Download The Upper Extremity

Bones of Upper Limb
• Appendicular Skeleton
• Pectoral Girdle =
scapula,clavicle
• Upperlimb
– Arm: humerus
– Forearm: radius, ulna
• Interosseus membrane
– Hand: carpals, metacarpals,
phalanges
Joints of Upper Extremity
• Sternoclavicular
– Synovial of saddle
– Diarthrosis
• Acromioclavicular
– Synovialof plane
– Diarthrosis
• Shoulder joint
(Glenohumeral j )
–
–
–
–
Synovial of ball&socket
Many ligaments
Muscle reinforcement
Great Mobility !
Joints of the Upper Limb
• Elbow Joint :
Synovial of hinge
• Articulations
–Humerus with
Ulna & Radius
• Collateral
Ligaments
Joints of Upper Limb
• Sup.Radioulnar joint
– Synovial of pivot
• Inf. Radioulnar joint
– Synovial – pivot
• Allows pronation and
supination of forearm
Joints of the
Upper Limb
• Radiocarpal joint
– Synovial of condyloid
– Distal radius with
scaphoid and Lunate
• Intercarpal joints
– Synovial of plane
• Carpometacarpal (2-5)
– Synovial of plane
• Trapezium-metacarpal 1
– Synovial of saddle
• Metacarpo-phalangeal
– Synovial of condyloid
• Interphalangeal
– Synovial of hinge
Review of Naming
What do the following names TELL you about the muscle?
• Naming
–Flexor carpi ulnaris
–Flexor digitorum superficialis
–Flexor pollicis longus
–Pronator quadratus
–Extensor carpi radialis brevis
• If ORIGIN on scapula = Move Arm
Muscles of
Scapula
–
–
–
–
–
–
–
Subscapularis
Rotator
Supraspinatus
Cuff
Infraspinatus
Teres Minor
Teres Major
Latissimus Dorsi (partial O on scap)
Coracobrachialis
• If INSERTION on scapula = Move
•
scapula
–
–
–
–
–
Rhomboids
Trapezius
Pectoralis Minor
Serratus Ventralis
Levator Scapulae
Nerve supply of Scapula Muscles
• Origin on Scapula:
– Latissimus dorsi = Thoracodorsal nerve
– Subscapularis, Teres Major = Subscapular nerves
– Supraspinatus, Infraspinatus = Suprascapular nerves
– Teres Minor = Axillary nerve
• Insertion on Scapula
– Levator Scapular, Rhomboids = Dorsal Scapular nerve
– Pectoralis Minor = Pectoral n.
– Serratus Ventralis = Long Thoracic n.
– Trapezius = Accessory n.
Muscles of Arm: Cross elbow, Move forearm
• 2 Compartments
– Anterior: Flexors of forearm
– Posterior: Extensors of forearm
• Anterior Compartment
– Biceps brachii = MC nerve
– Brachialis
= MC nerve
– Brachioradialis = Radial nerve
• Coracobrachialis = MC nerve
– O = coracoid process of scapula
– I = medial side humeral shaft
– A = flex, adduct arm
• Posterior Compartment
– Triceps brachii =
– Anconeus
=
Radial nerve
Radial nerve
N.B. MC = musclocutaneous nerve
Muscles of forearm:
•
•
•
•
Cross wrist & finger
joints, flexes hand & fingers
Cross Wrist = flex, extend, abduct, adduct hand
Cross Fingers = flex, extend fingers
Most muscles fleshy proximally, long tendons distally
Flexor + Extensor Retinacula :
– The retinaculum is a thick band of deep fascia has bony
attachment ; it keeps tendons in position during movements
– Under the retinaculum, tendons are surrounded by synovial
sheathes
Compartments of the forearm :
1.Anterior Flexor Compartment :
(Superficial + Deep layers)
Most of superficial flexors originate by a
common origin from medial epicondyle
Contains 2 pronators, are supplied by
Median and Ulnar nerves
2.Posterior Extensor Compartment :
(Superficial + Deep layers)
Are supplied by Radial and post.
