Download INNERVATION OF THE LIMBS The scheme has been used

INNERVATION
J.
R.
Lecturer
in
A nato;nv,
LAST,
In
this
paper
supply
of muscles.
of
dermatomes
the
by
the
of
nerve
the
szppl’
the
form
is
a sounti
a
double
a basis
muscles-The
author
in
of
new
of
anatomical
supply-Apparent
matter
the
1923.
That
will
be
anomalies
appears
it
the
warranted
study
of
supply.
more
than
Segmental
in
the
discussion.
supply
of
has
a
the
of motor
scheme
is
nerve
discussion
be
consideration
The
nerve
but
to
segmental
new.
shown
in
the
the
tiouble
Moreover,
to
are
headings:
the
is presented
facts
motor
presented
three
anti
students.
with
fact,
under
introduction
here
.S’cholar,
muscles,
the
postgraduate
since
Research
limb
skin-No
comparison
practice
of
restatement
a convenient
for
Sutton
England
is considered
supply
many
conceptions
clinical
statement
nerve
by
Bland
of
limbs
of the
provides
and
Surgeons
the
because
shown
supply
to
of limb
segmental
is included
segmental
segmentation
of
the
supply
Segmental
of
LIMBS
ENGLAND
Curator,
College
supply
skin,
misconceptions
sensory
by
the
sUPPlY
THE
LONDON,
A natomical
Royal
segmental
OF
been
used
mnemonic,
and
Muscles
certain
with
muscles
are
explained.
SEGMENTAL
In
all
vertebrates
innervation
the
that
for
the
SUPPLY
musculature
most
of
part
For
supplied
by
the
abdomen
example,
the
cranial
however,
the
towards
the
is
myotomes
be
in
said
to
nerves,
Each
mixed
spinal
FIG.
1
mixed
spinal
the terminal
butis arise from
supplied
the
anterior
primary
probably
and
arise
number
location
that
it
the
dermis
lateral
branch
*
, ‘
452
nerves
of
sensory
supply
the
roots
‘ ‘
1).
limbs
of
arises
of each
anterior
and
posterior
‘ ‘
ventral
extensor
skin
; the
branches
Detwiler
embryonic
from
The
of
“
or
plexuses
‘ ‘
flexor
plurisegmental
adult,
wall
wall
is
is
embryos
branches
of
limb
muscles
origin,
correspond
to
(1928)
Murray
is projected
of the
; and
“
THE
into
posterior
a separation
“
that
the
three
vertebral
from
the
body
body
showed
bud.
and
compartments
limb
of the
ventral
its
gives
and
in
the
In all vertebrate
by the lateral
the
in
the
indicated
somatopleure.
plexus
anterior
ends
is supplied
lateral
part
; and
the
limb
the
limb
wall
; but
interprimary
midline
; it
into
anterior
muscles
of
are
innervated
(1936)
plexus
the
anterior
ramus
ventral
divides
by
sequence.
from
and
body
primary
rami.
wall, supplied
limb
of the
fibres.
vertebrate
the
and
is supplied
emergence
primary
mesoderm
likewise
motor
to
and
the
nerve
and
of all
corresponding
Miller
to
length
the
anterior
of body
limbs,
segmental
segmental
posterior
the
: the
overlying
somatopleure
contributing
branch
both
in the
Anterior
(Fig.
unsegmented
cranio-caudal
The
with
find
of
and
rami
from
after
into
anterior
rami
lateral
the
from
the
dermatomes
vertebrates
in regular
Thus
primary
by
branches
of the
the lateral
strip
by
limb
The
divisions.
posterior
In
of
the
thorax
traced
sequence
of all
terminal
branch
near
the
lateral
branch
which
itself
supplied
the
wall
nerve
strips
the
skin
correspond.
(Fig.
with
are
the
of the
when
trunk.
could
anterior
off a
longitudinal
column
nerves.
orderly
sense
myotomes
of the
rami
posterior
The
three
#{149}
strips
of
both’
vall.
The
limb
buds
emerue
from
the lateral
strip
(stippled
in the diagram)
innervated
b’
the
lateral
l)ranches
of
the
such
space
innervates
sequence
end
motor
segmental
intercostal
that
caudal
divides
2).
of an
anti
arranged
foramen
segmental
cutaneous
segment
body
spinal
vertebral
muscles
no
Dermatomes-The
mixed
regular
in orderly
no
and
a
overlying
tiermatt)mes
arranged
there
the
spinal
are
innervation,
has
the
same
and
SKIN
wall
with
the
space,
and
THE
body
corresponds
supply.
over
OF
the
posterior
JOURNAL
the
limb
divisions
limb
to supply
the
respectively.*
into
‘ ‘
of
anterior
to
OF
‘ ‘
and
dorsal
BONE
“
AND
lateral
Thus
or
JOINT
posterior
“
extensor.”
SURGERY
we
INNERVATION
OF
FIG.
The
distribution
of
THE
453
LIMBS
2
a typical
mixed
spinal
nerve.
.-
C1N
TkI
1.
:-
11G.
The
the
VOL.
31
12
B,
NO.
3,
destination
brachial
AUGUS
T
of
plexus
1949
the
to
anterior
the
ail
3
posteru)r
fleXor
afl(l
extensor
1lI)1)Cr IiIfll).
(livisions
of
compartments
the
truuks
of
of
the
454
R.
J.
LAST
‘;*
/
-i,’i
FIG.
The
.
:
dermatomes
ia/ante
b’
.
and
Rodin-”
anterior
Iris
4
axial
lines
(from
Messag#{232}re
des
i)ieux
a
Figure
“).
..
r
5
FIG.
