CASE BASED LEARNING JOINTS OF UPPER LIMB

BYDR. ABDUL WAHEED ANSARI

CHAIRPERSON & PROFESSOR OF ANATOMY,RAKCOMS. RAKMHSU.

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Learning our comes are as follows:-

• Identify the elements forming shoulder joint, demonstrate movements at the shoulder joint, muscles involved in the movements and applied aspects of shoulder joint.

• Learn the gross anatomy of elbow joint and muscles involved in the movements at elbow joint.

• Gross features of wrist joint and muscles producing these movements.

• Features of small joints of the fingers and muscles responsible for the movements of fingers.

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A case of dislocation of shoulder joint• The goalkeeper in a soccer match

fell on his outstretched left arm.

• He felt an immediate pain in the

shoulder region and was unable to

move his arm.

• At the hospital the arm was

abducted and the deltoid muscle

looked flat or hollow.

• The injured arm looked "too long",

and there was intense pain on

attempting to move the arm.

• A plain radiograph of the region

showed that the humeral head was

lying below the glenoid labrum and

that there was no fracture of the

humerus.

• The diagnosis was an anterior

dislocation of the shoulder. 12/18/2014 3

Elements of shoulder joint

• The shoulder joint is glenohumeral joint.

• It is a synovial joint of ball and socket variety.

• The skeletal elements of the joint are the head of humerus and the glenoid cavity of the scapula.

• The ligaments of the shoulder joints are:-

capsular ligament,

coracohumeral ligament,

coracoacromial ligament,

transverse humeral ligament, and

glenohumeral ligament.

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Movements at the shoulder joint

• It is a freely mobile joint.

• The following movements occur at the joint:-

• Abduction

• Adduction

• Flexion

• Extension

• Lateral rotation

• Medial rotation and

• Circumduction

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Muscles involved in the movement of shoulder joint

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Applied anatomy of shoulder joint

• Dislocation of shoulder joint. Anterior dislocation is very common.

• Rotator cuff muscles injuries and inflammation –Frozen shoulder. The supraspinatus, infraspinatus, teres minor and subscapularis constitute the rotator cuff muscles.

• Osteoarthritis, septic arthritis.

• Winged scapula-paralysis of serratus anterior.

• Deltoid paralysis

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This 45 year old man presented following a fall from a

ladder. He has suffered an injury to his right arm.

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The anatomy of elbow joint• The elbow is a hinge joint

and consists of the humero-ulnar, humero-radial and proximal radio-ulnar articulations.

• The radial head articulates with the humeral capitellumwhilst the trochlear notch of the ulna articulates with the humeral trochlea.

• Posteriorly the ulna forms the olecranon, which contacts the olecranon fossa of the humerus at full elbow extension.

• The elbow joint allows 0° -140° of flexion.

• Movement at the proximal and distal radio-ulnar joints combine to produce 75° of pronation and 80° of supination.

• When fully extended the elbow joint forms a valgus angle, this is commonly referred to as the carrying angle and is generally greater in women.

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Bony landmarks of the elbow palpable on

examination are the:

• Medial and lateral humeral epicondyles.

• Olecranon process and proximal ulnar shaft.

• Head of radius.

• Imaging studies in AP and lateral views showing elbow joints elements.

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Ligaments of elbow joint

• Capsular ligament

• Radial collateral ligament

• Ulnar collateral ligament

• Annular ligament

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Movements at elbow joint• Elbow flexion results from

the actions of the biceps brachii, brachialis, brachioradialis and pronator teres muscles, which cross the joint anteriorly.

• The triceps tendon inserts into the olecranon process posteriorly and together with the anconeus muscle is responsible for elbow extension.

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Neurovascular bundles around the elbow joint

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• The ulnar nerve passes just behind the medial epicondyle.

• The radial nerve passes anterior to the lateral epicondyle.

• Median nerve and brachial artery pass in front of the elbow.

• Median nerve, ulnar nerve and brachial artery are at risk of injury in elbow dislocation & supracondylar fracture of humerus.

Posterior dislocation of elbow• This injury is seen in both children and adults and is usually caused

by a fall onto the outstretched hand.