Interosseus nerves
Anterior Compartment of Forearm s
Muscle
Nerve
• Superficial Muscles
–
–
–
–
–
Flexor digitorum superficialis
Flexor carpi radialis
Pronator teres
Palmaris longus
Flexor carpi ulnaris
Median
Median
Median
Median
Ulnar
• Deep Muscles
– Pronator quadratus
– Flexor pollicis longus
– Flexor digitorum profundus
Median
Median
Ulnar (med 1/2)
Median (lat 1/2)
Anterior Compartment Forearm
Medial Epicondyle
Brachioradialis
Pronator Teres
Flexor Carpi Radialis
Flexor Carpi Ulnaris
Flexor Retinaculum
Anterior View
Flexor Digitorum Superficialis
is deep to other flexors
Posterior Compartment of Forearm
Muscle
Nerve
• Superficial
– Extensor carpi radialis longus
– Extensor digitorum
– Extensor carpi ulnaris
Radial
Radial
Radial
• Deep
– Supinator
– Abductor pollicis longus
– Extensor pollicis longus + brevis
– Extensor indicus
Radial
Radial
Radial
Radial
Posterior Compartment of Forearm
Lateral Epicondyle
Extensor digitorum
Extensor carpi ulnaris
Posterior View
Brachioradialis
Ext Carpi Radialis Longus
Muscles of Hand
Muscle
Nerve
• Pinky (little finger)
– All digiti minimi
(Flexor, Abductor, Opponens)
Ulnar
• Thumb
– Abductor pollicis brevis
– Flexor pollicis brevis
– Opponens pollicis
– Adductor pollicis
Median
Median
Median
Ulnar
• Other Intrinsic Muscles
– Palmar & Dorsal Interossei
– 4 Lumbricals
Ulnar
Median, Ulnar
Muscles of Hand
Palmar
Interossei
Dorsal
Interossei
Lumbricals
3rd
ADDuction
ABduction
2nd
4th
1st
Interossei help the lumbricals to extend I P joints and flex MC-P joints
Blood Supply of U.L: 1. The Veins
SUPERFICIAL
•Cephalic (arm-forearm)
•Basilic (arm-forearm)
•Median Cubital (elbow)
•Median Vein
•SF. Palmar Venous Arch
•Digital
DEEP
•Subclavian (neck)
•Axillary (axilla)
•Brachial (arm-elbow)
•Radial (forearm)
•Ulnar (forearm)
•Deep Palmous Venous arch
Blood Supply of the U.L: 2.Arteries
• Subclavian A (neck)
• Axillary A (armpit)
– Subscapular A
• Brachial A (arm)
– Deep brachial
• Radial A (forearm)
• Ulnar A (forearm)
Common Interosseous A
• Superficial & Deep
Palmar arches
Axilla = Armpit
• Region between arm and chest
• Boundaries
– Ventral - pectoral muscles
– Dorsal = latissimus dorsi, teres major
subscapularis
– Medial = serratus ventralis
– Lateral = bicipital groove of humerus
• Contents
– Axillary lymph nodes, Axillary vessels
Brachial Plexus
The Axilla
•
•
•
•
Surface Anatomy of Upper Limb
Biceps + Triceps brachii
Olecrenon Process
Medial Epicondyle
Cubital Fossa
– Anterior surface elbow
– Contents
• Median Cubital Vein
• Brachial Artery
• Median Nerve
– Boundaries
• Medial= Pronator teres
• Lateral= Brachioradialis
• Superior= Line between epicondyles
• Carpal Tunnel
Surface Anatomy of
Upper Limb
– Carpals concave anteriorly
– Carpal ligament covers it
– Contains: long tendons,
Median nerve
– Inflammation of tendons =
compression of Median
nerve
• Anatomical Snuffbox
– Lateral = E. pollicis brevis
– Medial = E. pollicis longus
– Floor = scaphoid, styloid of
radius
– Contains Radial Artery
(pulse)
Brachial Plexus
• Network of nerves starts in
in the neck, then to the
axilla
• Is motor to muscles of
upper limb except trapezius
• Sensory to skin of U.L
except tip of shoulder &
upper part of skin covers
deltoid.