-4
‘-
‘:
CS
.
..l..-
6
FIG.
The
connected
early
innervation
with
formation
of the
early
forelimb
the
trunk
(Fig.
5).
of the
axial
line-C.
bud.
Fig.
7
the
At
an
early
6 represents
dermatome
stage
a
is
C.7
dermatome
and
later
stage
no longer
is
shows
connected
still
the
with
trunk.
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
INNERVATION
.
divisions.
In the
; in
divide
form
the
the
the
which
spots
spots
continued
:
nearest
fourth
in the
axis
in the
post-axial
for
that
the
flexor
Axial
proximal
in
to
meet.
the
the
growing
the
axial
line
contact
with
roots
become
attached
and
5).
gap
(Fig.
6).
In
angle
limb
and
At
turn
Th.2
become
have
line
extends
from
the
the
C.8,
in
of
He
parts
Th.1,
lying
fifth
anti
Th.2)
in
the
Herringham’s
the
that
and
sixth,
way,
they
limb
encounters
the
order
flexor
movement
on
or
both
the
still.
line
second
the
the
this
way
“
from
just
cartilage
the
of
an
axial
skin
supplied
skin
to
beginning
Th.
trunk
has
the
of
1 coming
by
into
the
cranially
wrist
just
the
below
extensor
C.4
five
(C.4)
limb.
sternal
and
posterior
deltoid
of
the
branch
The
the
surfaces
to
(supraclavicular
no cutaneous
into
a point
and
above
dermatomes
nerve
outwards
to
the
and
moving
is attached
the
and
first,
distally
sides
(C.7)
at
bud.
at
beginning
C.5
some
central
limb
4.
intercostal
flexor
The
of the
caudal
contact
trunk,
stolen
extends
distracted
prominens
on
“
into
discontinuous
is projected
plexus
the
which
is supplied,
and
the
of the
come
In
costal
first
of skin
represents
from
indeed,
skin
cranial
segment
C.8
tip
in
along
way.
growing
The
down
which
following
the
area
breaks
is a line
across
the
the
meet
and
law
there
limb.
on
in Figure
; the
vertebra
this
central
has,
been
dermatomes
grows,
distracted
axial
of the
in contact
supply
on
nerve;
nerve.
made
across
to Herringham,
Th.1
to
lower
C.6
as shown
are
the
the
anterior
dermatomes
of
where
limb
proximally
missing
nerve
higher
across
is
a gap,
in the
bud
line
Th.3)
level
lower
another
border
in
dermatomes
which
five
arrangement
5.1
limb
limb,
the
the
or
Proximally
more
and
upper
of Louis.
nerves)
limb.
the
(Th.2
the
the
upper
other
on
L.5
adjacent
in their
each
caudally
and
The
in the
of the
line
As
in
that
Herringham’s
extensor
surfaces
to
trunk,
is entirely
out
and
first
limb
Put
6, 7, 8 and
is the
the
; they
C.5,
produced
(Fig.
tip
crosses
the
the
and
spots
limb.
(1893)
pointed
On both
flexor
from
example,
vein
higher
while
(i.e.,
the movement
example,
according
represents
alone
For
to post-axial
that
upper
fill
pre-axial
to
body,
tenth
trunk.”
possibly
in the
to
the
is
is C.7
line.
and
line
This
root
ninth
the
by
tend
of the
flexor
two
by
by
Herringham
both
1) Of
supplied
to
divisions
3).
on
headings:
supplied
unite
posterior
(Fig.
supplied
themselves
divisions
and
supplied
be
always
axis
axial
plexus
this
will
missing-a
limb
is distracted
C.7
be
be
approach
of the
to
to
to
are
of the
in
basilic
is
two
tends
tends
whether
4).
For
skin
vhich
the
anterior
under
This
root
by
eighth,
order
surfaces
dermatomes
dermatomes
the
trunks
and
compartments
“
the
into
first
the
the
tends
arm
from
unite
case
law
lower
the
from
the
extensor
“
farthest
and
that
lines-Sherrington
area of a limb.
certain
in
and
area,
his
455
divide
extensor
which
lower
numerical
sequence
of the limb
(Fig.
cephalic
and
example,
limb
each
border
the
the
first
roots
by
pre-axial
area,
progression
the segments
in
extensor
surfaces
from
the
LIMBS
roots
and
stated
area
pre-axial
will
flexor
He
THE
the
In
the
pre-axial
of the
area,
stated
law
limb.
post-axial
Thus,
“
the
for
is nearer
in the
the
plexus
arrangement
of the
that
plexus
extremity.
orderly
surfaces
2) of two
two
lower
innervation
showed
skin,
brachial
lumbo-sacral
of the
separate
(1886)
extensor
of the
of the
nerves
provide
the
case
case
OF
insertion
the
limb
the
axial
; the
is
roughly
symmetrical.
In
of
the
skin
the
limb
there
limb
from
the
foetal
and
L.1
supplied
by
limb
is mostly
axial
line
presented
post-axial
is also
the
31 B,
on
limb
3,
asymmetry.
position
on to
posterior
visible
the
lower
surface
accepted
down
to
by
extremity
thigh.
their
its
pre-axial
rotation
these
been
seems
well
easiest
segmental
and
lower
posterior
have
It
side
of the
of the
facts
regular
of trunk
line
part
investigators.
noting
along
axial
4 where
All
and
encroachment
anterior
Figure
most
to extension
to the
The
in
of the
by
partly
partly
extremity.
dermatomes
its
is due
and
is shown
are
of the
is traced
the
flexor
and
This
of flexion,
surface-it
(1943)
(Fig.
upper
NO.
is great
arrangement
line
lower
the
Harris
side
In the
in the
Th.12
on
by
summarise
if the axial
VOL.
lower
adult
to
sequence
back
along
its
4).
limb
the
Li,
2, 3, 4,
AUGUST
1949
segments
5, 5.1,
encountered
2, 3.
are
Adjacent
C.4,
5, 6, 7, 8, Th.1,
dermatomes
overlap
2 in that
order
considerably,
and
but
456
there
is
in
overlap
fl()
the
across
investigation
localisation
to
cutaneous
the
overlap
in the
itself.
