A tube was inserted between the ribs, and the air was sucked out to re-inflate the lung.
The first rib is a deep structure at the base of the neck. It is not uncommon for ribs to be broken after minor injuries, including sports injuries. However, rib I, which lies at the base of the neck, is surrounded by muscles and soft tissues that provide it with considerable protection. Therefore a patient with a fracture of the first rib has undoubtedly been subjected to a considerable force, which usually occurs in a deceleration injury. Other injuries should always be sought and the patient should be managed with a high level of concern for deep neck and mediastinal injuries.
A resident was asked to carry out a clinical assessment of a patient’s hand. He examined the following:
The musculoskeletal system includes the bones, joints, muscles, and tendons. The resident looked for abnormalities and muscle wasting. Knowing which areas are wasted identifies the nerve that supplies them. She palpated the individual bones and palpated the scaphoid with the wrist in ulnar deviation. She examined the movement of joints because they may be restricted by joint disease or inability of muscular contraction.
Palpation of both radial and ulnar pulses is necessary. The resident looked for capillary return to assess how well the hand was perfused.
Examination of the nerves
The three main nerves to the hand should be tested.
The median nerve innervates the skin on the palmar aspect of the lateral three and one-half digits, the dorsal aspect of the distal phalanx, half of the middle phalanges of the same fingers, and a variable amount on the radial side of the palm of the hand. Median nerve damage results in wasting of the thenar eminence, absence of abduction of the thumb, and absence of opposition of the thumb.
The ulnar nerve innervates the skin of the anterior and posterior surfaces of the little finger and the ulnar side of the ring finger, the skin over the hypothenar eminence, and a similar strip of skin posteriorly. Sometimes the ulnar nerve innervates all the skin of the ring finger and the ulnar side of the middle finger.
An ulnar nerve palsy results in wasting of the hypothenar eminence, absent flexion of the distal interphalangeal joints of the little and ring fingers, and absent abduction and adduction of the fingers. Adduction of the thumb also is affected.
The radial nerve innervates a small area of skin over the lateral aspect of metacarpal I and the back of the first web space.
The radial nerve also produces extension of the wrist and extension of the metacarpophalangeal and interphalangeal joints and of the digits.
A very simple examination would include tests for the median nerve by opposition of the thumb, for the ulnar nerve by abduction and adduction of the digits, and for the radial nerve by extension of the wrist and fingers and feeling on the back of the first web space.
A 45-year-old man came to his physician complaining of pain and weakness in his right shoulder. The pain began after a fall on his outstretched hand approximately 6 months previously. The patient recalled having some minor shoulder tenderness but no other specific symptoms. He was otherwise fit and well.
On examination of the shoulder, there was marked wasting of the muscles in the supraspinous and infraspinous fossae. The patient found initiation of abduction difficult and there was a weakness of lateral rotation of the humerus.
The wasted muscles were the supraspinatus and infraspinatus. The cause of the muscle wasting was disuse.
Muscle atrophy (wasting) occurs through a variety of disorders. Disuse atrophy is one of the most common causes. Examples of disuse atrophy include the loss of muscle bulk after fracture immobilization in a plaster cast. The opposite effect can also be demonstrated—when muscles are overused they become bulkier (hypertrophy).