CLINICAL NOTES ON UPPER LIMB By: Dr. Mujahid Khan.

CLINICAL NOTES ON CLINICAL NOTES ON UPPER LIMBUPPER LIMB

By: Dr. Mujahid KhanBy: Dr. Mujahid Khan

Lymphatic Drainage of BreastLymphatic Drainage of Breast

Its importance is the relation to the spread Its importance is the relation to the spread of cancer from breastof cancer from breast

The lymph vessels from the medial The lymph vessels from the medial quadrants of breast pierce 2quadrants of breast pierce 2ndnd, 3, 3rdrd and 4 and 4thth intercostal spaces intercostal spaces

Enter the thorax to drain into the internal Enter the thorax to drain into the internal thoracic lymph nodes thoracic lymph nodes


The lymph vessels from the lateral quadrants of The lymph vessels from the lateral quadrants of the breasts drain into pectoral group of axillary the breasts drain into pectoral group of axillary nodesnodes

Cancer occurring in the lateral quadrant of Cancer occurring in the lateral quadrant of breast tends to spread to the axillary nodesbreast tends to spread to the axillary nodes

Lymph nodes of axilla can be removed surgically Lymph nodes of axilla can be removed surgically but thoracic metastases are difficult or but thoracic metastases are difficult or impossible to treatimpossible to treat


60% of breast cancers occur in the upper 60% of breast cancers occur in the upper lateral quadrantlateral quadrant

The lymphatic spread of the cancer to the The lymphatic spread of the cancer to the opposite breast, abdominal cavity or to the opposite breast, abdominal cavity or to the root of the neck is caused by obstruction root of the neck is caused by obstruction of the normal lymphatic pathways by of the normal lymphatic pathways by malignant cells or destruction of lymph malignant cells or destruction of lymph vessels by surgery or radiotherapyvessels by surgery or radiotherapy

Lymphatic Drainage of BreastLymphatic Drainage of Breast In localized breast cancers, simple mastectomy In localized breast cancers, simple mastectomy

or lumpectomy, followed by radiotherapy of or lumpectomy, followed by radiotherapy of axillary lymph nodesaxillary lymph nodes

The excised mass includes following:The excised mass includes following:

The large area of skin overlying the tumor The large area of skin overlying the tumor including the nippleincluding the nipple

All the breast tissueAll the breast tissue

The pectoralis major muscle and fasciaThe pectoralis major muscle and fascia


The excised mass includes following:The excised mass includes following:

Pectoralis minor and fasciaPectoralis minor and fascia

All the fat, fascia and lymph nodes in the axillaAll the fat, fascia and lymph nodes in the axilla

Fascia covering the upper part of the rectus sheathFascia covering the upper part of the rectus sheath

Serratus anterior, subscapularis and latissimus dorsi Serratus anterior, subscapularis and latissimus dorsi musclesmuscles

Axillary blood vessels, brachial plexus and nerves to Axillary blood vessels, brachial plexus and nerves to serratus anterior and latissimus dorsi are preservedserratus anterior and latissimus dorsi are preserved

Fractures of the ClavicleFractures of the Clavicle Clavicle is exposed to trauma because of its position Clavicle is exposed to trauma because of its position

It is the most commonly fractured bone in the bodyIt is the most commonly fractured bone in the body

Its fracture usually occur as a result of a fall on the Its fracture usually occur as a result of a fall on the shoulder or outstretched handshoulder or outstretched hand

The force is transmitted along the clavicle and breaks it The force is transmitted along the clavicle and breaks it at the weakest point, that is the junction of the middle at the weakest point, that is the junction of the middle and outer thirdand outer third

After the fracture, the lateral fragment is depressed by After the fracture, the lateral fragment is depressed by the weight of the arm and is pulled medially and forwardthe weight of the arm and is pulled medially and forward

Fractures of the ClavicleFractures of the Clavicle

The medial end is tilted upward by the The medial end is tilted upward by the sternocleidomastoid musclesternocleidomastoid muscle

The close relationship of the The close relationship of the supraclavicular nerves to the clavicle may supraclavicular nerves to the clavicle may result in their involvement is callus result in their involvement is callus formation after the fractureformation after the fracture

