Download 1 - Unit 3 Upper Limb Objectives

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.