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PRE COURSE READING Thoracic Outlet Syndrome 1. Making use of the internet or other sources that may be available to you, investigate and bring to the training day two home exercises advocated for patients in the treatment of Thoracic Outlet Syndrome. Make a note of what you believe to be the clinical reasoning underpinning the use of these two exercises. 2. Add to the diagram of the brachial plexus on the next page, the nerve root components of each peripheral nerve as given in the table below. Please trace down the plexus to gain an idea as to how these numbers are arrived at. The suprascapular nerve has been done for you e.g. C5,6. (Please note that the diagram does not show the fascicular pathways for each nerve root) 3. Please revise the brachial plexus picture and memorise the names of each peripheral nerve and its nerve root origins. Name of nerve Nerve root (s) Suprascapular Nerve C5,6 Nerve to subclavius C5 Lateral Pectoral Nerve C5,6,7 Musculocutaneous Nerve C5,6,7 Upper Subscapular Nerve C5,6 Thoracodorsal Nerve C6,7,8 Lower Subscapular Nerve C5,6 Axillary Nerve C5,6 Radial Nerve C5,6,7,8 Median Nerve C5,6,7,8,T1 Medial Pectoral Nerve C8,T1 Medial Brachial Cutaneous Nerve C8,T1 Medial Antebrachial Cutaneous Nerve C8,T1 Ulnar Nerve C8,T1 Long Thoracic Nerve C5,6,7 Dorsal Scapular Nerve C5 Lateral Pectoral Suprascapular Dorsal scapular C5,C6 Musculocutaneous Nerve to Subclavius Axillary Median Radial Lowr Subscap Uppr Subscap Thoracodorsal Med. Ante-Brachial Cut Ulnar Medial Pectoral Medial Brachial Cut Long Thoracic © T.Bayford 2009 Please revise the following facts prior to attendance of Thoracic Outlet Syndrome course. Anatomy review:Please revise these basic facts Ribs 1. A typical rib consists of a head, neck, tubercle and shaft. 2. The head of a typical rib articulates with the vertebral body. The lower portion of the head forms a synovial joint with the vertebral body of its corresponding number and the upper part forms a synovial joint with the vertebral body above. 3. The tubercle of the rib articulates with the articular facet of the transverse process of its corresponding number 4. The first rib is atypical and it only articulates with T1 vertebral body. 5. The first rib has a short broad shaft. Its superior surface has a tubercle for the attachment of anterior scalene. In front of this tubercle is a groove for the passage of the subclavian vein and behind the tubercle lies a groove for the passage of the subclavian artery and inferior trunk of the brachial plexus Thoracic Vertebrae 1. The spinous process of the vertebrae is approximately adjacent to the transverse process of vertebrae below Muscles supplied by the median and ulnar nerves Muscles supplied by the Median Nerve Muscles supplied by the Ulnar nerve Pronator Teres Flexor Carpi radialis Palmaris longus Flexor digitorum superficialis Flexor digitorum profundus I and II (Anterior interosseous) Flexor pollicis longus (Anterior interosseous) Pronator Quadratus (Anterior interosseous) Abductor pollicis brevis Opponens pollicis brevis Flexor pollicis brevis Lumbricals I and II Flexor carpi ulnaris Flexor digitorum profundus III and IV Palmaris brevis Abductor digiti minimi Opponens digiti minimi Flexor digiti minimi Palmar interossei PAD Dorsal interossei DAB Lumbricals III and IV Adductor pollicis Flexor pollicis brevis (deep head) Anatomy of the Cubital Tunnel • • The tendinous arcade between the humeral and ulnar attachments of Flexor Carpi Ulnaris and the underlying bones and ligaments forms an osseo-fibrous foramen often called the cubital tunnel The cubital tunnel houses the ulnar nerve. Anatomy of Guyons canal • • • • The curved convex ulnar surface of the hook of hamate forms the lateral wall. The roof is composed of the thin volar ligament and fibres of the palmaris brevis. The floor is composed of the flexor retinaculum and piso-hamate ligament. This canal houses the ulnar artery and ulnar nerve distal to the wrist creases