This may be the cause of persistent pain This may be the cause of persistent pain over the side of the neck over the side of the neck

Compression of Brachial PlexusCompression of Brachial Plexus

The interval between the clavicle and the The interval between the clavicle and the first rib in some patients may become first rib in some patients may become narrowed and thus is responsible for narrowed and thus is responsible for compression of nerves and blood vessels compression of nerves and blood vessels

Fractures of ScapulaFractures of Scapula

They are usually occur in a runover accident They are usually occur in a runover accident victims or occupants of automobiles involved in victims or occupants of automobiles involved in crashescrashes

Injuries are usually associated with fractured ribsInjuries are usually associated with fractured ribs

Most fractures of scapula require little treatment Most fractures of scapula require little treatment because the muscles on the anterior and because the muscles on the anterior and posterior surfaces adequately splint the fragmentposterior surfaces adequately splint the fragment

Humeral Head FractureHumeral Head Fracture

Humeral head fracture can occur during Humeral head fracture can occur during the process of anterior and posterior the process of anterior and posterior dislocations of the shoulder jointdislocations of the shoulder joint

The fibrocartilaginous glenoid labrum of The fibrocartilaginous glenoid labrum of the scapula produces the fracture the scapula produces the fracture

Labrum can become jammed in the defect Labrum can become jammed in the defect making the reduction of the shoulder joint making the reduction of the shoulder joint difficultdifficult

Greater Tuberosity FractureGreater Tuberosity Fracture

It can be fractured by direct trauma, displaced by It can be fractured by direct trauma, displaced by the glenoid labrum during dislocation of shoulder the glenoid labrum during dislocation of shoulder jointjoint

When associated with a shoulder dislocation, When associated with a shoulder dislocation, severe tearing of the rotator cuff with the fracture severe tearing of the rotator cuff with the fracture can result in the greater tuberosity remaining can result in the greater tuberosity remaining displaced posteriorly after the shoulder joint is displaced posteriorly after the shoulder joint is reducedreduced

Open reduction of the fracture is necessary to Open reduction of the fracture is necessary to

attach the rotator cuff back into placeattach the rotator cuff back into place

Lesser Tuberosity FractureLesser Tuberosity Fracture

Lesser tuberosity fracture accompanies Lesser tuberosity fracture accompanies posterior dislocation of the shoulder jointposterior dislocation of the shoulder joint

The bone fragment receives the insertion The bone fragment receives the insertion of the subscapularis tendon, a part of the of the subscapularis tendon, a part of the rotator cuffrotator cuff

Surgical Neck FractureSurgical Neck Fracture

Surgical neck of the humerus lies Surgical neck of the humerus lies immediately distal to the lesser tuberosityimmediately distal to the lesser tuberosity

It can be fractured by a direct blow on the It can be fractured by a direct blow on the lateral aspect of the shoulderlateral aspect of the shoulder

In indirect manner by falling on the In indirect manner by falling on the stretched handstretched hand

Fracture of Shaft of HumerusFracture of Shaft of Humerus

Fractures of humeral shaft is commonFractures of humeral shaft is common

The radial nerve can be damaged where it The radial nerve can be damaged where it lies in the spiral groove on the posterior lies in the spiral groove on the posterior surface of the humerus under cover of the surface of the humerus under cover of the triceps muscletriceps muscle

Fracture of the Distal End of Fracture of the Distal End of HumerusHumerus

Supracondylar fractures are common in childrenSupracondylar fractures are common in children

Occur when the child falls on the outstretched Occur when the child falls on the outstretched hand with the elbow partially flexedhand with the elbow partially flexed

Injuries to the median, radial and ulnar nerves Injuries to the median, radial and ulnar nerves are commonare common

Damage to or pressure on the brachial artery Damage to or pressure on the brachial artery can occur at the time of fracture or from swelling can occur at the time of fracture or from swelling of the surrounding tissuesof the surrounding tissues

Fracture of the Distal End of Fracture of the Distal End of HumerusHumerus

The circulation to the forearm may be The circulation to the forearm may be interferedinterfered