Another
end
of which
lies
are
line.
The’
less
fl()
than
are
Research
all
on
the
maps
to
of the
Sherrington’s
and
Foerster’s
the
posterior
the
pre-axial
evidence
spiral
around
of the
limb.
If
(lermatome
maps
will
are more
extensive
are
open
to
algesia,
accept
made
4)
certain
must
in face
of the
Their
claim
that
medical
atijacent
nerve
an
1) The
error.
the
site
of the
Office
and
overlap
the
level
of L.1;
anterior
axial
axial
lines
a
‘ ‘
the
Metlical
reproduced
in
of dermatomes
axial
lines,
root
the
and
see
is
Foerster
meet
at
of
affected
in
may
the
accepted
and
findings
by
hypo-
is tlifficult
3) Nt) mention
known
cases
of
been
article
Garrett
their
dermatomes
have
axial
the
Keegan
are
their
to
plexus
anterior
of
observers.
well
consult
the
a dermatome
of adjacent
plexuses
of
with
of each
Nevertheless,
of mapping
of the
series
according
roots
alteration
of countless
should
particular,
dermatomes
method
; there
interested
to
a large
fundamentally
caudal
Foerster.
of overlap
is
convincing
anti
behind
Head
from
In
cranial
whole,
post-fixation
nerve
is not
findings
disagreed
dermatomes.
opinions
and
their
from
lack
unanimous
Those
scrotum
one-third
the
Injuries,
a fundamental
subjective
2) The
isolated
roots.
to
Nerve
the
they
: the
confirmed
On
pre-fixation
students
maps
ignoring
limb
exist
of Sherrington,
almost
vet
of the
of the
vill
‘ ‘
proximal
anterior
end
the
Stationery
borders
are
required.
to wide
and
respects
of the
post-axial
criticisms.
of variability,
injected
and
those
the
4).
Peripheral
reported
several
do not
lines
findings
be
(Fig.
these
spinal
line,
higher
is
matter,
low
the
proximal
skin
for that
two-thirds
segments
dermatome,
(1948)
In
delineation
their
be open
In
Garrett
axial
than
H.M.
‘ ‘
there
(1943).
and
experimental.
their
by
A
is,
anti
and,
axial
posterior
the
of
(1943).
of each
Atlas
Keegan
and
across
published
abruptly
To anaesthetise
to go seven
it with
changes
limb
great
accurate
to be able
dermatomes-that
anterior
of dermatomes
of Anatomy
in Grant’s
recently,
The
For
it is helpful
analgesia.
is 5.3.
is very
cord.
missing
of the
as the
Investigation
map
rest
spinal
forwards
covering
the
skin
lines
the
protrusions)
the
(clitoris).
axial
of
of
in the
in
far
distribution
to
a separate
modified
clinical
line
as exists
of the
regions
to
dermatomes
pamphlet
For
More
such
penis
limb,
Aids
‘ ‘
Text-book
disregardeti.
cases,
missing
out
Council
Cunningham’s
(1933)
supply
arises
of the
six
in disc
nerve
as
value
lesions
in
are included,
for the dermatome
(labium
majus)
it is necessary
accurate
is referred
For
reader
the
perineum
root
clinical
segmental
for example,
application
the
at
of
paraesthesia
of dermatomes
of the
LAST
The
or
(as,
or
here
skin
(labium
majus)
of the scrotum
lines.
lesions
lesion
well-known
the
there
root
lines-for
no confusing
anaesthetise
axial
root
anaesthesia
axial
trunk
the
of
of a single
test
across
to
J.
N.
is
to be common.
tiisc
protrusions
some
or
involvement
of Keegan
and
of
Garrett
(1948).
SEGMENTAL
but
The
position
of the
axial
the
existence
of an
orderly
widely
appreciateti.
is not
so
limb
every
are
to
muscle
it has
meaningless.
be
myotomes
The
has
often
whom
the
chaos
of myotomes.
and
can
Rules
of segmental
upper
limb
segments.
than
The
be
a source
mastered
four
lower)
segments
concerned
long
of any
spinal
at
least
manner
in which
subject
which,
perplexity,
joint
of
to
to cover
movements
muscle
nerve
to
in themselves,
of a limb
root
seems
musculature
motor
dermatomes
dermatomes
complex
remembered;
limb
of the
tables
overlying
or
of the
plexus
has
and
underlying
the
student
to
a bewildering
are segmentally
segmentation
becomes
of minutes.
general
any
origin
to memorise
easily
of the
segmental
between
of the
in a matter
that
the
of confusion,
and
known
innervation
distribution
fundamental
whole
MUSCLES
motor
learn
arrangement
if the
the
LIMB
is well
the
necessary
innervation-In
the
to
muscular
orderly
But
in
of correspondence
proved
is appreciated
OF
dermatomes
order
been
the
comparatively
innervated
rational
hitherto
lack
and
sequence
In
Similarly
memorised.
