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Objectives for the Upper Limb (Chapter 7) Gray’s Anatomy for Students Conceptual Overview When you have completed this section, you should be able to: 1. Describe the “spaces” of the axilla, cubital fossa and carpal tunnel. 2. Describe the functional rationale for the osseous, jointed structure of the upper limb. 3. Describe the compartmentation of the upper limb. Include fascias involved and major actions of each compartment. 4. Describe the origins of the muscular innervation of the upper limb. 5. Describe the dermatomal innervation of the upper limb. 6. Describe the superficial venous drainage of the upper limb. 7. Describe the lymphatic drainage pattern of the upper limb (both right and left). Regional Anatomy of the Upper Limb When you have completed this section, you should be able to: Shoulder 1. Describe the osseous anatomy of the upper limb. What structures are most at risk in a fracture involving the: surgical neck of humerus, midshaft humerus, medial epicondyle of humerus? 2. Describe the attachments, action and innervation of the muscles of the shoulder. Realize that most shoulder muscles are innervated by C5, C6 – this will be critical to understanding the effects of an upper brachial plexus injury. 3. Identify the muscles that compose the rotator cuff. What is their importance regarding glenohumeral (shoulder) stability? What rotator cuff muscle is most often involved in pathology and why? 4. Discuss the structure/function relationship between the deltoid and rotator cuff musculature. Which initiates abduction and takes arm to ~15 deg.? Which is mainly abduction ~15-~90deg.? What muscles and actions are necessary for abduction above 90 deg.? 5. Discuss the serratus anterior relative to attachments, innervation, and function. What is the clinical scenario when this muscle or its nerve are damaged? How can this be assessed by a clinician? What are typical mechanisms of injury? 6. Describe the formation of the quadrangular and triangular spaces and identify the structures that traverse them. 7. Descibe the arterial anastomosis around the shoulder. What segment of the axillary artery could be ligated if necessary while still retaining collateral blood supply to the distal portions of the upper limb? 8. Understand the clinical items in the section in order to place them in the scenario of a patient presentation – anatomical/clinical rationale, patient complaints (effects on patient), physical findings (e.g., loss of sensation, muscle weakness…), items pertinent in history (e.g., mechanism of injury, typical age/sex/occupation for pathology). Axilla and Pectoral 1. Describe and discuss the regional anatomy of the axilla – structures involved and borders of the region. 2. Realize the communication between the axilla and the neck and the structures connecting these two regions. 3. Describe the formation, course, relationships to other structures and termination of the axillary artery and distribution of its branches. 4. Describe the formation of the axillary vein and list its major tributaries. 5. Describe and discuss the lymphatic drainage of the upper limb and the drainage from these nodes as they reach the central venous circulation. 6. Describe and discuss the attachments, actions, and innervation of the muscles in the axillary region. 7. Describe the attachments of the fascia which surrounds the pectoralis minor, its specific specializations. 8. Revisit objective #5 from “shoulder”. 9. Understand the clinical items in the section in order to place them in the scenario of a patient presentation – anatomical/clinical rationale, patient complaints (effects on patient), physical findings (e.g., loss of sensation, muscle weakness…), items pertinent in history (e.g., mechanism of injury, typical age/sex/occupation for pathology). Brachial Plexus 1. Describe the formation of the brachial plexus in terms of its roots, trunks, divisions, cords and branches. 2. Describe the branches from the plexus; including root origin (i.e., C5,C6 for axillary n.), origin from plexus portions (i.e., axillary n. from posterior cord, suprascapular n. from superior trunk), and the compartment/function/muscles served by the branches. 3. Which nerves (e.g., median) innervate specific compartments and limb muscles is required knowledge and the overall root levels (e.g., C5-T1 for median) that form the nerve are required knowledge. The specific segmental innervation of all muscles is not required however (e.g., the fact that flexor pollicis longus is only supposedly supplied by C7,C8 fibers from median n.). 4. Describe the compartmental innervation of the upper limb provided by the terminal branches of the brachial plexus. Understanding and utilizing compartmentalization is critical to efficient studying of the limb. 5. Examine the course of the plexus and its branches in relation to surrounding structures in order to understand common injury scenarios found in the clinical correlation section. Arm (Brachium) 1. Describe the attachments, action and innervation of the muscles of the brachium. 2. Describe the course of nerves from the brachial plexus as they course through the brachium in order to understand their susceptibility to common injury scenarios presented in the text and clinical correlations. 