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Arm and Cubital Fossa

1) Bicipital Myotatic Reflex


a. Confirm integrity of Musculocutaneus nerve (C5 and C6 spinal cord segments)
i. Relaxed limb passively pronated and extended at elbow
ii. Examiner place thumb over biceps tendon
iii. Reflex hammer briefly tapped at base of nail bed
iv. involuntary contraction of Biceps, jerk-like flexion of elbow
b. Excessive, diminished, prolonged(hung) response =>
i. CNS disease
ii. PNS disease
iii. Metabolic disorder eg Thyroid Disease
2) Venipuncture in Cubital Fossa
a. Medial cubital vein (merged cephalic and basilica vein)
used because of its prominence and accessibility
b. Uses:
i. Sampling
ii. Blood transfusion
iii. IV injections
iv. Cardiac Catheters- Coronary Angiography
c. Procedure:
i. Tourniquet placed ard midarm (to distend veins in
cubital fossa)
ii. Vein punctured
iii. Tourniquet removed (prevent excessive bleeding
when needle removed)
3) Variation of veins in Cubital Fossa
a. Varies in 20% of ppl
b. Median antebrachial vein divides into median basilic vein and medial cephalic
vein (M formation) (these veins join back to their main veins respectively)
c. Ideal for drawing bld
d. NOT ideal for injecting drugs (may pierce brachial artery)
i. Brachial artery separated from medial basilic/cubital vein by bicipital
aponeurosis
e. In obese ppl- fatty tissue overlies vein
4) Interruption of bld flow in brachial artery- Hemostasis (stopping bleeding
through manual/surgical control)
a. Best place to compress brachial artery to control haemorrhage:
i. Middle of arm medial to humerus
1. Arteriole anastomoses ard elbow ensures ulnar and radial arteries
receive sufficient bld flow ( functionally and surgically impt collateral
circulation) Same as scapula
b. Ischemic (restriction of blood supply) compartment syndrome/ volkman/ischemic
contracture
i. Sudden occlusion/laceration of brachial artery
1. Surgical emergency: Ischemia of elbowparalysis of muscles
a. muscles and nerves tolerate up to 6 hours of ischaemia
before fibrous scar replaces necrotic tissue
2. Loss of hand power
a. Flexion of fingers and wrist loss of hand power due to
irreversible necrosis of forearm flexor muscles

b.
5) Biceps Tendinitis
a. Cause: (common in sports)
i. Repetitive microtrauma
1. Throwing eg baseball, cricket
2. Tennis/racquet sports
ii. Irritation of tendon
1. Tight, narrow intertubercular sulcus
2. Rough intertubercular sulcus
b. Result:
i. Tendon inflamed due to wear and tear of constant movement
ii. Tenderness
iii. Crepitus (cracking sound)
c. Anatomy basis:
i. Tendon of long head of biceps enclose by synovial sheath can move back
and forth in the intertubercular sulcus/bicipital groove of humerus
ii. Wear and tearshoulder pain
6) Dislocation of Tendon Long head of Biceps Brachii
a. Partial or complete dislocation
b. In young:
i. Traumatic separation of proximal epiphysis of humerus (see slide on
humerus fracture)
c. Older ppl:
i. Hx- Biceps tendinitis
d. Characteristics:
i. Pain
ii. Sensation of popping or catching during rotation of arm
7) Rupture of Tendon of Long Head of Biceps Brachii
a. Cause:
i. Wear and tear of inflamed tendon (moves back and forth in intertubercular
sulcus of humerus) => usually occurs in ppl >35 years old
ii. Forceful flexion of arm against excessive resistance eg lifting weights
iii. Tendon weakened by prolonged tendonitis
iv. Repeated overhead movements eg swimmers and baseball pitchers
(weakened tendon in intertubercular sulcus torn)
b. Result:
i. Popeye deformity detached muscle belly forms ball at distal part of
anterior arm
1. Tendon torn from attachment to supraglenoid tubercle of scapular @
Origin
2. Dramatic rupture
3. Associated w snap/pop
8) Fracture of Humeral Shaft
a. Midhumeral Fracture
i. Radial nerve in radial groove injured
ii. X paralyse triceps (nerves originate higher than 2 heads of biceps)
b. Supra- epicondylar fracture (distal humerus fracture)
i. Shortened limb
1. Brachialis and triceps pull distal fragment over proximal one (distal
bone fragment may be displace anteriorly or posteriorly)
c. Nerves or branches of brachial vessels related to humerus may be injured by
bone fragments
9) Injury to Musculocutaneous Nerve
a. Uncommon (musculocutaneous nerve is in protected area)

b. Causes:
i. Knife stab
c. Result:
i. Paralysis of :
1. Coracobrachialis
2. Brachialis
3. Biceps
ii. Weakened flexion of GH joint
iii. Weakened flexion and supination of forearm
1. WEAK flexion and supination possible by brachioradialis and
supinator-supplied by radial nerve
iv. Loss of sensation @ lateral surf of forearm
1. supplied by lateral antebrachial cutaneous nerve, a continuation of
musculocutaneous nerve
10)
Injury to Radial Nerve in Arm Wrist Drop- Wrist partially flexed (due to
unopposed tonus of flexor muscles and gravity )(inability to extend wrist and fingers at
metacarpalphalangeal joints)
a. Injury superior to origin of branches to triceps brachii
i. Paralysis of:
1. Triceps
2. Brachioradialis
3. Supinator
4. Extensor muscles of wrist and fingers
ii. Loss of sensation in areas supplied by radial nerve
b. Injury in radial groove
i. Triceps weakened (not completely paralysed)
1. Only medial head of triceps affected
ii. Muscles in posterior component of forearm (supplied by more distal
branches of nerve) paralysed