to secure blood samples from the great vessels and chambers of the heart. These veins may also used for cardioangiography
  90. 90. Variation of Veins in the Cubital Fossa • The pattern of veins in the cubital fossa varies greatly. In approximately 20% of people, the median antebrachial vein (median vein of the forearm) divides into a median basilic vein, which joins the basilic vein. and a median cephalic vein, which joins the cephalic vein. In these cases, a clear M formation is produced by the cubital veins. It is important to observe and remember that either the median cubital vein or the median basilic vein, whichever pattern is present, crosses superficial to the brachial artery, from which it is separated by the bicipital aponeurosis. These veins are good sites for drawing blood but are not ideal for injecting an irritating drug because of the danger of injecting it into the brachial artery. In obese people, a considerable amount of fatty tissue may overlie the vein.
  91. 91. Dermatomes and Cutaneous Nerves It may be necessary for a physician to test the integrity of the spinal cord segments of C3 through T1. It is seen that the dermatomes for the upper cervical segments C3 to 6 are located along the lateral margin of the upper limb; the C7 dermatome is situated on the middle finger; and the dermatomes for C8, T1, and T2 are along the medial margin of the limb. The nerve fibers from a particular segment of the spinal cord, although they exit from the cord in a spinal nerve of the same segment, pass to the skin in two or more different cutaneous nerves. The skin over the point of the shoulder and halfway down the lateral surface of the deltoid muscle is supplied by the supraclavicular nerves (C3 and 4). Pain may be referred to this region as a result of inflammatory lesions involving the diaphragmatic pleura or peritoneum. The afferent stimuli reach the spinal cord via the phrenic nerves (C3, 4, and 5). Pleurisy, peritonitis, subphrenic abscess, or gallbladder disease may therefore be responsible for shoulder pain.
  92. 92. Lymphangitis Infection of the lymph vessels (lymphangitis) of the arm is common. Red streaks along the course of the lymph vessels are characteristic of the condition. 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.
  93. 93. Lymphadenitis Once the infection reaches the lymph nodes, they become enlarged and tender, a condition known as lymphadenitis. 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.
  94. 94. Enlargement of the Axillary Lymph Nodes • An infection in the upper limb can cause the axillary nodes to enlarge and become tender and inflamed, a condition called lymphangitis (inflammation of lymphatic vessels). The humeral group of nodes is usually the first to be involved. Lymphangitis is characterized by the development of warm, red, tender streaks in the skin of the limb. Infections in the pectoral region and breast, including the superior part of the abdomen, can also produce enlargement of axillary nodes. In metastatic cancer of the apical group, the nodes often adhere to the axillary vein, which may necessitate excision of part of this vessel. Enlargement of the apical nodes may obstruct the cephalic vein superior to the pectoralis minor.
  95. 95. Dissection of the Axillary Lymph Nodes • Excision and pathologic analysis of axillary lymph nodes are often necessary for staging and determining the appropriate treatment of a cancer such as breast cancer (see Chapter 1). Because the axillary lymph nodes are arranged and receive lymph (and therefore metastatic breast cancer cells) in a specific order, removing and examining the lymph nodes in that order is important in determining the degree to which the cancer has developed and is likely to have metastasized. Lymphatic drainage of the upper limb may be impeded after the removal of the axillary nodes, resulting in lymphedema, swelling as a result of accumulated lymph, especially in the subcutaneous tissue. • During axillary node dissection, two nerves are at risk of injury. During surgery, the long thoracic nerve to the serratus anterior is identified and maintained against the thoracic wall. As discussed earlier in this chapter, cutting the long thoracic nerve results in a winged scapula. If the thoracodorsal nerve to the latissimus dorsi is cut, medial rotation and adduction of the arm are weakened, but deformity does not result. If the nodes around this nerve are obviously malignant, sometimes the nerve has to be sacrificed as the nodes are resected to increase the likelihood of complete removal of all malignant cells.
