Arm and Cubital Fossa (741-744)

Bicipital Myotactic Reflex - Biceps reflex tested routinely, positive response confirms integrity of musculocutaneous nerve & C5, C6 segments. Excessive, diminished or prolonged responses may indicate CNS or PNS diseases or metabolic disorders (e.g. thyroid disease) - Relaxed limb is passively pronates and partially extended at elbow. Examiner places thumb firmly on biceps tendon and hammer is tapped briskly on the base of the nail bed of the examiners thumb. - Normal (positive) response is an involuntary contraction of the biceps (tensed tendon, jerk like flexion at elbow) Biceps Tendonitis - Wear on the long head biceps tendon in the synovial sheath can cause shoulder pain. - Inflammation of the tendon, usually the result of repetitive microtrauma, is common in sport involving throwing and use of a racquet. - A tight, narrow, or rough bicipital groove may irritate and inflame the tendon, producing tenderness and crepitus (crackling sound). Dislocation of Tendon of Long Head of Biceps Brachi - When tendon is partially or completely dislocated from bicipital groove. - Painful. May occur in young persons during traumatic separation of the proximal epiphysis of the humerus. - Also occurs in older persons with a history of biceps tendinitis. - Usually a sensation of popping or catching is felt during arm rotation. Rupture of Tendon of Long Head of Biceps Brachii - Results from wear and tear on an inflamed tendon as it moves through bicipital groove. - Usually in ppl >35. - Typically, the tendon is torn from its attachment on the supraglenoid tubercle. Usually a dramatic and loud rupture. - The detached muscle belly forms a ball near the center of the distal part of the anterior aspect of the arm (Popeue deformity). - Rupture may result from the forceful flexion of the arm against excessive resistance, as occurs in weightlifters. Typically though from prolonged tendinitis. The rupture results from repetitive overhead motions that tear the weakened tendon in the bicipital groove. Interruption of Blood Flow in Brachial Artery - Hemostasis stopping bleeding through manual or surgical control of blood flow. - Best place to compress brachial artery to control hemorrhage is medial to the humerus near the middle of the arm. - Because of collateral circulation around elbow, the brachial artery may be clamped distal to the origin of the deep artery of the arm without producing tissue damage. The anatomical basis for this procedure is that the ulnar and radial arteries will still receive sufficient blood through the anastomoses around the elbow. - Sudden complete occlusion or laceration of the brachial artery creates a surgical emergency because paralysis of muscles results from ischemia of the elbow and forearm within a few hours. - Muscles and nerves can tolerate up to 6 hours of ischemia. After this, fibrous scar tissue replaces necrotic tissue and causes the involved muscles to shorten permanently, producing a flexion deformity the ischemic compartment syndrome (Volkmann or ischemic contracture). Flexion and sometimes at the wrist results in loss of hand power as a result of irreversible necrosis of the forearm flexor muscles. Fracture of the Humeral Shaft - A midhumeral fracture may injure the radial nerve in the radial groove. When this nerve is damaged, the fracture is not likely to paralyze the triceps because of the high origin of the nerves to two of its three heads.

A fracture to the distal part of the humerus, a supra-epicondylar fracture, can be displaced anteriorly or posteriorly. The brachialis and triceps tend to pull the distal fragments over the proximal fragment shortening the limb. Any of the nerves or vessels may be injured.

Injury to the Musculocutaneous Nerve - This is typically inflicted with a weapon such as a knife (not a very common injury). - This nerve injury results in paralysis of the coracobrachialis, biceps, and brachialis. - Weak flexion may occur at the shoulder joint owing to the injury of the nerve affecting the long head off the biceps and the coracobrachialis. - Flexion at the elbow joint and supination of the forearm are greatly weakened but not lost. This flexion and supination is still produced by the brachioradialis and supinator, respectively, which are innervated by the radial nerve. - Loss of sensation may occur on the lateral surface of the forearm supplied by the lateral antebrachial cutaneous nerve (the continuation of the musculocutaneous). Injury to Radial Nerve in Arm - Injury to this nerve superior to the origin of its branches to the triceps results in paralysis of the triceps, brachioradialis, supinator, and extensor muscles of the wrist & fingers. Loss of sensation in areas of skin supplied also occurs. - When the nerve is injured in the radial groove the triceps usually not completely affected (medial head affected). Muscles in the posterior compartment of the forearm are paralyzed. The characteristic sign is wrist drop inability to extend the wrist and fingers at the metacarpophalangeal joints. Instead, the relaxes wrist assumes a partly flexed position owing to unopposed tonus of flexor muscles and gravity. Venipuncture in Cubital Fossa - The cubital fossa is the common site for sampling the transfusion of blood and IV injections. - Medial cubital vein most popular. Crosses the bicipital aponeurosis, which separates it from the underlying brachial artery and median nerve and provides some protection to the latter. - A tourniquet is placed around the midarm. Once the vein is punctures, the tourniquet is removed so that when the need is removed the vein will not bleed extensively. - The median cubital vein is also a site for the introduction of cardiac catheters to secure blood samples from the great vessels and chambers of the heart. These veins may also be used for coronary angiography. Variation of Veins in Cubital Fossa - Varies greatly. - 20% of people a median antebrachial vein (median vein of the forearm) divides into a median basilica vein and median cephalic vein, which join their respective veins of the arm. In these cases, a clear M formation is produced by the cubital veins. - It is important to remember that either vain, whichever pattern is present, crosses superficial to the brachial artery (separated by the bicipital aponeurosis). - These veins are good sites for drawing blood but are not ideal for injecting and irritating drug because of the danger of injecting it into the brachial artery. - In obese people, a considerable amount of fatty tissue may overlie the vein.