Case 44 carpal tunnel syndrome-

Tingling and burning over palmar aspect over thumb, middle, index, and lateral ring finger of right hand,
fingers get puffy and stiff, gradually get better through morning, difficulty holding things, weakened
thumb, wasting of thenar eminence, recently pain and burning in corresponding left hand, limitation of
abduction and opposition of thumb, hypasthesia and hypalgesia, sensation over lateral aspect of hand
unaffected, pressure and tapping on lateral part of flexor retinaculum causes tingling, no interference of
wrist, elbow, or fingers, extreme flexion and extension in wrist produce pain in 3.5 fingers—diagnosed
with carpal tunnel---caused by median nerve disturbance, palmar cutaneous branch given off just before
flexor retinaculum, so sensation unaffected, million dollar nerve-recurrent branch of the median nerve

Case 43 tendon sheath and thenar space infections

Pt. cut index finger right above MP joint, no pain flexion, but extension cause remarkable pain, most
sharp at proximal end of MP joint, extension of other fingers causes little increase in pain, swollen lymph
nodes, and increased temperature, swelling most on dorsum of hand, but with hand infections most
swelling does not indicate where most infection—dx. Synovial tendon sheath infection of index finger
with MP joint involvement, lymph node and lymph vessel-eventually finger is amputated, tendons from
FDS and FDP in this tendon sheath, tendon ends at neck of 2 nd MC and distally at baser of distal phalanx
—easily could move form 2nd phalanx to thenar space, 2nd, 3rd, and 4th sheaths begin at level where deep
spaces end, flexor pollicis longus may also move into thenar space—radial bursa could spread easily to
thenar space and vice versa

Case 42 peripheral venous access

Cough, severe shortness of breath, swelling of legs, with hx. Of heart disease.-dx. Heart failure following
rheumatic lesion-burning on fourth injection into cubital fossa in lateral portion, increases in day, and
radiates over palmar aspect of the forearm., in evening complains of numbness and prickling on radial
aspect of forearm, no muscular or motion atrophy, but complete loss of sensation over most of area of
lateral antebrachial cutaneous nerve-thombosis with occlusion of injected vein is consequence of IV
injection, other nerves may be injured by cutaneous IV injection-lateral antebrachial cutaneous nerve,
medial antebrachial cutaneous nerve, lateral antebrachial cutaneous is termination of
musculocutaneous nerve, pierces fascia lateral to biceps tendon, and branches into anterior and
posterior to supply radial part of anterior and posterior forearm, median nerve with impairment to
lateral antebrachial cutaneous has been described in IV injection, resulting in severe motor function loss,
and sensory deficits in median and medial antebrachial cutaneous nerves, intraarterial injection is also
an accident that may happen, deep fascia and bicipital aponeurosis only things that protect artery

Case 41 embolism of brachial artery

Patient admitted for general arteriosclerosis, lesions of aortic valves, and cardiac failure, upon stay he
suddenly complains of sharp pain and partial paralysis of right forearm of about an hour’s duration,
forearm arm cold and pale, hand and fingers in contracted position, loss of movement and sensation
below elbow, radial and ulnar pulses are absent, dx. Embolism of brachial artery, occlusion of artery by a
blood clot originating elsewhere, taken to surgery and embolism is removed, amputation would have
been required without surgery, median nerve usually crosses in front of, not behind, brachial artery,
often basilic vein and cutaneous nerve of forearm are often mistook for brachial artery and median
nerve, separated by deep brachial fascia, also brachial usually accompanied by two veins, bifurcation of
the brachial artery is usually at neck of radius-block in brachial artery above origin of deep brachial
artery, not favorable , circulation relies essentially on anastomosis between the descending branch of
the posterior humerual circumflex artery from the axillary artery and an ascending branch of the the
deep brachial artery-block below origin of the deep brachial artery more favorable—here anastomosing
vessels are available both above and below—brachial divides itself into anterior and posterior
descending branches, and superior and inferior ulnar collateral arteries distally, collateral anastomose
with recurrent branches distally from radial, ulnar, and posterior interosseous arteries in front of and
behind elbow

