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83 Cards in this Set

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In relation to the transepicondylar axis of the humerus, is the humerus retroverted or anteverted and to what degree?

What is the normal neck shaft angle?
Retroverted 30 degrees

Neck shaft angle: 130 degrees
Which is more commonly involved in fractures, the anatomic or surgical neck of the humerus?
The surgical
From anterior to posterior, what 3 cuff muscles attach at the greater tuberosity?
Supraspinatus, Infraspinatus, Teres Minor
What part of the humerus articulates with the olecranon of the ulna? What articulates with the radial head?
The trochlea of humerus articulates with the olecranon medially.
The capitellum articulates with the radial head
Normal articular alignment of the distal humerus has what type of tilt and to what degree?
A 7-degree valgus tilt (carrying angle)
What is the axis of rotation for the elbow?
Axis of rotation for the elbow is centered through the trochlea and capitellum and passes through a point anteroinferior on the medial epicondyle.
In what position will patients hold their arm if they have an elbow effusion because it is the most comfortable?
Capsule allows maximum distension at approximately 70 to 80 degrees of flexion
Where does the anterior capsule attach at the elbow?
Approximately 6 mm distal to the tip of the coronoid. The coronoid tip is an intraarticular structure that is visualized during elbow arthroscopy
Where does the MCL of the elbow arise from, where does it insert, how many bundles does it have, and in what motion does it provide stability?
Arises from the anteroinferior portion of the medial humeral epicondyle.
The anterior bundle (which is the most important) inserts 18mm distal to the coronoid tip.
Made up of 3 bundles: anterior, posterior, and transverse
Provides stability in valgus stress - valgus stability with the arm in pronation suggests that the anterior bundle is intact
What parts make up the radial collateral (lateral collateral) ligament of the elbow? Where does this ligament originate?
Annular, Radial, and Ulnar parts. Originates on the lateral humeral epicondyle near the axis of elbow rotation
The lateral ulnar collateral ligament (LUCL) is an essential elbow stabilizer and runs between where?
Runs from the lateral epicondyle to the ulna supinator crest
A deficiency of the LUCL of the elbow manifests as what?
Posterolateral rotatory instability of the elbow
The musculocutaneous nerves comes from the ______________________ cord of the brachial plexus, pierces the __________ muscle ____________centimeters distal to the ___________. It innervates the ____________, ___________, and ___________ then gives off a branch to the elbow joint before terminating as the ________________ which is located deep to the cephalic vein
The musculocutaneous nerves comes from the lateral cord of the brachial plexus, pierces the coracobrachialis muscle 5-8 centimeters distal to the coracoid. It innervates the coracobrachialis, brachialis, and the biceps then gives off a branch to the elbow
The musculocutaneous nerves comes from the lateral cord of the brachial plexus, pierces the coracobrachialis muscle 5-8 centimeters distal to the coracoid. It innervates the coracobrachialis, brachialis, and the biceps then gives off a branch to the elbow joint before terminating as the lateral antebrachial cutaneous nerve of the forearm which is located deep to the cephalic vein
The radial nerve comes from the __________ cord of the brachial plexus, spirals around the humerus (medial to lateral) in the ________ at a distance of approximately ________ cm from the ________. It emerges on the lateral side of the arm after piercing the _____________ approximately __________ cm above the trochlea between the _________and __________ muscles anterior to the _____________ (where it supplies the ____________ muscle)
The radial nerve comes from the posterior cord of the brachial plexus,spirals around the humerus (medial to lateral) in the SPIRAL GROOVE  at a distance of approximately 13 cm from the TROCHLEA. It emerges on the lateral side of the arm after piercing the
The radial nerve comes from the posterior cord of the brachial plexus,spirals around the humerus (medial to lateral) in the SPIRAL GROOVE at a distance of approximately 10-14 cm from the ACROMION. It emerges on the lateral side of the arm after piercing the LATERAL INTERMUSCULAR SEPTUM approximately 7.5 cm above the trochlea between the BRACHIALIS and BRACHIORADIALIS muscles anterior to the LATERAL EPICONDYLE (where it supplies the ANCONEUS muscle)
What vessel does the median nerve run with in the arm?
The brachial artery. The median nerve crosses the brachial artery lateral to medial during its course
The brachial artery. The median nerve crosses the brachial artery lateral to medial during its course
The ulnar nerve comes from what cord of the brachial plexus? Where does it run in the arm?
The medial cord. Passes medial to the brachial artery in the arm and then runs behind the medial epicondyle of the humerus, where it is superficial
The medial cord. Passes medial to the brachial artery in the arm and then runs behind the medial epicondyle of the humerus, where it is superficial
What structures form the cubital fossa? (3)
Distal humerus proximally, the brachioradialis laterally, and the pronator teres medially
The brachial artery originates at the lower border of the tendon of the _________ and continues to the elbow, where it bifurcates into the _______ and ________ arteries. It lies medial in the arm, curving laterally to enter the ________________
The brachial artery originates at the lower border of the tendon of the TERES MAJOR and continues to the elbow, where it bifurcates into the RADIAL and ULNAR arteries. It lies medial in the arm, curving laterally to enter the CUBITAL FOSSA
The brachial artery originates at the lower border of the tendon of the TERES MAJOR and continues to the elbow, where it bifurcates into the RADIAL and ULNAR arteries. It lies medial in the arm, curving laterally to enter the CUBITAL FOSSA
What are the principal branches of the brachial artery?
▪   	Deep brachial (also known as the profunda, this artery accompanies the radial nerve posteriorly in the triangular interval)
  	▪   	Superior and inferior ulnar collateral arteries
  	▪   	The nutrient and muscular branches
  	▪   	...
▪ Deep brachial (also known as the profunda, this artery accompanies the radial nerve posteriorly in the triangular interval)
▪ Superior and inferior ulnar collateral arteries
▪ The nutrient and muscular branches
▪ The supratrochlear artery (the least flexible branch)
What is the interval for the proximal approach to the anterior humerus and what structures are at risk?
Deltoid (axillary nerve) and pectoralis major (medial and lateral pectoral nerves).
Risk: the anterior circumflex humeral vessels may need to be ligated
What is the interval for a distal anterior approach to the humerus?
Distal approach: between the biceps (musculocutaneous) and brachialis (musculocutaneous/radial) laterally, or the brachialis can be split because of its dual innervation.

