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Gross Anatomy Pissant Details You Might Need to Know Unit I Boundaries of Semi-Important Anatomical Structures AXILLA Border Apex Anterior Wall Posterior Wall Medial Wall Lateral Boundary Floor Structures 1st rib coracoid process anterior of scapula posterior edge of clavicle Pec major and minor Clavicalpectoral fascia subscapularis teres major latissimus dorsi First 4 ribs w/ intercostals muscles Superior portion of serratus anterior anterior and posterior walls into intertubercular groove of the humerus Skin of Armpit TRIANGULAR SPACE Boundary Superior Inferior Lateral Structure Teres minor Teres major Long head of triceps Contents: circumflex scapular artery QUADRANGULAR SPACE Boundary Superior Inferior Medial Lateral Structure Teres minor Teres major Long head of triceps Humerus (surgical neck) Contents: posterior circumflex humeral artery, axillary nerve TRIANGULAR INTERVAL Lateral Medial Superior Lateral head of triceps Long head of triceps Teres major Contents: radial nerve, profunda brachii artery (or deep brachial artery) CUBITAL FOSSA Roof Floor Lateral Medial Proximal Antebracial fascia Cephalic vein Brachial vein Median cubital vein Medial Antebrachial Cutaneous Nerve Musculocutaneous Nerve -> Lateral Antebrachial Cutaneous Nerve Bicipital Aponeurosis Brachialis Muscle Supinator Muscle Brachioradialis Pronator teres Line between epicondyles Contents: TAN (from lateral to medial) T = tendon of biceps brachii A = brachial artery N = median nerve CARPAL TUNNEL Structures passing through tunnel Structures passing in front of the tunnel Roof Lateral boundary Medial boundary Flexor pollicis longus Flexor digitorum superficialis Flexor digitorum profundus Median Nerve Palmaris longus Flexor carpi ulnaris Ulnar nerve Ulnar artery Flexor retinaculum Scaphoid Trapezium Pisiform Hamate ANATOMICAL SNUFF BOX Boundaries Contents in roof Contents in floor Tendons of .. Abductor pollicis longus Extensor pollicis brevis Extensor pollicis longus Superficial radial nerve Scaphoid Trapezium Radial artery Tendon compartments of the extensors (lateral to medial) 1 2 3 4 5 6 Abductor pollicis longus Extensor pollicis brevis Extensor carpi radialis longus Extensor carpi radialis brevis Extensor pollicis longus Extensor digitorum Extensor indicis Extensor digiti minimi Extensor carpi ulnaris THENAR COMPARTMENT Muscles Nerve Artery Abductor pollicis brevis Flexor pollicis brevis Opponens pollicis Median nerve Except deep head of FPB – ulnar nerve Princeps pollicis (off of radial) Superficial palmar branch (from radial) HYPOTHENAR COMPARTMENT Muscles Nerve Artery Palmaris brevis Abductor digiti minimi Flexor digiti minimi Opponens digiti minimi Ulnar nerve Deep branches of the ulnar artery MIDPALMAR COMPARTMENT Anterior Posterior Lateral Medial Palmar aponeurosis Interossous fascia Thenar fascia and compartment Hypothenar fascia and compartment Movements Associated with Sexual Positions UPPER LIMB Flexion of Upper Limb Extension of Upper Limb Medial Rotation Lateral Rotation Abduction in Scapular Plane Abduction in Coronal Plane Adduction Adduction from elevated position SCAPULA Rotation of Scapula (moving laterally and upward) Rotation of Scapula (moving medially and downward) Elevation of Scapula Depression of Scapula Forward movement of Scapula Backward movement of Scapula FOREARM Flexion of forearm Extension of forearm Stabilizing elbow Supinators Pronators Flexion of wrist Extension of wrist Abduction of wrist Adduction of wrist Pectoralis major Deltoid (anterior) Aids: coracobrachialis and biceps Latissimus Dorsi Deltoid (posterior) Subscapularis Aids: pec major, deltoid, lat dorsi, teres major Infraspinatus Teres minor Aid: Deltoid (posterior) Deltoid Supraspinatus Needs extension, lateral rotation (to clear the acromion), and abduction Pectoralis major Latissimus Dorsi Teres major Deltoid (middle) Supraspinatus Serratus Anterior Aid: Trapezius Levator Scapulae Rhomboids Levator Scapulae Trapezius (upper fibers) Serratus Anterior Trapezius (lower fibers) Serratus Anterior Trapezius and rhomboids (italic muscles in the hand) Brachialis, coracobrachialis, biceps brachii Triceps brachii, anconeus Anconeus Supinator, biceps brachii Pronator teres, quadratus All carpi flexors, palmaris longus All carpi extensors Flexor carpi radialis, Extensor carpi radialis longus and brevis Flexor carpi ulnaris, Extensor carpi ulnaris Flexion of digits Extension of digits HAND Abduction of thumb Adduction of thumb Abduction of pinky Opposition (touching thumb to pinky) Abduction of digits Adduction of digits Flexion at metacarpo-phalageal joints Extension at interphalangeal joints LIMITED MOVEMENTS OF THE VERTEBRAE Cervical region Thoracic region Lumbar region BACK Depression of inferior ribs Elevation of superior ribs Lateral flexion and rotation of head Extension of head and neck Extension of vertebral column Lateral flexion of vertebral column Posterior extension of vertebral column Elevation of ribs Flexor digitorum superficialis, digitorum profundus Flexor pollicis longus, Flexor pollicis brevis, Abductor pollicis brevis Flexor digiti minimi Extensor digitorum, digiti minimi, indicis, pollicis longus, pollicis brevis, Abductor pollicis longus Abductor pollicis longus, pollicis brevis Adductor pollicis Abductor digiti minimi Opponens pollicis, Opponens digiti minimi, Adductor pollicis Dorsi interossei Palmar interossei Lumbricals, dorsi and palmar interossei Lumbricals, dorsi and palmar interossei Lateral rotation Anterior flexion Posterior extension (horizontal articular facets) Lateral flexion (thick discs, superior surface concaved) Extension of thorax (vertical articular facets) Some lateral rotation Minimal anterior flexion, lateral flexion Posterior extension (interlocking articular facets) Little anterior flexion No lateral rotation Serratus posterior inferior Serratus posterior superior Splenius muscle (acting alone) Splenius muscles (acting together) Erector spinae muscles Semispinalis, multifundus, rotatores (acting alone) Semispinalis, multifundus, rotators (acting together) Levator costorum Clinical Correlations Breast Cancer Perky in a bad way - Tumors invade the retromammary space and attaches to the fascia overlying pec major. This makes the breast less movable, but contracting pec major makes the breast move superiorly. Fruity in a bad way - If cancer infiltrates along the ligaments the skin begins to invaginate -- like dimples on an orange peel. Connections of the intercostals veins w/ vertebral venous plexus make it possible for tumors to invade from breast -> vertebra -> skull -> brain. Rotator Cuff Disease Posterior or superior displacement of the humerus – most common cause of shoulder pain – could be caused by tearing any of the tendons of the musculotendinous cuff that keep the humerus in the glenoid cavity – subscapularis, supra- and infraspinatus, teres minor. Supraspinatus helps keep the head of the humerus in glenoid fossa – prevents deltoid from pulling it toward the acromion. Lesion - suprascapular nerve Difficulty initiating abduction due to supraspinatus paralysis Lesion - axillary nerve (due to humeral fraction at surgical neck) Difficulty abducting greater than 120 degrees due to deltoid paralysis Lesion – long thoracic nerve (at axilla) “Winged scapula” – inferior angle is not held against thoracic wall by serratus anterior, difficulty abducting upper limb because scapula cannot rotate. Patient cannot hold scapula against wall when pushing a wall. Articular cartilage in synovial joints often degenerate with age/injury The costoclavicular ligament is the most important in preventing displacement of the sternoclavicular joint, but the acromioclavicular joint is more likely to displace. Carpal Tunnel Median nerve compressed. Affects thenar muscles, lateral 2 lumbricals and sensory impairment to lateral 3 1/2 digits. BUT no sensory impairment to palmar cutaneous branch. Lesion – ulnar nerve Sensory impairment of medial 2 digits (anterior and posterior). Decreased adduction and abduction of digits. Adductor pollicis paralysis. Medial two lumbricals are paralyzed. Wrist fracture Mostly occurs at distal part of radius, scaphoid likely to fracture Waiter’s tip C5/C6 or superior trunk lesion. Loss of flexion, abduction, and lateral rotation of upper limb. Makes a weird medial rotation of the arm. Most severely affected muscles: deltoid, biceps brachii, brachialis, brachioradialis, supraspinatus, infraspinatus, teres minor Wrist drop Posterior cord lesion, pressure on radial nerve. Unable to extend forearm, hand, digits. Lower brachial plexus injuries (C8/T1) can be a result of cervical rib or pulmonary carcinoma Lesion – musculocutaneous nerve (at axilla) Weakness of upper limb flexion. Severe weakness of forearm flexion. Weakness when supinating arm. Lesion – radial nerve (fractured humerus) Loss of forearm extension. Wrist drop occurs. Lesion – radial nerve (neck of radius) Wrist drop not severe because extensor carpi radialis longus and brevis are spared. Loss of digital extension of proximal phalanges and thumb impaiments. Lesion – median nerve (at axilla) No forearm pronation. Diminished hand and digital flexion. Wasting of thenar eminence. Loss of sensation. Claw hand Lesion of ulnar nerve (at axilla or due to medial epicondular fracture). Imbalance of flexion/extension occurring at IP and MP joints (hyperextended at MP, flexed at IP). Also can’t make a fist. Kyphosis (Hunchback) Increased curvature of thoracic vertebrae. (erosion of anterior portion with age) Lordosis (Swayback) Increased lumbar curvature. Pelvic gurdle rotates anterior-inferiorly, gluteal region accentuated posteriorly (ghetto booty). Scoliosis Any lateral curvature of vertebral column. More common in women (manifests during puberty). Spondylolisthesis LV5 fuses with sacrum. LV5/SV1 unsupported my articular processes. LV5 moves ventrally over SV1, compressing cauda equine (particularly LV5 and SV1 rootlets). Gluteal and lower limb pain. Happens to 5-8% of the population after damage of neural arch fusion to body of LV5. Spina Bifida Nonfusion of neural arch at midline – opening of vertebral canal. Slipped Disk Not literally a slipped disk. Pulpus gelatinous center bulges out posteriorly, impinging on spinal nerves. Posterior longitudinal ligament confines herniation to one side – so pain can be traced to specific dermatomes. Most common in lower lumbar region. Nerve that is inferior to vertebral disk will be pinched. Epidural (during labor) Injected into sacral hiatus to reduce innervation of pelvic nerves. Spinal Tap Needles inserted into lumbar cistern (between LV1-2 and SV2). Easier to get CSF here than other parts of the spinal cord to prevent nerve lesions. Reduced blood flow of the vertebral arteries (eg. arteriosclerosis) may be excerbated by prolonged turning of the head – causes dizziness and other symptoms (interference of blood supply to brain stem) Cisternal puncture Spinal tap in the neck region – subarachnoid space tapped by inserting needle in the back of the neck and penetrating the posterior alanto-occipital membrane.