  96. 96. Biceps Brachii and Osteoarthritis of the Shoulder Joint The tendon of the long head of biceps is attached to the supraglenoid tubercle within the shoulder joint. Advanced osteoarthritic changes in the joint can lead to erosion and fraying of the tendon by osteophytic outgrowths, and rupture of the tendon can occur.
  97. 97. Fractures of the Radius and Ulna Fractures of the head of the radius can occur from falls on the outstretched hand. As the force is transmitted along the radius, the head of the radius is driven sharply against the capitulum, splitting or splintering the head . Fractures of the neck of the radius occur in young children from falls on the outstretched hand . Fractures of the shafts of the radius and ulna may or may not occur together. Displacement of the fragments is usually considerable and depends on the pull of the attached muscles. The proximal fragment of the radius is supinated by the supinator and the biceps brachii muscles. The distal fragment of the radius is pronated and pulled medially by the pronator quadratus muscle. The strength of the brachioradialis and extensor carpi radialis longus and brevis shortens and angulates the forearm. In fractures of the ulna, the ulna angulates posteriorly. To restore the normal movements of pronation and supination, the normal anatomic relationship of the radius, ulna, and interosseous membrane must be regained. A fracture of one forearm bone may be associated with a dislocation of the other bone. In Monteggia’s fracture, for example, the shaft of the ulna is fractured by a force applied from behind. There is a bowing forward of the ulnar shaft and an anterior dislocation of the radial head with rupture of the anular ligament. In Galeazzi’s fracture, the proximal third of the radius is fractured and the distal end of the ulna is dislocated at the distal radioulnar joint. Fractures of the olecranon process can result from a fall on the flexed elbow or from a direct blow. Depending on the location of the fracture line, the bony fragment may be displaced by the pull of the triceps muscle, which is inserted on the olecranon process . Avulsion fractures of part of the olecranon process can be produced by the pull of the triceps muscle. Good functional return after any of these fractures depends on the accurate anatomic reduction of the fragment.
  98. 98. Elbow Tendinitis or Lateral Epicondylitis • Elbow tendinitis (tennis elbow) is a painful musculoskeletal condition that may follow repetitive use of the superficial extensor muscles of the forearm. Pain is felt over the lateral epicondyle and radiates down the posterior surface of the forearm. People with elbow tendinitis often feel pain when they open a door or lift a glass. Repeated forceful flexion and extension of the wrist strain the attachment of the common extensor tendon, producing inflammation of the periosteum of the lateral epicondyle (lateral epicondylitis).
  99. 99. Fracture of the Olecranon • Fracture of the olecranon, called a “fractured elbow―by laypersons, is common because the olecranon is subcutaneous and protrusive. The typical mechanism of injury is a fall on the elbow combined with sudden powerful contraction of the triceps. The fractured olecranon is pulled away by the active and tonic contraction of the triceps, and the injury is often considered to be an avulsion fracture. This is a serious fracture requiring the services of an orthopedic surgeon. Because of the traction produced by the tonus of the triceps on the olecranon fragment, pinning is usually required. Healing occurs slowly, and often a cast must be worn for nearly a year.