• It is more common in children than dislocation of the shoulder.

• Examination may reveal obvious deformity of the elbow.

• The triangular relationship of the epicondyles and olecranon will be disrupted.

• It is important to check the distal neurovascular status of the limb due to possible damage to the brachial artery or median and ulnar nerves.

• The dislocation is most commonly in a posterior or posterolateral direction and will be confirmed on x-ray, along with the presence of any associated fractures.

• Associated epicondylar fractures and fractures of the lateral condyle are known to occur in children.

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Supracondylar fracture

• Typically follow a fall onto an outstretched hand.

• Children are more prone to supracondylar fracture than adults.

• 90% of these fractures are caused by hyperextension injury due to ligament laxity.

• The force is transmitted up through the ulna and into the distal humerus.

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Complications of supracondylar fractures include:

• Cubitus varus (gun stock deformity)

• Malunion and stiffness

• Myositis ossificans

• Nerve injury (most commonly median nerve)

• Brachial artery (due to stretch and posterior displacement)

• Volkmann’s ischaemic contracture (due to compartment swelling)

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Lateral epicondylosis / Tennis elbow• This condition occurs as a

result of overuse of the forearm extensor tendons.

• The patient may complain of a diffuse ache located over the lateral aspect of the elbow.

• Examples include golfers, baseball players, bowlers, gardeners or landscapers, house or office cleaners (because of vacuuming, sweeping, and scrubbing), carpenters, mechanics, and assembly-line workers.

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Medial epicondylosis / Golfers elbow

• This condition is seen less commonly than lateral epicondylosis and is similarly an overuse injury, this time of the forearm flexor tendons, giving rise to pain over the medial aspect of the elbow.

• In 20% of cases there may be associated ulnar nerve symptoms, specifically paraesthesia in an ulnar nerve distribution.

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Wrist joint-Radiocarpal Joint

The radiocarpal joint consists of four bones in total.

These involve:

• Radius

• Scaphoid

• Lunate

• Triquetrum

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Radiocarpal articulation

• The radius is the lateral bone of the forearm, the lower or distal end meets the carpal bones of the hand.

• The Triquetrum, Lunate and the Scaphoid bone cluster together to form the proximal row of the carpus or the bunch of small eight bones located underneath the wrist.

• The lunate and scaphoid bones meet the radius bone situated in the radiocarpal joint.

• The Triquetrum does so only once, when the hand is drawn towards the body or bent in the way of the pinky finger.

• This joint within the carpal and the radial bones is known as an ellipsoid or condyloid joint

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Movements at the wrist joint

• Extension:-The ulnar extensors and the radial extensors aided by the extensors of thumb and fingers produce extension.

• Abduction (radial deviation):-The Abductor Pollicis Longusproduce abduction.

• Adduction (ulnar deviation):-Two radial extensors and the flexor carpi radialis act together to produce abduction when the wrist moves from the midline.

• Flexion:-Flexion is primarily produced by flexor carpi ulnaris and flexor carpi radialis assisted by abductor pollicis longus, palmaris longus and the thumb and finger flexors.

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Small joints of hand

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Case of rheumatoid arthritis (RA)

• Joint inflammation from RA comes with pain, warmth, and swelling.

• The inflammation is typically symmetrical, occurring on both sides of the body at the same time (such as the wrists, knees, or hands).

• Other symptoms of RA include joint stiffness, particularly in the morning or after periods of inactivity; ongoing fatigue, and low-grade fever.

• Affecting about 1% of the U.S. population, RA usually strikes between ages 30-60, but younger and older people can also be affected.

• RA occurs two to three times more often in women than in men. Other risk factors include cigarette smoking and family history.

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References

• http://www.med.umich.edu/lrc/coursepages/m1/anatomy2010/html/musculoskeletal_system/joints_case.html

• http://www.medicalartlibrary.com/shoulder-joint.html

• http://www.slideshare.net/badamvamshikiran/anatomy-of-shoulder-joint-vamshi-kiran

• http://www.enlightenme.org/knowledge-bank/cempaedia/elbow-injuries

• http://www.webmd.com/rheumatoid-arthritis/ss/slideshow-ra-overview

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