Leading to Volkmann’s ischemic Leading to Volkmann’s ischemic contracturecontracture

Ulnar nerve can undergo irritation on the Ulnar nerve can undergo irritation on the irregular bony surface after the bone irregular bony surface after the bone fragments are reunitedfragments are reunited

Rotator Cuff TendinitisRotator Cuff Tendinitis

Rotator cuff consists of the tendons of the Rotator cuff consists of the tendons of the subscapularis, supraspinatus, infraspinatus and subscapularis, supraspinatus, infraspinatus and teres minor musclesteres minor muscles

These muscles are fused to the underlying These muscles are fused to the underlying capsule of the shoulder jointcapsule of the shoulder joint

Plays an important role in stabilizing the Plays an important role in stabilizing the shoulder jointshoulder joint

Lesions of the cuff are a common cause of pain Lesions of the cuff are a common cause of pain in the shoulder regionin the shoulder region


Excessive overhead activity of the upper Excessive overhead activity of the upper limb may be the cause of tendinitislimb may be the cause of tendinitis

During abduction of the shoulder joint, the During abduction of the shoulder joint, the supraspinatus tendon is exposed to friction supraspinatus tendon is exposed to friction against the acromionagainst the acromion

Under normal conditions, the amount of Under normal conditions, the amount of friction is reduced to a minimum by the friction is reduced to a minimum by the large subacromial bursalarge subacromial bursa


Degenerative changes in the bursa are followed Degenerative changes in the bursa are followed by degenerative changes in the underlying by degenerative changes in the underlying supraspinatus tendonsupraspinatus tendon

These may extend into the other tendons of the These may extend into the other tendons of the rotator cuffrotator cuff

Clinically the condition is known as subacromial Clinically the condition is known as subacromial bursitis, supraspinatus tendinitis or pericapsulitisbursitis, supraspinatus tendinitis or pericapsulitis

It is characterized by the presence of a spasm of It is characterized by the presence of a spasm of pain in the middle range of abductionpain in the middle range of abduction


In advanced cases, the necrotic supraspinatus tendon In advanced cases, the necrotic supraspinatus tendon can become calcified or rupturecan become calcified or rupture

Causes serious interference in the normal abduction of Causes serious interference in the normal abduction of the shoulder jointthe shoulder joint

Patient will be unable to initiate the abduction of the armPatient will be unable to initiate the abduction of the arm

If the arm is passively assisted for the first 15If the arm is passively assisted for the first 15° of ° of abduction abduction

Deltoid can then take over and complete the movement Deltoid can then take over and complete the movement to a right angleto a right angle

Sternoclavicular Joint InjuriesSternoclavicular Joint Injuries

The strong costoclavicular ligament firmly The strong costoclavicular ligament firmly holds the medial end of the clavicle to the holds the medial end of the clavicle to the first costal cartilagefirst costal cartilage

Violent forces directed along the long axis Violent forces directed along the long axis of the clavicle usually result in fracture of of the clavicle usually result in fracture of the bonethe bone

Dislocation of sternoclavicular joint takes Dislocation of sternoclavicular joint takes place occasionallyplace occasionally

Sternoclavicular Joint Injuries Sternoclavicular Joint Injuries Anterior DislocationAnterior Dislocation

It results in the medial end of the clavicle It results in the medial end of the clavicle projecting forward beneath the skinprojecting forward beneath the skin

It may also pulled upward by the It may also pulled upward by the sternocleidomastoid musclesternocleidomastoid muscle

Sternoclavicular Joint Injuries Sternoclavicular Joint Injuries Posterior DislocationPosterior Dislocation

It usually follows direct trauma applied to the It usually follows direct trauma applied to the front of the joint that drives the clavicle backwardfront of the joint that drives the clavicle backward

Displaced clavicle may press on the trachea, Displaced clavicle may press on the trachea, esophagus and major vesselsesophagus and major vessels

If the costoclavicular ligament ruptures If the costoclavicular ligament ruptures completely, it is difficult to maintain the normal completely, it is difficult to maintain the normal position of the clavicle once reduction has been position of the clavicle once reduction has been accomplishedaccomplished