  100. 100. Fractures of the Radius and Ulna • Fractures of both the radius and the ulna are usually the result of severe injury. A direct injury usually produces transverse fractures at the same level, usually in the middle third of the bones. Isolated fractures of the radius or ulna also occur. Because the shafts of these bones are firmly bound together by the interosseous membrane, a fracture of one bone is likely to be associated with dislocation of the nearest joint. • Fracture of the distal end of the radius is a common fracture in adults > 50 years of age and occurs more frequently in women because their bones are more commonly weakened by osteoporosis. A complete transverse fracture of the distal 2 cm of the radius, called a Colles fracture, is the most common fracture of the forearm (Fig. B6.3). The distal fragment is displaced dorsally and is often comminuted (broken into pieces). The fracture results from forced dorsiflexion of the hand, usually as the result of trying to ease a fall by outstretching the upper limb. Often the ulnar styloid process is avulsed (broken off). Normally the radial styloid process projects farther distally than the ulnar styloid; consequently, when a Colles fracture occurs, this relationship is reversed because of shortening of the radius . This clinical condition is often referred to as a dinner fork (silver fork) deformity because a posterior angulation occurs in the forearm just proximal to the wrist and the normal anterior curvature of the relaxed hand. The posterior bending is produced by the posterior displacement and tilt of the distal fragment of the radius. • The typical history of a person with a Colles fracture includes slipping or tripping and, in an attempt to break the fall, landing on the outstretched limb with the forearm and hand pronated. Because of the rich blood supply to the distal end of the radius, bony union is usually good. • When the distal end of the radius fractures in children, the fracture line may extend through the distal epiphysial plate. Epiphysial plate injuries are common in older children because of their frequent falls in which the forces are transmitted from the hand to the radius and ulna. The healing process may result in malalignment of the epiphysial plate and disturbance of radial growth.
  101. 101. Bursitis of the Elbow • The subcutaneous olecranon bursa is exposed to injury during falls on the elbow and to infection from abrasions of the skin covering the olecranon. Repeated excessive pressure and friction, as occurs in wrestling, for example, may cause this bursa to become inflamed, producing a friction subcutaneous olecranon bursitis (e.g.student's elbow). This type of bursitis is also known as dart thrower's elbow and miner's elbow.•Occasionally, the bursa becomes infected and the area over the bursa becomes inflamed. • Subtendinous olecranon bursitis is much less common. It results from excessive friction between the triceps tendon and olecranon, for example, resulting from repeated flexion extension of the forearm as occurs during certain assembly-line jobs. The pain is most severe during flexion of the forearm because of pressure exerted on the inflamed subtendinous olecranon bursa by the triceps tendon. • Bicipitoradial bursitis (biceps bursitis) results in pain when the forearm is pronated because this action compresses the bicipitoradial bursa against the anterior half of the tuberosity of the radius.
  102. 102. Avulsion of the Medial Epicondyle • Avulsion of the medial epicondyle in children can result from a fall that causes severe abduction of the extended elbow, an abnormal movement of this articulation. The resulting traction on the ulnar collateral ligament pulls the medial epicondyle distally . The anatomical basis of avulsion of the epicondyle is that the epiphysis for the medial epicondyle may not fuse with the distal end of the humerus until up to age 20. Usually fusion is complete radiographically at age 14 in females and age 16 in males. Traction injury of the ulnar nerve is a frequent complication of the abduction type of avulsion of the medial epicondyle. The anatomical basis for this stretching of the ulnar nerve is that it passes posterior to the medial epicondyle before entering the forearm.
  103. 103. Dislocation of the Elbow Joint • Posterior dislocation of the elbow joint may occur when children fall on their hands with their elbows flexed. Dislocations of the elbow may result from hyperextension or a blow that drives the ulna posterior or posterolateral. The distal end of the humerus is driven through the weak anterior part of the fibrous layer of the joint capsule as the radius and ulna dislocate posteriorly. The ulnar collateral ligament is often torn, and an associated fracture of the head of the radius, coronoid process, or olecranon process of the ulna may occur. Injury to the ulnar nerve may occur, resulting in numbness of the little finger and weakness of flexion and adduction of the wrist.
  104. 104. Wrist Fractures • Fracture of the distal end of the radius (Colles fracture), the most common fracture in people >50 years of age, is discussed in the clinical correlation Fractures of the Radius and Ulna, earlier in this chapter. Fracture of the scaphoid, relatively common in young adults, is discussed in the clinical correlation • Anterior dislocation of the lunate is an uncommon but serious injury that usually results from a fall on the dorsiflexed wrist. The lunate is pushed out of its place in the floor of the carpal tunnel toward the palmar surface of the wrist. The displaced lunate may compress the median nerve and lead to carpal tunnel syndrome (discussed earlier in this chapter). Because of its poor blood supply, avascular necrosis of the lunate may occur. In some cases, excision of the lunate may be required. In degenerative joint disease of the wrist, surgical fusion of carpals (arthrodesis) may be necessary to relieve the severe pain.