3. Describe the arterial distribution of the brachium and sites for obtaining a patient pulse. 4. Identify the arteries of the brachium that participate in anatomosis of the elbow. What is the significance of this arrangement? 5. Describe and discuss the superficial and deep venous circulation of the upper limb and the formation of the axillary vein from its major tributaries. Cubital fossa 1. Identify and describe the boundaries and contents of the cubital fossa. How can this information assist in competent venipuncture in this region? 2. Identify the vascular structures that cross the roof of the cubital fossa. How could an aberrant superficial ulnar artery in this region complicate venipuncture? Forearm Anterior and Posterior Compartment 1. Describe and discuss the muscles of the forearm in terms of compartments (anterior=flexor, posterior=extensor) that share an innervation, function, and general attachment. Any exceptions to compartmental characteristics (innervation, function, attachment) should be highlighted. 2. Flexor compartment muscles: -general proximal attachment is at medial epicondyle of humerus (more specific proximal attachment is not necessary) -distal attachments must be specific as in text 3. Extensor compartment muscles: -general proximal attachment is at lateral epicondyle of humerus (more specific proximal attachment is not necessary) -distal attachments must be specific as in text 4. Describe the structures forming the carpal tunnel and identify the structures that course through this tunnel. Is this tunnel expandable? 5. Describe the extensor retinaculum and the flexor retinaculum (transverse carpal ligament). What function do these structures serve? What is the consequence of edema in structures passing beneath either retinaculum? 6. Describe the formation of the anatomical snuffbox. What tendons form its posterior and anterior limits, what artery passes through, what bone is in its floor, and what vein and nerve pass superficial? What is the clinical significance of pain upon palpation in this region? What is the clinical significance of pain in the anterior bordering tendons upon ulnar deviation? 7. Describe the course and branches of the arterial supply to the forearm. Where are they more susceptible to injury? Where would pulse be assessed? 8. Discuss the path and relationships of the median, radial and unlar nerves relative to muscles, bones and arteries. Where are they most susceptible to injury and what would the signs/symptoms in the patient presenting with such an injury? Hand 1. Describe the contents of the hand from superficial to deep and medial to lateral (intrinsic and extrinsic muscles, bursae, vessels, and nerves). 2. Describe the functions of the intrinsic and extrinsic hand muscles as well as their attachments and innervations. Realize that all intrinsic hand muscles are innervated by T1 with some contribution from C8 - this will be critical to understanding the effects of a lower brachial plexus injury. 3. Intrinsic hand muscles (i.e., mm. that have origin and insertion in hand): 4. 5. 6. 7. - specific knowledge of distal attachments is required as in text - specific knowledge of proximal attachments is not required Revisit forearm objective #6. Describe the formation of the superficial and deep arterial arches relative to their origin, major contributors, size, location in the palm and the branches provided in the palm and fingers. Where are they susceptible to injury and palpation? Describe the motor and sensory distribution of the nerves of the hand; be able to describe the dermatome for the nerve (i.e., median n.) and specific cord levels of sensory supply (i.e., C7 distribution). What functions would be weak or lost in a patient presenting with injury to a specific muscle, group of muscles or nerves supplying hand muscles. Would there be any different findings if the nerve was injured at the wrist or at the elbow? Describe the anatomical rationale underlying clinical correlations in the text and the clinical correlation section of notes. Be able to describe clinical scenarios including patient presentation, signs/symptoms, mechanism of injury, diagnosis, typical patient profile, and underlying anatomical rationale. Joints of the Upper Limb Objectives for the following joints of the upper limb: Sternoclavicular (sc), acromioclavicular (ac), glenohumeral, elbow, proximal radio-ulnar, distal radio-ulnar, radiocarpal, intercarpal, carpometacarpal, intermetacarpal, metacarpal phalangeal, and interphalangeal joints. 1. 2. 3. 4. Identify the type of joint. Identify types of movement allowed. Identify major supportive structures (i.e., ligaments and muscles) Describe internal joint architecture. Clinical and Surface Anatomy When you have completed this section, you should be able to: 1. Identify the superficial landmarks associated with the upper limb [features of the skin, superficial and deep fascia, spaces, compartments, boney landmarks, muscles, ligaments, nerves, vasculature and joints]. 2. Apply anatomic knowledge and understanding to clinical scenarios presented in the chapter (see green boxes) and clinical correlations section in notes.