The radial and axillary nerves could be at risk mostly due to traction
Distal approach: between the biceps (musculocutaneous) and brachialis (musculocutaneous/radial) laterally, or the brachialis can be split because of its dual innervation.

The radial and axillary nerves could be at risk mostly due to traction
What is the interval for the posterior approach to the humerus? Describe the superficial and deep approaches.
None, it is triceps splitting (radial nerve).

Superficial approach: Dissect between the lateral and long heads of the triceps.

Deep approach: Split the medial head of the triceps.
What structure would be at risk with proximal extension of the posterior approach to the humerus?

What structure is at risk if a subperiosteal dissection is not performed meticulously?
The Radial nerve: limits proximal extension of approach
Identify and protect the radial nerve as it passes from medial to lateral in the proximal part of the exposure.

Ulnar nerve: jeopardized unless subperiosteal dissection of the humerus is performed meticulously
In the posterior approach to the elbow, how is predrilling of the olecranon osteotomy best performed?
With a chevron cut 2cm distal to the tip
With a chevron cut 2cm distal to the tip
What is the interval for the proximal medial approach to the elbow? What is at risk?
between the brachialis (musculocutaneous nerve) and the triceps (radial nerve) proximally. Incise the anterior third of the flexor pronator mass to reach the anterior elbow capsule

Risks: The ulnar and medial antebrachial cutaneous nerves are in the fi
between the brachialis (musculocutaneous nerve) and the triceps (radial nerve) proximally. Incise the anterior third of the flexor pronator mass to reach the anterior elbow capsule

Risks: The ulnar and medial antebrachial cutaneous nerves are in the field and must be protected
What is the interval for the distal medial approach to the elbow?
Between the brachialis (musculocutaneous) and pronator teres (median nerve) distally.

Risks: The ulnar and medial antebrachial cutaneous nerves are in the field and must be protected
Between the brachialis (musculocutaneous) and pronator teres (median nerve) distally.