  105. 105. Subluxation and Dislocation of Radial Head • Preschool children, particularly girls, are vulnerable to transient subluxation (incomplete temporary dislocation) of the head of the radius (also called nursemaid's elbow and “pulled elbow). The history of these cases is typical. The child is suddenly lifted (jerked) by the upper limb while the forearm is pronated (e.g., lifting a child into a bus) . The child may cry out, refuse to use the limb, protects the limb by holding it with the elbow flexed and the forearm pronated. The sudden pulling of the upper limb tears the distal attachment of the anular ligament, where it is loosely attached to the neck of the radius. The radial head then moves distally, partially out of the anular ligament. The proximal part of the torn ligament may become trapped between the head of the radius and the capitulum of the humerus. The source of pain is the pinched anular ligament. Treatment of the subluxation consists of supination of the child's forearm while the elbow is flexed. The tear in the anular ligament soon heals when the limb is placed in a sling for 2 weeks.
  106. 106. Colles’ fracture Colles’ fracture is a fracture of the distal end of the radius resulting from a fall on the outstretched hand. It commonly occurs in patients older than 50 years. The force drives the distal fragment posteriorly and superiorly, and the distal articular surface is inclined posteriorly . This posterior displacement produces a posterior bump, sometimes referred to as the “dinner-fork deformity” because the forearm and wrist resemble the shape of that eating utensil. Failure to restore the distal articular surface to its normal position will severely limit the range of flexion of the wrist joint.
  107. 107. Smith’s fracture Smith’s fracture is a fracture of the distal end of the radius and occurs from a fall on the back of the hand. It is a reversed Colles’ fracture because the distal fragment is displaced anteriorly.
  108. 108. Olecranon Bursitis A small subcutaneous bursa is present over the olecranon process of the ulna, and repeated trauma often produces chronic bursitis.
  109. 109. Bull Rider's Thumb • Bull rider's thumb refers to a sprain of the radial collateral ligament and an avulsion fracture of the lateral part of the proximal phalanx of the thumb. This injury is common in individuals who ride mechanical bulls.
  110. 110. Skier's Thumb • Skier's thumb (historically, game-keeper's thumb) refers to the rupture or chronic laxity of the collateral ligament of the 1st MP joint. The injury results from hyperabduction of the MP joint of the thumb, which occurs when the thumb is held by the ski pole while the rest of the hand hits the ground or enters the snow. In severe injuries, the head of the metacarpal has an avulsion fracture
  111. 111. Synovial Cyst of the Wrist • Sometimes a non-tender cystic swelling appears on the hand, most commonly on the dorsum of the wrist. Usually the cyst is the size of a small grape, but it varies and may be as large as a plum. The thin-walled cyst contains clear mucinous fluid. The cause of the cyst is unknown, but it may result from mucoid degeneration. Flexion of the wrist makes the cyst enlarge, and it may be painful. Clinically, this type of swelling is called a ganglion(G. swelling or knot). Anatomically, a ganglion refers to a collection of nerve cells (e.g., a spinal ganglion). These synovial cysts are close to and often communicate with the synovial sheaths on the dorsum of the wrist. The distal attachment of the ECRB tendon to the base of the 3rd metacarpal is another common site for such a cyst. A cystic swelling of the common flexor synovial sheath on the anterior aspect of the wrist can enlarge enough to produce compression of the median nerve by narrowing the carpal tunnel (carpal tunnel syndrome). This syndrome produces pain and paresthesia in the sensory distribution of the median nerve and clumsiness of finger movements
  112. 112. Fracture of the Scaphoid • The scaphoid is the most frequently fractured carpal bone. It often results from a fall on the palm when the hand is abducted, the fracture occurring across the narrow part (waist•) of the scaphoid. Pain occurs primarily on the lateral side of the wrist, especially during dorsiflexion and abduction of the hand. Initial radiographs of the wrist may not reveal a fracture; often this injury is (mis-)diagnosed as a severely sprained wrist. Radiographs taken 10-14 days later reveal a fracture because bone resorption has occurred there. Owing to the poor blood supply to the proximal part of the scaphoid, union of the fractured parts may take at least 3 months. Avascular necrosis of the proximal fragment of the scaphoid (pathological death of bone resulting from inadequate blood supply) may occur and produce degenerative joint disease of the wrist. In some cases, it is necessary to fuse the carpals surgically (arthrodesis).