Acromioclavicular Joint InjuriesAcromioclavicular Joint Injuries

A severe blow on the point of the shoulder, A severe blow on the point of the shoulder, during blocking or tackling in football can result during blocking or tackling in football can result in the acromion being thrust beneath the lateral in the acromion being thrust beneath the lateral end of the clavicle, tearing the coracoclavicular end of the clavicle, tearing the coracoclavicular ligamentligament

The condition is known as shoulder separationThe condition is known as shoulder separation

The displaced outer end of clavicle is easily The displaced outer end of clavicle is easily palpablepalpable

The dislocation is easily reduced but withdrawal The dislocation is easily reduced but withdrawal of support results in redislocationof support results in redislocation

Stability of Shoulder JointStability of Shoulder Joint

The shallowness of the glenoid fossa and lack of The shallowness of the glenoid fossa and lack of support provided by weak ligaments make this support provided by weak ligaments make this joint unstablejoint unstable

Its strength almost entirely depends on the tone Its strength almost entirely depends on the tone of the short muscles that bind the upper end of of the short muscles that bind the upper end of humerus to scapulahumerus to scapula

The tendons of these short muscles form the The tendons of these short muscles form the rotator cuffrotator cuff

The least supported part of the joint lies in the The least supported part of the joint lies in the inferior locationinferior location

Anterior Dislocation of Anterior Dislocation of Shoulder JointShoulder Joint

Sudden violence applied to the humerus with Sudden violence applied to the humerus with joint fully abducted tilts the humeral head joint fully abducted tilts the humeral head downward onto the inferior week part of the downward onto the inferior week part of the capsulecapsule

The humeral head comes to lie inferior to the The humeral head comes to lie inferior to the glenoid fossaglenoid fossa

The strong flexors and adductors of the shoulder The strong flexors and adductors of the shoulder pull the humeral head forward and upward pull the humeral head forward and upward

Posterior Dislocation of Posterior Dislocation of Shoulder JointShoulder Joint

Posterior dislocations are rarePosterior dislocations are rare

Usually caused by direct violence to the front of Usually caused by direct violence to the front of the jointthe joint

The rounded appearance of the shoulder is lostThe rounded appearance of the shoulder is lost

A subglenoid displacement of the humeral head A subglenoid displacement of the humeral head can cause axillary nerve damagecan cause axillary nerve damage

Downward displacement of humerus can also Downward displacement of humerus can also stretch and damage the radial nervestretch and damage the radial nerve

Dermatomes and Dermatomes and Cutaneous NervesCutaneous Nerves

Dermatomes for the upper cervical Dermatomes for the upper cervical segments C3 to 6 are located along the segments C3 to 6 are located along the lateral margin of the upper limblateral margin of the upper limb

C7 dermatome is situated on the middle C7 dermatome is situated on the middle fingerfinger

C8, T1 and T2 dermatomes are along the C8, T1 and T2 dermatomes are along the medial margin of the limbmedial margin of the limb

Dermatomes and Dermatomes and Cutaneous NervesCutaneous Nerves

Skin over the shoulder point and halfway down Skin over the shoulder point and halfway down the lateral surface of deltoid is supplied by the lateral surface of deltoid is supplied by supraclavicular nerves C3 & 4supraclavicular nerves C3 & 4

Pain may be referred to this region as a result of Pain may be referred to this region as a result of inflammatory lesions involving diaphragmatic inflammatory lesions involving diaphragmatic pleura or peritoneumpleura or peritoneum

Pleurisy, peritonitis, subphrenic abscess or gall Pleurisy, peritonitis, subphrenic abscess or gall bladder disease may be responsible for shoulder bladder disease may be responsible for shoulder painpain

Venipuncture and Blood Venipuncture and Blood TransfusionTransfusion

The superficial veins are used for venipuncture, The superficial veins are used for venipuncture, transfusion and cardiac catheterizationtransfusion and cardiac catheterization

When the patient is in shock, the superficial When the patient is in shock, the superficial veins may not be visibleveins may not be visible

The cephalic vein lies in the superficial fascia The cephalic vein lies in the superficial fascia posterior to the styloid process of radiusposterior to the styloid process of radius