SUPPLY
lines
movement
in
it may
of
be said
a joint
a movement
(though
and
THE
this
is innervated
JOURNAL
its
opposite
OF
is less
by
BONE
are
AND
true
of the
two
adjoining
in
numerical
JOINT
SURGERY
INNERVATION
sequence
for
control
; they
the
hip
rotation
lateral
joint
and
rotation
limb
the
lower
in the
lumbar
segments
cord.
that
the
for the
centre
ankle,
into
are
namely
flexor
and
centres
extensor
innervated
joint
the
knee
the
the
in the
example,
2 and
the
3 control
upper
the
3, 4-5,
by
Hip
are,
knee
ankle
in the
and
centre
and
en
These
and
saying
JOINTS
and
lower,
consist
each
dissociate
anterior
Extend
3
Flex
4
5
Dorsiflex
5
I
Plantarfiex
learning
the
muscle
joint
movements
movements
is all that
is now
in this
of an
exercise
required
Psoas
\‘astus
The
above
are
(flexes
simple
innervation
way
OF
first.
(Table
THE
4
5
1
describetl
the
whole
give
7).
its
LOWER
ankle)
muscles
1
This
gives
by
L.4,
an
muscles.
not
also
be
that
control
It
by
noted
indication
5.1
that
flexion
of the
is important
and
all
5.2
the
and
like
the
.
knee)
.
.
.
.
.
.
.
.
.
other
at
(Table
INNERVATION
OF
foot
31
B,
NO.
3,
are
joints
of the
TARSAL
limb.
The
II.
MOVEMENTS
.
.
.
4
.
.
.
.
5
of the
this,
anterior
tibialis
among
foot
flexing
muscles
the
hip
innervated
are
and
because
posterior
tibial
posterior
the
it lies.
same
four
III).
III
AND
ROTATIONAL
MOVEMENT
AT
medial
rotation
(ci.
flexion)
.
.
2
Abduction
and
lateral
rotation
(cf.
extension)
.
.
4
anti
the
is innervated
which
by
and
1949
in
of any
examples:
lower
in Table
Adduction
AUGUST
as
action
2, 3
3, 4
I , 2
is shown
.
LATERAL
mentally)
readily,
primary
5
VOL.
only
II
OF
TABLE
SEGMENTAL
of the
of the
(if
memorised
following
.
remember
movements
extension
The
.
innervation
to
be
of the
supply.
TABLE
peroneal
performed
can
A knowledge
eversion
foot
foot
be
.
INNERVATION
Invert
Evert
can
movements
and
SEGMENTAL
2
.
.
antero-posterior
of inversion
These
I).
J,1i113
Intrinsic
system
nerve
(flex
hip)
(extends
four
centres
Foot
be
(Fig.
to
an(l
iliacus
intermedius
Soleus
segmental
to
and
of
the
muscles
joint
Ankle
2
3
4
numbers
segment
I
OF
Knee
other
the
one
will be one segment
2
while
centre
medial
respectively)
To
of each
bloc,
sacral
, 2.
the
case
spinal
flexion,
namely,
extension,
one joint into the
ankle
4, 5-1
contracting
segments
INNERVATION
the
hip,
1 ; and
start
two
centre
limb,
TABLE
Extend
For
innervation
controlling
5 ; knee
SEGMENTAL
Flex
joint.
is 3, 4, 5, 1 (lumbar
lower
components,
from
in
457
LIMBS
2, 3, 4, 5, of which
the
for
one joint
2, 3-4,
: hip
THE
4 and 5 control
the opposite
movements,
The second
rule is that in passing
distally
comprising
Thus
namely, 4, 5, 1,2.
Lower
limb-The
spinal
segments,
possible
segments
adduction,
while
and abduction.
four
it follows
all movements
includes
OF
THE
HIP
It
should
segments
458
J.
R.
From
this
movement
by
analysis
the
tWo
will
value
distribution
limb-In
through
two
lower
farther
segments
Table
IV.
with
two
numerical
exception
of inversion
segments,
and
sequence.
it
muscle
the
spinal
but
If
becomes
also
these
a simple
mentally
to
foot,
opposite
not
out
with
only
the
each
movement
movements
matter
work
of the
the
to
their
state
essential
the
muscular
segment.
case
of the
contiguous
the
upper
spinal
In
down
The
that,
memorised
a given
the
limb.
in
are
of
of any
Upper
seen
from
next
numbers
segmental
be
is controlled
segments
corresponding
the
it
a joint
of
LAST
three
cases
limb
are
limb
segments
the
the
of
spinal
the
centres
upper
INNERVATION
Shoulder
each
quite
joint
one.
lower
limb
movement
so universally
is a single
TABLE
SEGMENTAL
that
hold
segment
by
joints
rule
not
essential
controlled
controlling
the
does
are
But
down
the
in
shown
in
is controlled
as
the
their
in
the
case
rule
that
cord
still
of
joints
holds.
simplest
form
in
IV
OF
JOINTS
OF
THE
Elbow
UPPER
LIMB
\Vrist
Hand
Al)(ltlct,
externally
rotate
5
Flex
5
6
Adduct,
internally
It
6
7
8
rotate
is to be
latissimus
the above
major
Extend
Pronate
Supinate
that
flexion
and
extension
and
deltoid
are
used
and
latissimus
segments
dorsi).