Risks: The ulnar and medial antebrachial cutaneous nerves are in the field and must be protected
What is the interval for the lateral or posterolateral (Kocher's) approach to the elbow? How would you protect the PIN from injury?
Interval: between the anconeus (radial nerve) and the origin of the main extensor (extensor carpi ulnaris, posterior interosseous nerve [PIN]). 

Dissection: Pronate the arm to move the PIN anteriorly and radially, and approach the radial head through t
Interval: between the anconeus (radial nerve) and the origin of the main extensor (extensor carpi ulnaris, posterior interosseous nerve [PIN]).

Dissection: Pronate the arm to move the PIN anteriorly and radially, and approach the radial head through the proximal supinator fibers
What is the interval to proximally extend the lateral approach to the elbow?
Why should you place a retractor under the brachialis anteriorly?
Interval: along lateral intercondylar ridge, between triceps and extensor carpi radialis longus (ECRL) (brachioradialis nerve)
Dissection: Subperiosteally expose the anterior humerus and lateral column.
Risks: retractor placed under brachialis anteriorly to protect radial nerve, distally limited by PIN
What are the 3 portals for elbow arthroscopy and what structures are at risk when placing them?
1. Anterolateral portal (risk for injury to the radial nerve)
2. Anteromedial portal (risk for injury to the medial antebrachial cutaneous and median nerves)
3. Posterolateral portals
What is the origin, insertion, action, and innervation of the following muscle?
Coracobrachialis
Origin: Coracoid process
Insertion: Medial mid-humerus
Action: Flexion, adduction of the arm
Innervation: Musculocutaneous (C5-C7)
Origin: Coracoid process
Insertion: Medial mid-humerus
Action: Flexion, adduction of the arm
Innervation: Musculocutaneous (C5-C7)
What is the origin, insertion, action, and innervation of the following muscle?
Brachialis
Origin: Distal half of anterior surface of humerus
Insertion: Coronoid process and tuberosity of ulna
Action: Flexes forearm
Innervation: Musculocutaneous (C5-C6), Radial <-- ??
Origin: Distal half of anterior surface of humerus
Insertion: Coronoid process and tuberosity of ulna
Action: Flexes forearm
Innervation: Musculocutaneous (C5-C6), Radial Nerve (C5-C7)
What is the origin, insertion, action, and innervation of the following muscle?
Biceps brachii
Origin: Coracoid (short); Supraglenoid tubercle (long)
Insertion: Radial tuberosity
Action: Supination, flexion of forearm
Innervation: Musculocutaneous (C5-C6)
Origin: Coracoid (short); Supraglenoid tubercle (long)
Insertion: Radial tuberosity
Action: Supination, flexion of forearm
Innervation: Musculocutaneous (C5-C6)
What is the origin, insertion, action, and innervation of the following muscle?
Triceps brachii
Origin: Long head: infraglenoid tubercle of scapula; Lateral head: posterior surface of humerus, superior to radial groove; Medial head: posterior surface of humerus, inferior to radial groove

Insertion: Olecranon
Action: Elbow extension
Inne...
Origin: Long head: infraglenoid tubercle of scapula; Lateral head: posterior surface of humerus, superior to radial groove; Medial head: posterior surface of humerus, inferior to radial groove