Case 39 cervical rib syndrome

39 yo woman with rheumatic pains in right arm, additional work recently led to worsening and radiating
down medial side of arm and forearm into the hand, pain increases toward end of day and at night,
sometimes the fingers on the ulnar side of the hand tingle and feel numb, right arm seems weaker than
the left, tenderness and some resistance in right supraclavicular area, downward pulling on the arm
increases the pain, wasting of right thenar eminence, opponens pollicis and abductor pollicis seem to be
involved.-involvement of lower trunk of brachial plexus, both sensory and motor fibers are affected,
accessory rib on right articulating with 7 th cervical vertebra, surgically end up elevating brachial plexus as
well as subclavian artery and excise cervical rib, sensory deficits in this case point to not one specific
nerve but three involved nerve-medial brachial and antebrachial cutaneous nerves and ulnar nerve, two
affected muscles in thenar compartment are supplied by median nerve, C8 and T1 affected on sensory
side, and median nerve C8 and T1 for motor function of thenar muscles, occurs outside spinal cord since
both types of cordes are affectee, must be beyond mixed point of spinal nerve because no neurological
deficiency in dorsal rami of C8 and T1, inferior trunk of brachial plexus, nerve fibers in hypothenar
eminence seem to have escaped, which happens to be nerve fibers involved, a common occurrence,
more noticeable later in life because less muscular resistance to downward pull on arm

Case 38 fracture of the clavicle

13 yo boy, fell on left shoulder, pain in collarbone, all movements of left arm are painful, fracture in
middle of bone, tenderness and swelling at fracture site, depression of outer fragment, clavicile only
skeletal connection of shoulder girdle to trunk, at sternoclavicular joint does not dislocate because of
the secure adaptation of the joint=costoclavicular, anterior and posterior sternoclavicular ligaments, and
articular disk attached, at acromioclavicular joint, equally stable with \coroclavicular ligaments-two
parts, conoid and trapezoid, fractures occur most often between costoclavicular and coracoclavicular
ligaments that anchor the clavicle at either end, displacement of bone common in clavicle fracture,
medial fragment pulled upward by sternocleidomastoid, other fragment would be pulled down by
deltoid and weight of limb, overlapping of fragments, adduction of arm, and decrease in distance
between acromion and midline would be pect major, supported by lat. Dorsi., because medial rotators
stronger than lateral rotators, braching action of clavicle nullified, and arm is also medially rotated—
pect major, subscapularis, teres major, lat, dorsi all responsible medial rotators ,medial rotation also
explains why lateral fragment points posteriorly

Case 31 appendicitis

22 yo male,appeared with cramplike pain above and around umbilicus, felt hot and uncomfortable,
nausea, no appetite, pain moved to right lower ab region, increased temp and pulse, localized
tendernesss and rigidity upon palpation in ab, changing pattern of pain:initial pain in epigastic and
umbilical regions is from visceral sensory fibers in wall of inflamed appendix—path of pain from visceral
sensory=closely intermingled with sympathetic efferent fibers, through superior and inferior plexuses
and ganglia, greater and lesser and lumbar splanchnic nerves, the sympathetic chain ganglia, and via
white communicantes to spinal nerves and their dorsal root ganglia-cell bodies located in dorsal root
ganglia, where central fibers continue into spinal cord…pain is then referred to areas of body that
receive pain from same segment of cord-T10, with overlap from T9 and T11, later pain is stimulation of
somatic sensory fibers supplying the parietal peritoneum of the abdominal wall (that carry somatic
sensory sensory fibers from this area)—11th intercostals, subcostal, and first lumbar nerves—irriation of
the parietal peritoneum.