The
of the
in
these
are
following
examples
Pectoralis
major
(adducts
Latissimus
dorsi
(adducts
l)eltoid
(abducts
shoulder)
Subscapularis
(internally
It
may
be
complete,
as
be pointed
muscles
of the
C.3,
fibres
4 and
5,
outlined
in
here
purposes.
remembering
any
spinal
and
student
is intended
the
the
roots
and
the
roots
6, not
nerve,
but
for
the
essential
of any
limb
C.5
as
that
it is not
poor
C.4.
and
the
for
of
is no
without
innervation
to
include
The
scheme
for
a simple
muscular
are
There
accuracy
provides
may
Although
teaching
to
it
roots
is C.4,
sufficient
scheme
muscle
these
point.
segmental
equal
is not
; or
here.
all
the
the
emphasis
the
given
segment
with
formula:
quoted
plexus
not
purposes
segments
student
segments
brachial
essential
whether
an
of
illustrates
practical
them
medical
list
true
of the
6, 7
5, 6
of the
nerve
in
6, 7, 8 for pectoralis
6, 7, 8
5
.
merely
covered
6, 7, 8
.
.
major,
already
and
.
the
five
debatable
supply
.
.
phrenic
give
the
.
it is usually
of the
of segmentation
a more
have
and
forearm
accurate
may
of the gluteal
and
lateral
rotation
is to
and
Therefore,
segmental
muscles
it
C.5
to indicate
The
contribute.
receives
should
.
.
examples
all
it is indeed
clinician
.
two
phrenic
.
Th.l
pectoralis
are
application
.
shoulder)
elbov)
from
function.
the
analysis
region
the
rotates
the
.
.
muscles
included;
they
deltoid
indicate
.
fibres
several
not
and
5, 6, 7, 8 (5 for
shoulder)
shoulder)
first
are
Intrinsic
clinical
method
distribution
of
segment.
Detailed
to
not
is C.4,
case
For
of
from
the
constitution
5 form
will
diaphragm
and
deltoid
The
diaphragm
in
receive
the
receive
that
it the
wish
that
(flexes
that
muscles
significance.
doubt
C.3
out
may
equal
objected
the
shoulder
movements,
involved
Brachioradialis
6
7
8
Extend
dorsi
The
Flex
7
8
noted
analysis.
6
6
considered
region-In
of the
Fortunately
remember
be
hip
there
the
in the
conception
superior
gluteal
of
and
forearm-For
those
innervation
of
muscles
innervation
of extension,
the
who
gluteal
further.
the
simple
scheme
is given
as L.4,
5.
is an easy
scheme
gluteal
region
segmental
nerve
These
the
are
the
of memorising
as 4, 5, 1 and
THE
essential
the
the
more
inferior
JOURNAL
detailed
gluteal
OF
abduction
segments,
BONE
but
as one
AND
others
arrangement:
JOINT
segment
SURGERY
INNER\’ATION
OF
THE
459
LIMBS
KNEE
INVERSION
FIG.
The
segmental
HAND
innervation
(unii,sK
of
the
VOL. 31 B,
NO.
3,
AUGUST
segmental
1949
movements
innervation
EVEP.SICN
of
the
lower
limb.
FINOE)S
MUSCLES)
FIG.
The
I
7
of the
8
movements
of the
upper
limb.
H.
460
lower,
namely,
femoris
and
segments
5, 1 , 2.
The
same
nerve
to
obturator
the
apparently
the
supplies
three
J. LAST
segments
are
internus
lower
muscles).
Nerve
to
to
the
muscles
to
limb
remaining
muscles
of the
the
forearm
is given
in
enlarge
the
this
as
formula
7 ; and
than
is the
limbs
are
under
control
downwards,
innervation
case
with
case
of more
is shown
in Table
Fingers
and
flexor
carpi
cord,
ulnaris
from
over
90
described
per
a communication
(1904)
was
in
present
evitlence
found
of
lateral
centre
fibres
flexor
Harris
text-book
the
and
that
and
a constituent
current
at
are
C.6,
from
the
of the
and
.
.
.
.
.
.
.
.
.
Extend
lower,
one
that
(inferior
internus);
flexor
the
rule
distal
to
The
detailed
in
important
second
more
is best
.
muscles
more
joints
consider
them
segmental
the
to take
this
seventh
cervical
the
the
efferent
and
so
to
the
writer’s
from
carpi
of
nerve,
that
wrist
centre
ulnaris
the
the
must
reach
is, in fact,
nerve
clinical
of the
of its
reason
is under
Harris
ulnar
nerve
for
control
flexor
in
found
that
A frequency
in spite
he
\Vilfred
of
ulnar
\\‘alsh
axilla
remainder
nerve.
the
medial
But
in the
observation
fibres.
of the
this
the
is
that
The
only.
head
C.7
radialis
appear
nerve.
nerve
ulnar
head
suggestion
not
ulnar
lateral
other
carpi
it does
fibres
in half
the
with
flexion
the
Flexor
ulnar
significant
lateral
as any
the
Th.1
and
; the
adds
delicate
flexor
to
plexus,
cord
fibres
The
but
and
cord
brachial
is that
flexors.
formula;
C.8
is supplietl
is the
Th.1
as it is from
lateral
plexus
7,8
7,8
.
wrist
above
observations
the
nerve
.
contains
he
6, 7
6, 7
lower)
innervated
brachial
route.
.
of
and
FOREARM
lower)
.
segment
medial
It
ulnar
segment
.
in the
ulnaris
descriptions.
7,
.
.
similar
makes
THE
.
of the
the
OF
.
from
carpi
of the
head
forced
to
MUSCLES
.
dissections,
\\‘alsh
8)
(Fig.
.
is derived,
matle
suggests
by
constant
C.7
twenty-six
It
,8
.
scheme,
nerve
dissections
iii
centres.
.
innervation
dissections
from
thirty
this
ulnar
of 290
maximus
The
that
.
is indicated
a contribution
cent.
migrated
innervation
to obturator
buttock.