Insertion: Olecranon
Action: Elbow extension
Innervation: Radial (C6-C8)
What is the origin, insertion, action, and innervation of the following muscle?
Brachioradialis
Origin: Proximal 2/3 of lateral supracondyle ridge of humerus
Insertion: Lateral surface of distal end of radius
Action: Flexes forearm
Innervation: Radial Nerve (C5-C7)
Origin: Proximal 2/3 of lateral supracondyle ridge of humerus
Insertion: Lateral surface of distal end of radius
Action: Flexes forearm
Innervation: Radial Nerve (C5-C7)
What are the sites of compression of the median nerve?
Supracondylar process of humerus & ligament of Struthers
Lacertus fibrosis (bicipital aponeurosis)
Pronator teres
Arch of flexor digitorum superficialis
What are the possible compression sites of the AIN
Deep head of pronator teres
Flexor digitorum superficialis
Aberrant vessels
Accessory muscles (i.e., Gantzer's muscles, which is an accessory head of the FPL)
What are the possible sites of compression of the ulnar nerve?
1. Arcade of Struthers
2. Medial intermuscular septum
3. Medial epicondyle
4. Cubital tunnel
5. Proximal edge of FCU (Osborne fascia)
6. Deep flexor pronator aponeurosis
1. Arcade of Struthers
2. Medial intermuscular septum
3. Medial epicondyle
4. Cubital tunnel
5. Proximal edge of FCU (Osborne fascia)
6. Deep flexor pronator aponeurosis
What is the arcade of struthers?
A thin aponeurotic band extending from medial head of triceps to the medial intermuscular septum; it lies approximately 8 cm proximal to the medial epicondyle
What is the ligament of struthers?
Struthers' ligament is a ligament that extends between the shaft of the humerus and the medial epicondyle of the humerus. It is not a constant ligament and can be acquired or congenital. Its clinical significance arises from the fact that the median nerve, passes in the space between the ligament and the humerus and can be compressed
What are the possible compression sites of the PIN?
1. Fibrous bands
2. Recurrent leash of Henry
3. Extensor carpi radialis brevis
4. Arcade of Frohse (proximal edge of superficial head of supinator)
5. Supinator distal margin
A fracture at the surgical neck of the humerus could injure what neurovascular structures?
The axillary nerve and posterior humeral circumflex artery as they pass through the quadrangular space
What neurovascular structures could a fracture of the humeral shaft damage?
Radial nerve and deep brachial artery
A supracondylar fracture is common in children and occurs when the child falls on the outstretched hand with the elbow in what position? What neurovascular structure is at risk?
Elbow in extension. The median nerve is at risk
Where does the following cutaneous nerve arise from and what does it innervate?
Supraclavicular nerve
Arises from the cervical plexus (C3,C4) and innervates teh skin over the upper pectoral, deltoid, and outer trapezius area
Arises from the cervical plexus (C3,C4) and innervates teh skin over the upper pectoral, deltoid, and outer trapezius area
Where does the following cutaneous nerve arise from and what does it innervate?
Medial brachial cutaneous nerve
Arises from the medial cord and innervates the medial side of the arm
Arises from the medial cord and innervates the medial side of the arm
Where does the following cutaneous nerve arise from and what does it innervate?
Medial antebrachial cutaneous nerve
From the medial cord and innervates the medial side of the forearm
From the medial cord and innervates the medial side of the forearm
Where does the following cutaneous nerve arise from and what does it innervate?
Lateral brachial cutaneous
From the axillary nerve and innervates the lateral side of the arm
From the axillary nerve and innervates the lateral side of the arm
Where does the following cutaneous nerve arise from and what does it innervate?
Lateral antebrachial cutaneous
Arises from the musculocutaneous nerve and innervates the lateral side of the forearm
Arises from the musculocutaneous nerve and innervates the lateral side of the forearm
Where does the following cutaneous nerve arise from and what does it innervate?
Posterior brachial and antebrachial cutaneous nerves
Arise from the radial nerve and innervate the posterior sides of the arm and forearm
Arise from the radial nerve and innervate the posterior sides of the arm and forearm
Where does the following cutaneous nerve arise from and what does it innervate?
Intercostobrachial nerve
The lateral cutaneous branch of the second intercostal nerve and emerges from the second intercostal space by piercing the intercostal and serratus anterior muscles. May communicate with the medial brachial cutaneous nerve
The lateral cutaneous branch of the second intercostal nerve and emerges from the second intercostal space by piercing the intercostal and serratus anterior muscles. May communicate with the medial brachial cutaneous nerve
Describe the path of the radial nerve
From the posterior cord of the brachial plexus, passes anterior to the insertion of the latissimus dorsi then dives into the triceps on the posterior surface of the humerus crossing into the radial groove approximately 10-14 cm distal to the acromion. The nerve crosses the midline about 15 cm from the distal articular surface of the elbow and pierces the lateral intermuscular septum ~ 12 cm from the lateral epicondyle. 1-3 cm distal to the lateral epicondyle, deep to the brachioradialis, the radial nerve splits into the PIN and SBRN.
Describe the path of the superficial branch of the radial nerve

How far from the radial styloid does the SBRN become subQ?