Case 15 cancer of the breast

51 yo homemaker,lump in right breast, menopause three years ago, upper quadrant reddened area two
inches in diameter, skin seems dimpled, right nipple good inch higher than left, flatter than same area in
left breast, axilla on right more full than on the left dx. Adenocarcinoma w.metastases to axilla, radical
mastectomy done and dies 9mos later from metastasis to lung…reddening to area-due to increased
blood flow, breast supplied by internal thoracic, thoracoacromial arteries, and anterior intercostal
arteries-veins follow course of arteries, dimpling and fixation of skin was because of cancerous invasion
of suspensory ligaments that anchor the gland to the skin, orange peel appearance is because of
cancerous obstruction of lymphatics draining the skin, whereas hair follicles and cutaneous glands can
withstand the expansion caused by lymph blockage and appear as pits or depressions—elevation,
retraction, and fixation of nipple due to cancerous involvement and subsequent scarring of lactiferous
ducts, mass in axilla is metastasis to axillary lymph nodes, main site of lymph drainage to breast. 5
groups of axillary nodes, first three can be regarded as peripheral outposts, whereas other two more
centrally located within axillary fossa and towards apex MAY WANT TO REVIEW MORE DETAILED
DESCRIPTION OF NODES. Path of cancerous emboli from breast to venous bloodtream:pectoral, central,
apical,and possibly supraclavicular nodes, but shortcuts may occur. Vulnerable nerves in mastectomy-
long thoracic nerve, which supplies serratus anterior, thoracodorsal, which leads to lat.dorsio

Case 14 lumbar puncture

15 yo boy, sneezing, coughing, severe headache, stiffness of neck, and high fever, displays all signs of
upper resp.infection, yet lungs are clear, to confirm or exclude dx. Of infectious meningitis, lumbar
puncture is done, CSF is clear, colorless, and normal, which rules out meningitis-febrile URI with
meningeal irritation is dx. Lumbar puncture is tapping subarachnoid space in lumbar region for CSF
removal, or for introduction of drugs, signs of increased intracranial pressure should be ruled out
because sudden decrease in pressure in subarachnoid space by LP could lead to herniation of the tonsils
of the cerebellum through the foarmen magnum in to the spinal canal or to prolapsed of portions of the
temporal lobe, fatal compression of brain possible. Optimal site of LP is between L3 and L4, or L4 and L5,
external landmark=horizontal line that can be drawn from highest points of iliac crests crosses at about
L4 spinous process, spaces above and below can be chosen, entrance into thoracic is impossible because
of the sharp angle of spinous processes and overlap, arching of back and drawing up knees is done by
patient, lowest point on spinal cord in adult is conus medullaris, which is located at the lower border of
L1 or at body of L2. In infant or fetus, cord much lower, and extends through whole length of spinal
canal down to coccyx, as develop. Occurs, growth of spinal cord doesn’t keep up with vertebral
longitudinal growth, lowest extent of subarachnoid space is at S2, LP not done at lower points because
the solid bony mass prevents entrance, cauda equine, collection of spinal nerve roots, sensory and
motor, that descend from lowerst part of the cordto their exit as spinal nerves through lumbar
intervertebral and sacral foramina, usually “hairs” move out of the way, but if one is hit, patient may
receive shooting in lower extremity of that side, and the needle should be withdrawn slightly.ligaments
that are involved in LP? 3 ligaments must be traversed in typical midline puncture, supraspinous,
interspinous ligaments, and ligamentum flavum—two different types of anesthesia-epidural space used,
which is different than spinal anesthesia where anesthesia is injected into subarachnoid space., caudal
anesthesia is also an option, where needle is inserted through sacral hiatus, into distal part of sacral
canal, without penetrating dural sac, which ends at second scaral vertebra, often used for perineum in
ob. LP has one snap, second snap heard in penetrating dura and arachnoid

Case 13 prolapse of an intervertebral disk

43 yo college professor, sudden severe lower pain in back, felt something snap, pain extended down
posterior aspect of right thigh and leg, numbness and tingling over lateral part of right leg, foot, and
little toe, complains of hx. Of bad back, pain increases with coughing or sneezing, raising extended leg is
quite painful, tenderness palpation of right sciatic nerve in thigh, weakness in plantar flexion, loss of
sensory perception on dorsal side of right fourth and fifth toes, posterolateral herniation of nerve roots
in cauda equine, particularly apt to compress roots on next lower spinal nerve, herniation of disk
between L5 and S1 inviovles most commonly roots of S1, coughing increases IV pressure, also CSF, which
adds pressure to roots, S1 roots important for sciatic nerve, also takes origin from L4 and L5 and first 3
sacral nerves, raising the extended leg of the patient puts the sciatic nerve on the stretch and is painful if
nerve is compressed, weakness of plantar flexion of the right foot is sign of involvement of motor root of
S1, S1 dermatome supplies little toe side of leg