Venipuncture and Blood Venipuncture and Blood TransfusionTransfusion

The median cubital vein in the cubital fossa is The median cubital vein in the cubital fossa is separated from the underlying brachial artery by separated from the underlying brachial artery by the bicipital aponeurosisthe bicipital aponeurosis

This protects the artery from a mistaken injection This protects the artery from a mistaken injection of irritating drugs into itof irritating drugs into it

In extreme hypovolemic shock, excessive In extreme hypovolemic shock, excessive venous tone may inhibit venous blood flow and venous tone may inhibit venous blood flow and thus delay the introduction of intravenous blood thus delay the introduction of intravenous blood into the vascular systeminto the vascular system

Lymphangitis and LymphadenitisLymphangitis and Lymphadenitis

Once the infection reaches the lymph nodes, Once the infection reaches the lymph nodes, they become enlarged and tender, known as they become enlarged and tender, known as lymphadenitislymphadenitis

Most of the lymph vessels from the fingers and Most of the lymph vessels from the fingers and palm pass to the dorsum of the hand before palm pass to the dorsum of the hand before passing up into the forearmpassing up into the forearm

The frequency of inflammatory edema, or The frequency of inflammatory edema, or abscess formation may occur on the dorsum of abscess formation may occur on the dorsum of the hand after infection of the fingers and palmthe hand after infection of the fingers and palm

Biceps Brachii and Osteoarthritis of Biceps Brachii and Osteoarthritis of the Shoulder Jointthe Shoulder Joint

The tendon of the long head of biceps is The tendon of the long head of biceps is attached to the supraglenoid tubercle attached to the supraglenoid tubercle within the shoulder jointwithin the shoulder joint

Advanced osteoarthritic changes in the Advanced osteoarthritic changes in the joint can lead to erosion and fraying of the joint can lead to erosion and fraying of the tendon by osteophytic outgrowthstendon by osteophytic outgrowths

Rupture of the tendon may also occurRupture of the tendon may also occur

Fractures of Radius and UlnaFractures of Radius and Ulna

Fracture of the head of radius can occur from fall Fracture of the head of radius can occur from fall on the outstretched handon the outstretched hand

Fractures of neck of the radius occur in young Fractures of neck of the radius occur in young children from falls on the outstretched handchildren from falls on the outstretched hand

Fractures of the shafts of the radius and ulna Fractures of the shafts of the radius and ulna may or may not occur togethermay or may not occur together

Displacement of the fragment is usually Displacement of the fragment is usually consideredconsidered


Fracture of one forearm bone may be associated Fracture of one forearm bone may be associated with a dislocation of the other bonewith a dislocation of the other bone

In Monteggia’s fracture the shaft of the ulna is In Monteggia’s fracture the shaft of the ulna is fractured fractured

Anterior dislocation of the radial head with Anterior dislocation of the radial head with rupture of the anular ligamentrupture of the anular ligament

In Galezzi’s fracture the proximal third of the In Galezzi’s fracture the proximal third of the radius is fractured and distal end of ulna is radius is fractured and distal end of ulna is dislocated at the distal radioulnar jointdislocated at the distal radioulnar joint


Colles’ fracture is a fracture of the distal Colles’ fracture is a fracture of the distal end of radius resulting from a fall on the end of radius resulting from a fall on the outstretched handoutstretched hand

Commonly occurs in older than 50 yearsCommonly occurs in older than 50 years

Posterior displacement of the fragment Posterior displacement of the fragment referred as dinner-fork deformityreferred as dinner-fork deformity


Smith’s fracture of the distal end of the Smith’s fracture of the distal end of the radius occurs from a fall on the back of the radius occurs from a fall on the back of the handhand

It is reversed Colles’ fractureIt is reversed Colles’ fracture

The distal fragment is displaced anteriorlyThe distal fragment is displaced anteriorly

Injuries to the Bones of the HandInjuries to the Bones of the Hand

It is common in young adultsIt is common in young adults

Unless treated properly, the fragments will not Unless treated properly, the fragments will not unite unite

Permanent weakness and pain of wrist will resultPermanent weakness and pain of wrist will result