Where can this be compressed and what are the typical symptoms?
The SBRN continues along the lateral border of the brachioradialis (deep to it) and becomes subcutaneous at its middle 1/3 innervating the skin on the radial aspect of the forearm & the dorsal aspect of the radial 3 and 1/2 digits.

Becomes subQ ~9 cm proximal to the radial styloid

Compression can occur between brachioradialis and ECRL where it emerges between. Typical symptoms: numbness and dysaesthesia over the dorsal and lateral aspect of the hand (Tinnel's for dx) -- This is called Wartenberg's syndrome
Describe the path of the PIN
After branching from the radial nerve 1-3 cm distal to the lateral epicondyle deep to the brachioradialis, the PIN continues down the forearm, diving into the supinator and providing branches to the extensors of the wrist and hand in the following order:
1) Supinator
2) Brachioradialis
3) ECRL
4) ECRB
5) Supinator
6) EDC
7) ECU
8) EDM
9) APL
10) EPB
11) EPL
12) EIP
What is the terminal branch of the posterior interosseous nerve?
This is a sensory branch to the dorsal wrist capsule and lies in the radial aspect of the floor of the fourth dorsal compartment

Neurectomy procedures have been performed 3-4 cm proximal to the DRUJ to tx chronic wrist pain
Where is the first possible site of PIN entrapment?
Distal to its origin, the PIN passes deep to fibrous bands that are confluent with the brachialis, brachioradialis, ECRB, and the superficial head of the supinator. These form the roof of the radial tunnel and may compress the PIN against the deep head of the supinator which forms the floor of the radial tunnel along with the capsule of the radiocapitellar joint
What is the 2nd structure with the radial tunnel that can compress the radial nerve?
The leash of Henry which is made up of recurrent vessels of the radial artery at the level of the radial neck
What is the 3rd structure along the path of the PIN that may lead to compression?
At the point in which the PIN encounters the ECRB, it can be compressed
Where is the 4th and final location the PIN can be compressed?
The arcade of Frohse, found beneath the sharp proximal edge of the supinator
How would you reproduce pain caused by radial tunnel syndrome?
What is the main symptom of compression of the PIN?
Provoked by resisted supination and repetitive forearm pronation or wrist flexion

Because the PIN is mainly a motor nerve, weakness is the main symptom of compression
Why is full strength of extension at the wrist maintained with radial tunnel syndrome?
The mobile wad is spared because it is innervated proximal to the radial tunnel
What is the order of innervation of the radial nerve muscles?
Triceps, brachialis, brachioradialis, ECRL, ECRB, anconeus, (PIN): Supinator, EDC, ECU, EDQ, APL, EPB , EPL, EI
List the ossification center, ossification age, and fusion age for the ossification centers of the Humerus
CENTER OSSIFIES FUSES
Body (primary) 8 wk (fetal) Blends @ 6 yr unites _ @ 20 yr
Head 1 yr
Greater tuberosity 3 yr
Lesser tuberosity 5 yr
Capitulum 2 yr Blends unites w/ body at 16-18
Med epicondyles 5 yr
Trochlea 9 yr
Lat epicondyles 13 yr
Describe the course of the median nerve
Formed by contributions from the medial and lateral cords of the brachial plexus with contributions from the full plexus (C5-T1).  The median nerve does not provide motor or sensory innervation until reaching the elbow.

The nerve courses down t...
Formed by contributions from the medial and lateral cords of the brachial plexus with contributions from the full plexus (C5-T1). The median nerve does not provide motor or sensory innervation until reaching the elbow.

The nerve courses down the arm within the lateral intermuscular septum with the brachial artery (lateral to the artery), deep to the short head of the biceps. At the midbrachium, it crosses to the medial side of the brachial artery and descends to the antecubital fossa where it lies deep to the bicipital aponeurosis and medial to the antecubital vein