• Root value : C5,6,7,8,T1
Where Ventral Rami Come From
Dorsal Root
Dorsal Ramus of
spinal nerve
Ventral Ramus
of spinal nerve
spinal nerve
Ventral Root
Structure of the Spinal nerve
Parts of Brachial Plexus
•
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•
•
•
•
•
R = ROOTS (ventral rami)
T = TRUNKS
D = DIVISIONS
C = CORDS
B = BRANCHES
Roots join to form Trunks! (in neck)
• Ventral Rami
Trunks
•
•
•
•
•
Upper Trunk
C5
C6
C7
C8
T1
Middle Trunk
Lower Trunk
Trunks Split to form Divisions : (in neck)
• Trunks
• Upper
• Middle
• Lower
Divisions
Anterior
Posterior
Anterior
Posterior
Anterior
Posterior
Divisions Join to form Cords! (in axilla)
Trunks
U
M
L
Divisions
A
P
A
P
A
P
Cords
LATERAL CORD
MEDIAL CORD
POSTERIOR CORD
Cords Give off Branches!! (in axilla)
• Lateral
Musculocutaneous
Median
• Medial
• Posterior
Ulnar
Radial
Axillary
(thoracodorsal)
(subscapular)
Parts of the brachial plexus…..
Injury of the brachial plexus
Branches of the Posterior Cord
• Radial Nerve :
• ( is the largest branch of the post. cord)
– Course: Through arm, spiral groove of the humerus, then in
front of lat. epicondyle, then divides :
– Divides in the forearm to give :
• Superficial = skin of arm and dorsolateral surface of hand
• Deep ( post interosseus nerve ) = extensor muscles of forearm
(eg E. carpi radialis L , B., …)
– Innervates: posterior muscles of arm
Triceps brachii, anconeus, supinator, brachioradialis
– Sensory :……, skin of back
The Radial nerve
• 1.from post. cord
• 2.artificai triangular
space
• 3.spiral groove
• 4.pireces lat. I.M.S
• 5.in front of lat.
epicondyle, and
divides into : ……..
Damage to Radial Nerve = wrist drop
Inability to extend the hand
Branches of the Posterior Cord (continued)
• Axillary Nerve ( w . Circumflex vs..)
– Supplies:
• Deltoid and Teres minor (motor supply )
• Capsule of shoulder
• skin of lower part covering deltoid (sensory supply)
• Subscapular Nerves {branches of C5 + C6 rami}
– Innervates: Subscapularis, Teres major
• Thoracodorsal Nerve (runs w. thoracodorsal vs)
supplies: Latissimus dorsi
The brachial plexus
The Lateral Cord gives :
• .Lat. Root of median nerve
• .Lat.pectoral nerve
• Musculocutaneous :
–Course: branches to arm, distal to
elbow becomes cutaneous :sensory to
skin of lateral side of forearm .
–Motor :
• Biceps brachii, brachialis, coracobrachialis
The Median nerve
• The Median nerve : is formed by 2 roots :…..
– Course: middle of brachial plexus, distal to elbow provides
many branches to most forearm flexors, passes through carpal
tunnel to hand to lateral palmar intrinsics
– Motor supply to: most muscles of anterior of the
forearm flexors
thenar eminence (thumb), lat.2 Lumbrichals
– Sensory : skin of lateral 2/3 of palm ,lat. Three & half
fingers to back of middle phalanges
– Nerve Damage = “Ape” Hand
• Inability to Oppose Thumb
The median nerve
The median nerve : C5,6,7,8,T1
.Is formed by 2 roots
.Has 3 relations w. brachial A
.Enters forearm by piercing
pronator
teres(
supplies it 1st )
.Enters hand deep to flexor
retinaculum (
Carpal
tunnel )
. In the it gives deep &
superficial branches
The median nerve
Branches of the Medial Cord : 5
• The Ulnar nerve :
– Course: runs along medial side of arm, behind medial
epicondyle ( site of its injury )
– Enters the hand :superficial to flexor retinaculum .
– Supplies :
• Motor :FCU and medial part of FDP (in forearm1 1/2)
Ms. Of hand except 5
• Skin of medial 1/3 of hand Ant +Post + medial one &
half fingers
• Nerve Damage: Partial Claw hand
• Inability to extend fingers at interphalangeal joints,
results in permanent flexion = claw
The Ulnar nerve C7,8,T1
Ulnar nerve injury : Partial Claw hand
Dermatomal supply of the hand