.
muscles
(one
the
this
into
the
piriformis,
has
segmental
is probably
.
joint
intrinsic
note
fits
which
has
(1877)
to
7, and
except
VI
THE
thumb-Flex
(one
Hand
C.6,
I
maximus)
of all the
It
of the
6-7
,
I
medius,
femoris)
that
gluteus
namely,
placed
OF
Extend
by
of
4, 5, 1.
C.8.
5
its
(nerve
muscles
as
(gluteus
groups
innervation
forearm,
elbow
INNERVATION
W’rist-Flex
interesting
by
the
TABLE
is
group
VI.
SEGMENTAL
innervated
supplies
gemellus
extensors,
of the
the
5, 1 ,2,
the
caudally
remembering
retains
supplied
the
quadratus
(gluteus
fasciae
rectus
still
superior
of all
nerve
of these
and
scheme
nerve
tensor
prevertebral
group,
its
gluteal
other
limb
are
in the
or
of the
lower
simple
C.6,
holds
one
lower
buttock
to
higher
MUSCLES
gluteal
minimus,
Inferior
part
with
the
innervation
above
It
GLUTEAL
Superior
into
The
internus
of the forearm-In
from
1
,
but
(S.l,2).
obturator
muscles
of segmental
fall
to the
nerves
and
The
to
THE
5, 1 , 2
muscle
attachment
spinal
nerve)
the
and
buttock
lower
gain
separate
all
of the
a true
downwards
from
internus
gemellus
is not
gluteal
,
nerve
the
V.)
gluteus
obturator
superior
All
OF
gemellus
Nerve
which
and
the
that
V
INNERVATION
femoris
(itiaclratlis
inferior
in
(note
(Table
TABLE
SEGMENTAL
contained
respectively
order
almost
absence
the
existence
of the
carpi
innervateti
as
from
wrist
ulnaris,
by
these
segment.
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
INNERVATION
Discussion-Among
were
those
the
of Ferrier
stimulation
of single
stated
co-ordinated
dermatomes
and
apparent
border
has
the
peronei).
plan
:
little
no
that
in
are
pre-axial
medial
conception
His
conclusions
on
conclusions
were
a procedure
which,
normal
that
‘ ‘
at
to
the
writer’s
in
limitations
this
only
case.
The
of the
to confine
that
segmental
extent
of the
spinal
Much
more
accurate
or Sherrington,
innervation
of the
segmental
popliteal
nerve
(1947)
based
still
clinical
the foot ; such a distribution
a limb
are controlled
by
Sherrington’s
work
(1892)
wrote
almost
to
of the
foot
An
by
:
.
.
.
the
4 in the
exercised
B,
NO.
3,
AUGUST
own
experiments
interest.
of my
In
in man
the
though
are
whole
cortex
centres
generally
1949
it
limit
always,
outlined
system
of
controls
composed
in groups
not
muscles
of segments
of lour
are
which
is,
in
be arrived
in
as may
the
be
cat
by
expected.
observation
; once
was
final
tione,
of
the
In
of
how
but
joint
movements.
arranged
for each
sole
of
joints
connection
spacious
own
intrinsic
is the
sequence
innervation
medial
in
also
age
he
thinking
muscles
root.”
orderly
their
are
the
sacral
and
that
of the
in my
to
third
in regular
segments
this
a more
outflow
the
the
Guttmann’s
peripheral
amounts
motor
shows
in
in
most
either
segmental
of distribution
5.3
muscles
the
centres.
into
the
details
intrinsic
that
by
about
is significance
the
limbs
possessed
word
Many
probability
of the
myotomes
(1904)
It
can
It is by clinical
circumlocution
in the
cat,
results
example
truth
determined
there
spinal
above
distributed
the
destination
concept
extend
the
produce
Harris
its
movements
written.
that
the
and
never
investigation.
than
supplies
stately
mvotomes.
Sherrington’s
is an
results,
the
the
the
when
centre.
that
placed
the
lower
not
principles
spinal
downwards,
caudally
of the
prerolandic
that
in with
that
in
than
the
evidence.
been
feels
of
could
\\‘ilfred
precisely
particular,
author
showed,
Herringham’s
man.
It
is
the
1 segment
out
in Rhesus
that
available
means
most
segments
The
through
above
the
this
he
Th.
false
with
joint
joint
be
There
contrary,
court.
correct
equivocal
be stated
no
evidence,
fit
experimental
single
now
In
would
often,
muscle
Area
31
that
does
appreciation
which
movements.
VOL.
is of
In view
certainty
joint
from
“
by
; the
of
can
is
has
plexus.”
very
from
unknown.
uncertain
on
to one
it should
muscles
are
human
reproduce
with
inferred
agrees
who
or Th.l;
hand.
the
pointed
innervation
in
anti
underlying
CS
in
centres,
of approach
to
but
information
is very
view,
be
though
limb
fibres
attempted
distribution
can
author
the
of
nerves
spinal
brachio-
monkey
he
out
spinal
method
stimulus
Rhesus
approximately
method
columns,
motor
centres
Herringham
of
has
the
possible
in
the
analytical
synthetic
grey
It is not
man
of the
writer
The
than
of
by the
the
of
tibials
the
of the
dissection
of the
pre-axial
(1886)
variation
direct
on the
from
of dermatomes,
separate
9).
distribution
anterior
by
point
Herringham
on
the
minor
in
that,
centres
can
example,
never
muscles
In
are
sense
posterior
place
C.7,
showed
true
arrangement
is more
motor
or
deep
only.
made
(Fig.
methods
the
opinion,
stimulation
movements
these
deceive
hypothesis
of single
of the
no
intra-segmental
brilliantly
were
nature
Th.1
(for
of the hand.