Distal to the elbow, it is found between the FDS and FDP. It emerges from this relationship prior to entering the carpal tunnel and is found medial to the FCR and lateral to the palmaris longus.
Describe the course of the musculocutaneous nerve
Dives into coracobrachialis at ~5-8 cm distal to the coracoid and travels between the biceps and brachialis innervating the coracobrachialis, long and short heads of the biceps, and half of the brachialis (other half by radial nerve). It terminate...
Dives into coracobrachialis at ~5-8 cm distal to the coracoid and travels between the biceps and brachialis innervating the coracobrachialis, long and short heads of the biceps, and half of the brachialis (other half by radial nerve). It terminates as the lateral antebrachial cutaneous nerve providing sensation to the lateral volar surface of teh forearm
List the order of innervation for the muscles of the median nerve
1. Pronator teres (proximal to the elbow)
2. FCR
3. FDS
4. Palmaris Longus
5.APB
6. 2 lateral lumbricals
7. FPB
Where does the palmar cutaneous branch from the median nerve branch?
This branch provides sensation to the thenar skin of the palm and most commonly branches 4-5 cm proximal to the wrist on the ulnar side of the FCR. The palmar cutaneous nerve then branches into a radial and ulnar branch. The ulnar branch often penetrates the transverse carpal ligament and is at risk with a radially-placed incision during a carpal tunnel release
What are the 2 proximal entrapment syndromes of the median nerve?
Pronator syndrome and anterior interosseous syndrome
What are the 4 structures that can cause compression leading to pronator syndrome?
The ligament of struthers - a ligament about 5cm proximal to the medial epicondyle that extends between the shaft of the humerus and the medial epicondyle of the humerus

Lacertus fibrosis

Muscle belly of the pronator teres

Proximal edge of the FDS
What are the symptoms of pronator syndrome?
Pain in the proximal volar forearm with associated weakness and numbness of the radial digits
What is the provocate movememnt for dx of median nerve compression @ the ligament of struthers?
Symptoms reproduced by resisted elbow flexion
What is the provocate movememnt for dx of median nerve compression @ the lacertus fibrosis?
Resisted elbow flexion with a pronated wrist
or
Resisted supination
What is the provocate movememnt for dx of median nerve compression @ the proximal edge of th fdse
Resisted pronation with forearm stabilized on a table
What symptomatology is different with AIN vs median nerve compression?
AIN compression will lack sensory symptoms in the fingers. There may be weakness at the FPL and FDP but with AIN syndrome the thenar muscles should be spared
Describe the course of the ulnar nerve
Terminal branch from the medial cord with contributions from C8-T1. The ulnar nerve courses medial to the brachial artery anterior to the long head of the triceps. At the level of the attachment of the coracobrachialis to teh humerus (~10 cm proximal to medial epicondyle) it pierces the medial intermuscular septum and enters the posterior compartment and passes under the ARCADE of Struthers approximately 8cm proximal to the medial epicondyle. As the nerve passes posterior to the medial epicondyle through the cubital tunnel, it is covered by Osborne's ligament lateral and the head of the FCU posteromedially. Upon exiting through the cubital tunnel, it courses between the 2 heads of the FCU and enters the anterior compartment of the forearm and runs anterior to the FDP. In the middle of the forearm, approximately 12 cm distal to the medial epicondyle, the ulnar nerve becomes superficial and travels with the ulnar artery. ~ 5cm proximal to the pisiform a dorsal sensory branch is released and the ulnar nerve continues and turns medially at the pisiform to run through Guyon's canal where the nerve splits into motor and sensory branches...(the rest is for hand)
Which is more commonly present, the arcade of struthers or the ligament of struthers?
The arcade of Struthers is present in 70% of the population while the ligament of struthers is present in only 1% of the population

Arcade: ulnar nerve compression
Ligament: median nerve compression
What 2 structures form the cubital tunnel?
Osborne's ligament laterally
Head of the FCU posteromedially
What does the first branch of the ulnar nerve provide?
Sensory innervation to the elbow capsule
What are the 3 locations in the arm/elbow that the ulnar nerve can be compressed?
Medial intermuscular septum, arcade of struthers, cubital tunnel
What is the most common site for ulnar nerve compression?
The cubital tunnel
What is Froment's sign?
Used to detect compression of ulnar nerve (e.g. cubital tunnel). Ask patient to grasp piece of paper butween thumb and radial border of index metacarpal. If the patient has weakness in the adductor, they will attempt to recruit the FPL (innervated by AIN) to hold onto paper
What are the attachments of the medial intermuscular septum?
Medial lip of the intertubercular sulcus to the medial epicondyle
What are the attachments of the lateral intermuscular septum?
Lateral lip of the intertubercular sulcus to the lateral epicondyle