Dislocation of the lunate bone occasionally Dislocation of the lunate bone occasionally occurs in young adults falling on an outstretched occurs in young adults falling on an outstretched hand that causes hyperextension of the wrist hand that causes hyperextension of the wrist jointjoint

Involvement of median nerve is commonInvolvement of median nerve is common


Fractures of metacarpal bones may occur as a result of Fractures of metacarpal bones may occur as a result of direct violencedirect violence

Clenched fist striking a hard objectClenched fist striking a hard object

The boxer’s fracture commonly produces an oblique The boxer’s fracture commonly produces an oblique fracture of the neck of the fifth or fourth metacarpal fracture of the neck of the fifth or fourth metacarpal bonesbones

The distal fragment is commonly displaced proximallyThe distal fragment is commonly displaced proximally

Shortening the finger posteriorlyShortening the finger posteriorly


Bennett's fracture is a fracture of the base Bennett's fracture is a fracture of the base of the metacarpal of the thumbof the metacarpal of the thumb

Caused by a violence applied along the Caused by a violence applied along the long axis of the thumb or the thumb is long axis of the thumb or the thumb is forcefully abductedforcefully abducted

The fracture is oblique and causes The fracture is oblique and causes instability to the carpometacarpal joint of instability to the carpometacarpal joint of the thumbthe thumb

Compartment Syndrome of Compartment Syndrome of ForearmForearm

The forearm is enclosed in a sheath of deep fasciaThe forearm is enclosed in a sheath of deep fascia

This sheath with interosseous membrane and fibrous This sheath with interosseous membrane and fibrous muscular septa divides the forearm into several muscular septa divides the forearm into several compartmentscompartments

Any edema can cause secondary vascular compression Any edema can cause secondary vascular compression of blood vesselsof blood vessels

The deep fascia must be incised surgicallyThe deep fascia must be incised surgically

A delay of even 4 hours may cause an irreversible A delay of even 4 hours may cause an irreversible damage to the muscles damage to the muscles

Anatomic Snuff BoxAnatomic Snuff Box

The term commonly used for a triangular skin The term commonly used for a triangular skin depression on the lateral side of the wrist depression on the lateral side of the wrist

Bounded medially by the tendon of extensor Bounded medially by the tendon of extensor pollicis longus and laterally by abductor pollicis pollicis longus and laterally by abductor pollicis longus and extensor pollicis brevis longus and extensor pollicis brevis

Scaphoid bone can easily be palpated hereScaphoid bone can easily be palpated here

Pulsations of the radial artery can be felt herePulsations of the radial artery can be felt here

Tennis ElbowTennis Elbow

It is caused by a partial tearing or degeneration It is caused by a partial tearing or degeneration of the origin of the superficial extensor muscles of the origin of the superficial extensor muscles from lateral epicondyle of humerusfrom lateral epicondyle of humerus

It is characterized by pain and tenderness over It is characterized by pain and tenderness over the lateral epicondyle the lateral epicondyle

Pain radiating down the lateral side of forearmPain radiating down the lateral side of forearm

It is common in tennis playersIt is common in tennis players

Dupuytren’s Contracture Dupuytren’s Contracture

It is a localized thickening and contracture of palmar It is a localized thickening and contracture of palmar aponeurosisaponeurosis

It commonly starts near the root of the ring finger and It commonly starts near the root of the ring finger and draws that finger into the palmdraws that finger into the palm

Later the condition involves the little finger in the same Later the condition involves the little finger in the same mannermanner

In long standing cases, the pull on the fibrous sheaths of In long standing cases, the pull on the fibrous sheaths of these fingers results in flexion of the proximal these fingers results in flexion of the proximal interphalangeal joints interphalangeal joints

The distal interphalangeal joints are not involvedThe distal interphalangeal joints are not involved

Trigger FingerTrigger Finger

There is a palpable or even audible snapping There is a palpable or even audible snapping when a patient is asked to flex and extend the when a patient is asked to flex and extend the fingersfingers

Caused by the presence of a localized swelling Caused by the presence of a localized swelling of one of the long flexor tendons that catches on of one of the long flexor tendons that catches on a narrowing of the fibrous flexor sheath anterior a narrowing of the fibrous flexor sheath anterior to the metacarpophalangeal jointto the metacarpophalangeal joint