Furthermore
head has a higher
segmental
was
stimulation
the
joint
of
applied
illustrates
by
by
to
and
Herringham’s
supply
has
C.6
the
this
is no
side
lateral
distribution
made
regular
neither
directly
the
root
by
there
putting
pre-axial
as are
denied
supplied
hand
post-axial
the
head-thus
of higher
the
are
of the
from the pre-axial
to the
the case of the gastrocnemius
C.8
and
by
no
is one
and
They
cord
in
border
by
contract.
a muscle
anterior
muscles
obtained
spinal
that
situations
enough
of limb
that
There
; the
supplied
(1892)
said
post-axial
wrist
it was
by
been
fortuitous
are
supplied
hand
muscles
on the
of the
muscles
Sherrington
of the
the
one
Nevertheless,
muscles
of the
has
: in a fev
is entirely
thumb
hand.”
muscles
too,
arrangement
muscles
in the
intrinsic
an
than
extensor
of the
to correspond.
misleading
supply
and
said
supply
movements
enlargements
It
be
segmental
multi-jointed
most
lumbar
limbs
be very
flexor
superficial
finger
Th.I
can
segmentation.
The
‘ ‘
the
the
the
combinations.”
segmental
ulnar
and
461
LIMBS
into
reported
determined
cervical
of
that
Such
of limb
stated
the
mvotomes
the
who
and
muscular
a higher
and
the
THE
investigations
(1881),
nerves
that
resemblance
radialis
Yeo
spinal
It is evident
‘ ‘
of highly
earliest
and
OF
arrangement
for
consecutive
becomes
This
in orderly
joint.
clear.
control
sequence
It is probable
is
462
J.
R.
that
the
and
tlmt
it
(1892)
and
cord,
control
subcortical
in such
spinal
Bruce
(1901)
described
afl(l
the
htrn
cells
in each.
an
antcro-lattral
innervates
latter’s
movements
centres
as
the
gives
Physiological
body
wall,
‘ocietv
of
he
cell
cells
of
aggregates
showed
in
anti
the
the
the
the
of
anterior
-the
forefoot
side
from
had been
‘hen
than
the
animal
a
month
the
the
lateral
horns
exist
entities
in foetal
rat,
anatomical
l)laced
.
in
l)art
the
upper
limi)
in Tables
It
demarcated,
l)Ut
central
core
of
extentling
that
shade
areas
a further
plexus
The
the
in the
IV anti
off
cervical
VI.
The
that
as
(10 the
is intiicated
segment
would
of the
boundaries
in the
above
or
the
precisely
(Ic-
scribeti
by
Romanes
can
anything
but
for
the
joiit
spinal
movements
exist
tO
; and
by
the
a hypothetical
of
the
joint
can
be
made
with
Such
a
the lower
of
Inan.
enlargement
boundaries
seems
so
limb
centres
the
of
horn.
centres
in
indicated
are
psterirl’
some
confidence.
reconstruction
.
limb
more
centres
lateral
centres
lover
rabbit
the
m )re
the
spinal
man,
that
reconstructli)n
than
(1941
as
and
author
the
since
that
centres
inferred
of the
has
shovn
centres
fur
lie
of the
Romanes
has
be
ceiltres
motor
confirmat
1( )n,
and
experi-
inconceivable
.
less
His
regions
ample
clinical
anterior
as
was
old.
muscles
in
for
which
the
alflpUtate(l
limb
situated
s1)iIlal
side
that
of the
caudally
-1 he
‘as
one
on
conclusion
etc.)
9
cells
cells
and
At
group
horn
reduced
a
cat.
postero-lateral
mental.
JIG.
At
adult
much
received
1)0th
S
group
limbs.
of an
C.8
a metlial,
metiial
of the
cord
spinal
of anterior
horn;
anterior
3
adult
the
muscles
in
L2.
the
number
that
5J)iflal
spinal,
Sherrington
anterior
correctly,
groups
measure
in man.
in the
opinion,
lateral
1892
is in large
above
situation
groups
was
the
in
such
of
three
He
animals
described
of their
describeti
the
been
existence
a postero-lateral.
of
in lower
have
a description
Sherrington
muscles
the
of
atlas
and
the
meeting
common
of
exists
LAST
joint
of the
formulae
below
that
Fig.
in man
9.
be similar,
following
not
are
centres
centre
itself
the
precise
stateti-though
4.
sometimes
not
formulae
and
in Area
can
is shown
A reconstruction
centres
cortical
; the
centres
sharply
The
main
be taken
beyond
the
limit
itself.
clinical
()f the
importance
cortical
of
centres,
the
precise
because
location
a lesion
in
the
confined
THE
cord
of the
exclusively
JOURNAL
spinal
to
OF
BONE
centres
a single
AND
JOINT
is less
joint
area
SURGERY
INNERVATION
is unlikely
and
to occur
their
virtually
the
in the
I)reCise
scheme
Perhaps
class,
smile
whose
proceedeti.
At
age
knee
reference
its
and
and
anatomy
the
Tables
cases
subtracted
or
addeti.
But
vary
his
lesion
inability
for
the
segments
always
to
other,
Herringham
a
Each
fact
the
relative
which
A
an
of
anti
of
the
a
diyision
takes
brachi
in the
simpler
Place
before
the
The
place
formation
while
more
richer
segments
anti
post-fixation
is high
precisely
root
as
far
of
acting
than
derived
to
these
facts
with
its
we
figures
be
are
not
a
as
its
the
coarser
find
that
,
-
-
of
( fh.1
plexus
the
motor
flexor
I
Cross-section
The’
arrow
.