  113. 113. Mallet or Baseball Finger • Sudden severe tension on a long extensor tendon may avulse part of its attachment to the phalanx. The most common result of the injury is a mallet or baseball finger. This deformity results from the distal interphalangeal joint suddenly being forced into extreme flexion (hyperflexion when, for example, a baseball is miscaught or a finger is jammed into the base pad. These actions avulse the attachment of the tendon to the base of the distal phalanx. As a result, the person cannot extend the distal interphalangeal joint. The resultant deformity bears some resemblance to a mallet.
  114. 114. Fracture of the scaphoid bone Fracture of the scaphoid bone is common in young adults; unless treated effectively, the fragments will not unite, and permanent weakness and pain of the wrist will result, with the subsequent development of osteoarthritis. The fracture line usually goes through the narrowest part of the bone, which, because of its location, is bathed in synovial fluid. The blood vessels to the scaphoid enter its proximal and distal ends, although the blood supply is occasionally confined to its distal end. If the latter occurs, a fracture deprives the proximal fragment of its arterial supply, and this fragment undergoes avascular necrosis. Deep tenderness in the anatomic snuffbox after a fall on the outstretched hand in a young adult makes one suspicious of a fractured scaphoid.
  115. 115. Fracture of the Hamate • Fracture of the hamate may result in non- union of the fractured bony parts because of the traction produced by the attached muscles. Because the ulnar nerve is close to the hook of the hamate, the nerve may be injured by this fracture, causing decreased grip strength of the hand. The ulnar artery may also be damaged when the hamate is fractured.
  116. 116. Dislocation of the lunate bone Dislocation of the lunate bone occasionally occurs in young adults who fall on the outstretched hand in a way that causes hyperextension of the wrist joint. Involvement of the median nerve is common.
  117. 117. Fractures of the metacarpal bones Fractures of the metacarpal bones can occur as a result of direct violence, such as the clenched fist striking a hard object. The fracture always angulates dorsally. The “boxer’s fracture” commonly produces an oblique fracture of the neck of the fifth and sometimes the fourth metacarpal bones. The distal fragment is commonly displaced proximally, thus shortening the finger posteriorly.
  118. 118. Fracture of the Metacarpals • The metacarpals (except the 1st) are closely bound together; hence isolated fractures tend to be stable. Furthermore, these bones have a good blood supply, and fractures usually heal rapidly. Severe crushing injuries of the hand may produce multiple metacarpal fractures, resulting in instability of the hand. Fracture of the 5th metacarpal, often referred to as a boxer's fracture, occurs when an unskilled person punches someone with a closed fist. The head of the bone rotates over the distal end of the shaft, producing a flexion deformity.
  119. 119. Bennett’s fracture Bennett’s fracture is a fracture of the base of the metacarpal of the thumb causd when violence is applied along the long axis of the thumb or the thumb is forcefully abducted. The fracture is oblique and enters the carpometacarpal joint of the thumb, causing joint instability. Fractures of the phalanges are common and usually follow direct injury.