Can be treated surgically by incising the fibrous Can be treated surgically by incising the fibrous flexor sheathflexor sheath

Fascial Spaces of Palm and Fascial Spaces of Palm and InfectionsInfections

The fascial spaces of the palm are The fascial spaces of the palm are clinically important because they can clinically important because they can become infected become infected

Distended with pus as a result of the Distended with pus as a result of the spread of infection in acute suppurative spread of infection in acute suppurative tenosynovitistenosynovitis

They can be infected after a penetrating They can be infected after a penetrating wounds such as falling on a dirty nailwounds such as falling on a dirty nail

Pulp Space InfectionPulp Space Infection

The pulp space of the fingers is a closed fascial The pulp space of the fingers is a closed fascial compartment situated in front of the terminal compartment situated in front of the terminal phalanx of each fingerphalanx of each finger

Infection of such a space is common and seriousInfection of such a space is common and serious

Commonly occurring in the thumb and index Commonly occurring in the thumb and index fingerfinger

Bacteria are usually introduced into the space by Bacteria are usually introduced into the space by pinpricks or sewing needlespinpricks or sewing needles


Each space is subdivided into numerous Each space is subdivided into numerous smaller compartments by fibrous septasmaller compartments by fibrous septa

Accumulation of inflammatory exudate Accumulation of inflammatory exudate within the compartment causes quick rise within the compartment causes quick rise in pressurein pressure

If the infection is left without If the infection is left without decompression, infection of terminal decompression, infection of terminal phalanx can occurphalanx can occur


In children, pressure on the blood vessels In children, pressure on the blood vessels could result in necrosis of diaphysiscould result in necrosis of diaphysis

The close relationship of the proximal end The close relationship of the proximal end of the pulp space to the digital synovial of the pulp space to the digital synovial sheath accounts for the involvement of the sheath accounts for the involvement of the sheath in the infectious process when the sheath in the infectious process when the pulp-space infection has been neglectedpulp-space infection has been neglected

Elbow Joint InjuriesElbow Joint Injuries

The elbow joint is stable because of the The elbow joint is stable because of the wrench-shaped articular surface of the wrench-shaped articular surface of the olecranon and pulley-shaped trochlea of olecranon and pulley-shaped trochlea of the humerusthe humerus

It also has strong medial and lateral It also has strong medial and lateral ligamentsligaments

Dislocations of Elbow JointDislocations of Elbow Joint

Elbow dislocations are commonElbow dislocations are common

Most are posterior and usually follows Most are posterior and usually follows falling on the outstretched handfalling on the outstretched hand

Common in children because the part that Common in children because the part that stabilizes the joint is incompletely stabilizes the joint is incompletely developeddeveloped

Damage to the Ulnar nerveDamage to the Ulnar nerve

Close relationship of the ulnar nerve to the Close relationship of the ulnar nerve to the medial side of the joint makes it vulnerable in medial side of the joint makes it vulnerable in dislocation or in fracture dislocations in this dislocation or in fracture dislocations in this regionregion

The nerve damage can occur at the time of The nerve damage can occur at the time of injury or weeks, months or years laterinjury or weeks, months or years later

Continued friction between the medial Continued friction between the medial epicondyle and the stretched ulnar nerve epicondyle and the stretched ulnar nerve eventually results in ulnar palsyeventually results in ulnar palsy

Wrist Joint InjuriesWrist Joint Injuries

The joint is stabilized by the strong medial and The joint is stabilized by the strong medial and lateral ligamentslateral ligaments

A fall on the outstretched hand can strain the A fall on the outstretched hand can strain the anterior ligament of the wrist jointanterior ligament of the wrist joint

Synovial effusion, joint pain and limitation of Synovial effusion, joint pain and limitation of movement may occurmovement may occur

Sign and symptoms must not be confused with Sign and symptoms must not be confused with those produced by a fractured scaphoid or those produced by a fractured scaphoid or dislocation of the lunate bonedislocation of the lunate bone

CLINICAL NOTES ON UPPER LIMB By: Dr. Mujahid Khan.

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