; S..3)
fibres
are
intermuScular
10
IG
of the
indicates
above
arm
the
septum
site
of
hetvecn
compartments.
the
the
elbow.
foetal
flexor
and
compartment
in mind
branch
for
from
to
of tne
the
brachialis
compartment
and
anterior
from
compartment,
where
it fuseswith
Also
included
in the
flexor
radial
nerve
which
nerve,
a nerve
lateral
and
between
of the
medial
flexor
31 B,
runs
NO.
3,
flexor
intermuscular
anti
extensor
AUGUST
part
and
compartment,
septa
corilpartments.
1949
the
radial
in
the
to
by the
elbow
is contained
of the
adult
joint.
do
ratlial
The
tleveloped
of
of
the
not
septum
in
extensor
represent
between
the
that
extent
is
extensor
nerve
flexor
(Fig.
part
foetal
10).
of
of the
compartment.
the
is the
the
the
A similar
limb,
nerve
in
and
ulnar
explanation
brachialis
muscle
in
arm
the
the
upper
to understanti
musculocutaneous
brachio-radialis
the
difficult
for
position
part
(hgitorum
from
of the
muscle.
nerve
this
innervated
as flexor
supply,
is more
nerve,
is a flexor
included
are
anterior
It
alteration
has
compartment
above
by
a muscle
nerve
compartment
trunks.
brachialis
Subsequent
that
flexor
(musculospiral)
while
compartments
such
a tiouble
of the
of the
ratlial
limb.
have
is a nerve
innervated
foetal
extensor
that
can
divisions
the
brachialis
the
of
flexor
of these
compartment
of
understand
to
lumbricals
each
the
extensor
portion
it is easy
accompanying
nerves,
originally
nerve
VOL.
limb
must
limb.
metlian
the
; exact
extensor
entirely
profundus
that
placed
segments
of
flexors
the
consequently
cauclal
\Vith
the
normally
al
.
and
in
number
lumbo-sacral
formation
innervation
muscles;
of the
as
show.
extensor
the
it takes
distributed,
never
plexus
after
trunks,
concerned,
had
paralysis,
to
the
of the
is
He
L.4
division
anti
plexus
most
drop.
vith
the
i
the
the
at
weakness
may
limb
flexor
plexus
a
a
lecture
SUPPLY
posterior
respectively.
demand
will
of
the
plimyelitis
a pure
appropriate
know’n
NERVE
root
innervation
extensor
foot
was
clinical
positions
was
DOUBLE
anterior
compartments
branches.
as
Anterior
without
the
to
wider
quadriceps
the
column,
their
component
into
a limb
own.
II)
own
member
1886.
WITH
divides
to
but
I and
refer
of pre-
his
veakness,
moment-it
(Tables
figures
vertebral
maintain
in
MUSCLES
the
foot
post-fixation
a segment
to
was
taught
satisfaction.
their
a Jarnaical1
and
serve
to
has
great
from
wider
interest,
made
author
given
of
became
that
limb
incidence
it has
case
be
The
doctors
the
academic
can
muscle.
these
gluteal
the
until
lower
and
The
regard
each
pre-
with
any
to vliom
was
presenteti
invert
above
of
he
scheme
by
satisfaction
him
to
of
although
with
for
left
post-fixation-The
In
case
had
is of great
the
of
recalled
example
and
the
months
plexuses.
known.
striking
conclusion
the
to
been
centres
that
students,
have
most
of such
suppl’
postgratluate
463
LIMBS
remembered
segmental
of comprehension
jerk,
understood
the
THE
existence
easily
application
the
of eighteen
absent
the
so
hundreti
of its
experience.
But
be
to Place
to several
examples
Pre-
can
as a mnemonic
Many
the
cord.
levels
OF
the
ulnar
The
(livision
464
J.
R.
In
the
sciatic
case
nerve
although
nerve
a flexor
which
of the
is the
flexor
compartment.
always
developed
of the
the
lumbar
side of psoas
cephalic
of that
side
bone.
cases
that
In
part
(obturator)
some
cases
of the
brachialis,
by
the nerve
fusion
supply
out
true
is
the
lies
and
of all muscles
the
the
will
have
its
it emerges
the
caudal
nerve
developed
of
flexor
posterior
on the
it emerges
femoral
side
; in such
in the
the
is
supply
of the
obturator
border
it
nerve,
from
on
the
thigh,
femoral
arises
the
head
into
it derives
emerges
pre-axial
extensor
the
that
true
short
the
is a nerve
Like
the
the
migrated
by
fact
nerve
obturator
at
nerve,
of
; it
femoral.
from
sciatic
individuals
misnamed
obturator
This,
of the
is that
itself
of the
biceps.
adductor
nerve
moiety
of the
later
usually
of three
fibres
from
muscle
of flexor
only
is supplied
accessory
receives
innervated
The
the
; the
pectineus
muscle
is formed
In short,
bone
reason
and
notwithstanding
be called
pubic
The
An
obturator
head
component
leg.
nerve
3) and
(2,
compartment.
in one
The
popliteal
short
example.
and
; but
rightly
of the
of the
obturator
nerves
should
medial
the
compartment
nerve.
accessory
the
popliteal
another
compartment
But
lateral
compartment
obturator
by
except
extensor
affords
extensor
extensor
supplied
compartment
in the
Pectineus
accessory
are
by the
extensor
developed
compartment.
medial
Ofl the
flexor
is supplied
in the
an
divisions
all
compartment)
of the
was
of the
from
hamstrings,
of the
muscle,
nerve
biceps
the nerve
also
of the
(the
LAST
limb
flexor
and,
like
flesh.
is a certain
guide
to their
embryological
development.
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