  120. 120. Fracture of the Phalanges • Crushing injuries of the distal phalanges are common (e.g., when a finger is caught in a car door). Because of the highly developed sensation in the fingers, these injuries are extremely painful. A fracture of a distal phalanx is usually comminuted, and a painful hematoma (local collection of blood) soon develops. Fractures of the proximal and middle phalanges are usually the result of crushing or hyperextension injuries. Because of the close relationship of phalangeal fractures to the flexor tendons, the bone fragments must be carefully realigned to restore normal function of the fingers.
  121. 121. Compartment Syndrome of the Forearm The forearm is enclosed in a sheath of deep fascia, which is attached to the periosteum of the posterior subcutaneous border of the ulna . This fascial sheath, together with the interosseous membrane and fibrous intermuscular septa, divides the forearm into several compartments, each having its own muscles, nerves, and blood supply. There is very little room within each compartment, and any edema can cause secondary vascular compression of the blood vessels; the veins are first affected, and later the arteries. Soft tissue injury is a common cause, and early diagnosis is critical. Early signs include altered skin sensation (caused by ischemia of the sensory nerves passing through the compartment), pain disproportionate to any injury (caused by pressure on nerves within the compartment), pain on passive stretching of muscles that pass through the compartment (caused by muscle ischemia), tenderness of the skin over the compartment (a late sign caused by edema), and absence of capillary refill in the nail beds (caused by pressure on the arteries within the compartment). Once the diagnosis is made, the deep fascia must be incised surgically Interosseous Membrane The interosseous membrane is a strong membrane that unites the shafts of the radius and the ulna; it is attached to their interosseous borders . Its fibers run obliquely downward and medially so that a force applied to the lower end of the radius (e.g., falling on the outstretched hand) is transmitted from the radius to the ulna and from there to the humerus and scapula. Its fibers are taut when the forearm is in the midprone position—that is, the position of function. The interosseous membrane provides attachment for neighboring muscles. Flexor and Extensor Retinacula The flexor and extensor retinacula are strong bands of deep fascia that hold the long flexor and extensor tendons in position at the wrist. Flexor Retinaculum The flexor retinaculum is a thickening of deep fascia that holds the long flexor tendons in position at the wrist. It stretches across the front of the wrist and converts the concave anterior surface of the hand into an osteofascial tunnel, the carpal tunnel, for the passage of the median nerve and the flexor tendons of the thumb and fingers . to decompress the affected compartment. A delay of as little as 4 hours can cause irreversible damage to the muscles.
  122. 122. Patterns of cutaneous innervation occur in the upper limb • (1) Segmental innervation (dermatomes) by spinal nerves • (2) Innervation by multisegmental peripheral (named) nerves. • The former pattern is easiest to visualize if the limb is placed in its initial embryonic position (abducted with the thumb directed superiorly). The segments then progress in descending order around the limb (starting with C4 dermatome at the root of the neck, proceeding laterally or distally along the superior surface and then medially or proximally along the inferior surface, as the T2 dermatome continues onto the thoracic wall). Like the brachial plexus, which forms posterior, lateral, and medial (but no anterior) cords, the arm and forearm have posterior, lateral, and medial (but no anterior) cutaneous nerves.
  123. 123. Volkmann’s Ischemic Contracture Volkmann’s ischemic contracture is a contracture of the muscles of the forearm that commonly follows fractures of the distal end of the humerus or fractures of the radius and ulna. In this syndrome, a localized segment of the brachial artery goes into spasm, reducing the arterial flow to the flexor and the extensor muscles so that they undergo ischemic necrosis. The flexor muscles are larger than the extensor muscles, and they are therefore the ones mainly affected. The muscles are replaced by fibrous tissue, which contracts, producing the deformity. The arterial spasm is usually caused by an overtight cast, but in some cases the fracture itself may be responsible. The deformity can be explained only by understanding the anatomy of the region. Three types of deformity exist: ■■ The long flexor muscles of the carpus and fingers are more contracted than the extensor muscles, and the wrist joint is flexed; the fingers are extended. If the wrist joint is extended passively, the fingers become flexed. ■■ The long extensor muscles to the fingers, which are inserted into the extensor expansion that is attached to the proximal phalanx, are greatly contracted; the metacarpophalangeal joints and the wrist joint are extended, and the interphalangeal joints of the fingers are flexed. ■■ Both the flexor and extensor muscles of the forearm are contracted. The wrist joint is flexed, the metacarpophalangeal joints are extended, and the interphalangeal joints are flexed.
  124. 124. Absent Palmaris Longus The palmaris longus muscle may be absent on one or both sides of the forearm in about 10% of persons. Others show variation in form, such as centrally or distally placed muscle belly in the place of a proximal one. Because the muscle is relatively weak, its absence produces no disability.
  125. 125. Stenosing Synovitis of the Abductor Pollicis Longus and Extensor Pollicis Brevis Tendons As a result of repeated friction between these tendons and the styloid process of the radius, they sometimes become edematous and swell. Later, fibrosis of the synovial sheath produces a condition known as stenosing tenosynovitis in which movement of the tendons becomes restricted. Advanced cases require surgical incision along the constricting sheath.
  126. 126. Rupture of the Extensor Pollicis Longus Tendon Rupture of this tendon can occur after fracture of the distal third of the radius. Roughening of the dorsal tubercle of the radius by the fracture line can cause excessive friction on the tendon, which can then rupture. Rheumatoid arthritis can also cause rupture of this tendon.
  127. 127. Anatomic Snuffbox” The anatomic snuffbox is a term commonly used to describe a triangular skin depression on the lateral side of the wrist that is bounded medially by the tendon of the extensor pollicis longus and laterally by the tendons of the abductor pollicis longus and extensor pollicis brevis. Its clinical importance lies in the fact that the scaphoid bone is most easily alpated here and that the pulsations of the radial artery can be felt here.
  128. 128. Tennis Elbow Tennis elbow is caused by a partial tearing or degeneration of the origin of the superficial extensor muscles from the lateral epicondyle of the humerus. It is characterized by pain and tenderness over the lateral epicondyle of the humerus, with pain radiating down the lateral side of the forearm; it is common in tennis players, violinists, and housewives.
  129. 129. Dupuytren’s Contracture Dupuytren’s contracture is a localized thickening and contracture of the palmar aponeurosis, which limits hand function and may eventually disable the hand. It commonly starts near the root of the ring finger and draws that finger into the palm, flexing it at the metacarpophalangeal joint. Later, the condition involves the little finger in the same manner. In long-standing cases, the pull on the fibrous sheaths of thesefingers results in flexion of the proximal interphalangeal joints. The distal interphalangeal joints are not involved and are actually extended by the pressure of the fingers against the palm. Surgical division of the fibrous bands followed by physiotherapy to the hand is the usual form of treatment. The alternative treatment of injection of the enzyme collagenase into the contracted bands of fibrous tissue has been shown to significantly reduce the contractures and improve mobility.
  130. 130. Dupuytren Contracture of Palmar Fascia • Dupuytren contracture is a disease of the palmar fascia resulting in progressive shortening, thickening, and fibrosis of the palmar fascia and aponeurosis. The fibrous degeneration of the longitudinal bands of the palmar aponeurosis on the medial side of the hand pulls the 4th and 5th fingers into partial flexion at the metacarpophalangeal and proximal interphalangeal joints. The contracture is frequently bilateral and is seen in some men >50 years of age. Its cause is unknown, but evidence points to a hereditary predisposition. The disease first manifests as painless nodular thickenings of the palmar aponeurosis that adhere to the skin. Gradually, progressive contracture of the longitudinal bands produces raised ridges in the palmar skin that extend from the proximal part of the hand to the base of the 4th and 5th fingers. Treatment of Dupuytren contracture usually involves surgical excision of all fibrotic parts of the palmar fascia to free the fingers
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