Upper Limb Clinical Anatomy PDF

1 Upper Limb - clinical anatomy Upper limb girdle 2 Is created by Upper limb girdle muscles: - Deltoid - Supraspinatus - Infraspinatus - Subscapular - Teres minor - Teres major Upper limb girdle 3 Deltoid muscle - Origins: acromion, clav...

1 Upper Limb - clinical anatomy Upper limb girdle 2 Is created by Upper limb girdle muscles: - Deltoid - Supraspinatus - Infraspinatus - Subscapular - Teres minor - Teres major Upper limb girdle 3 Deltoid muscle - Origins: acromion, clavicle acromial end, spine of scapula. - Insertion: deltoid tuberosity - Movements: adbuction Lateral and medial rotation Extension and flexion - Innervation: axillary nerve Upper limb girdle 4 Supraspinatus Origin: supraspinatus fossa Insertion: greater tubercle Movements: abduction of the arm Innervation: suprascapular nerve Upper limb girdle 5 Infraspinatus Origin: infraspinatus fossa Insertion: greater tubercle (posteriorly) Movement: lateral rotation of the arm Innervation: suprascapular nerve Upper limb girdle 6 Subscapularis Origin: subscapular fossa Insertion: Lesser tubercle Movements: Adduction and medial rotation of the arm Innervation: subscapular nerves Upper limb girdle 7 Teres minor Origin: Lateral border of the scapula Insertion: Inferior facet of the greater tubercle Movements: lateral rotation of the arm Innervation: axillary nerve Upper limb girdle 8 Teres major Origin: Inferior angle of the scapula Insertion: medial lip of intertubercular groove Movements: adduction and medial rotation of the arm Innervation: subscapular nerves Upper limb girdle 9 CLAVICLE fracture is the most common in the middle third (80%), in the medial third (5%) and lateral third very rare but involving the coracoclavicular ligament tears. Upper limb girdle 10 CLAVICLE is the first long bone to ossify, beggining during the 5th and 6th embryonic weeks. A secondary ossification center appears at the sternal end and forms a scale like epiphysis that begins to fuse with the shaft between 18 – 25 years of age and is completely fused to it between 25 and 31 years old. This is the last of the epiphyses of the long bones to fuse. Upper limb girdle 11 Glenohumeral dislocation: Most of them (95%) are in an anterior direction. Types of anterior dislocation are: - Subcoracoid (most often) - subglenoid - Subclavicular (rare) During dislocation axillary and musculocutaneus nerve may be injured. Upper limb girdle 12 Tendinita la umar Shoulder tendinitis and bursistis Can be caused by inflamation of tendons surrounding the joint and bursa. The supraspinatus muscle is vulnerable because it can become pinched by the greater tubercle and acromion. Upper limb girdle 13 Rotator cuff muscles: - Supraspinatus - Infraspinatus - Subscapularis - Teres minor After extensive rupture of the cuff, shoulder girdle elevation is possible only to 45 degree. Deltoid muscle contracts strongly but only pulls humerus upward while scapula rotates. Upper limb girdle 14 Axillary cavity boundaries: Base: axillary fascia Axillary inlet: surrounded by first rib, superior border of the scapula and clavicle Anterior wall: pectoralis minor and major muscle and clavipectoral fascia Posterior wall: subscapularis, teres major, latissimus dorsi, and long head of triceps muscles Medial wall: serratus anterior and intercostal muscles Lateral wall: humerus  Upper limb girdle 15 Axillary cavity openings: Triangular foramen (medial axillary foramen) Limits: Superior – teres minor; Inferior – teres major; Lateral – long head of triceps Contents: circumflex scapular artery and vein Quadrangular foramen (lateral axillary foramen) Limits: Superior – teres minor; Inferior – teres major; Lateral – surgical neck of humerus; Medial – long head of triceps; Contents: posterior circumflex humeral artery and vein, axillary nerve Upper limb girdle 16 Axillary cavity content: - Axillary artery - Axillary vein - Axillary lymph nodes - Brachial plexus - Axillary tail (of Spence) of female brest - Coracobrachialis and biceps portions  Upper limb girdle 17 Arterial supply of the upper limb girdle Subclavian artery branches: - Vertebral artery - Internal thoracic artery - Thyrocervical trunk -- Inferior thyroid artery -- Suprascapular artery -- Transverse cervical artery - Costocervical trunk -- deep cervical artery -- supreme intercostal artery Upper limb girdle Arterial supply of the upper limb girdle 18 Axillary artery branches: From 1st part (above pectoralis minor) - Superior thoracic artery From 2nd part (behind pectoralis minor) - Thoracoacromial artery -- acromial branch -- clavicular branch -- deltoid branch -- pectoral branch - Lateral thoracic artery From 3rd part (below pectoralis minor) - Subscapular artery -- thoracodorsal artery -- circumflex scapular artery - Anterior circumflex humeral artery - Posterior circumflex humeral artery  Upper limb girdle 19 Compression of the third part of the axillary artery against the humerus sometimes is necessary when profuse bleeding occurs. If compression is required at a more proximal site, artery may be compressed at its origin by exerting downward pressure in the angle between the clavicle and the inferior attachment of the sternocleidomastoid. Aneurysm of axillary artery Can compress the trunks of the brachial plexus, causing pain and loss of sensation in the area of compressed nerves. (sometimes in baseball pitchers). Upper limb girdle 20 Injuries to Axillary vein can show up after wounds of the axilla. A wound in the proximal part of the axillary vein is dangerous because of the risk of air entering it and producing air emboli in the blood. Axillary vein is used as the entrance in subclavian vein puncture so it’s important to know that the axillary vein lies anterior and inferior to the axillary artery and the parts of the brachial plexus that begin to surround the artery at this point. C circumflex s... Upper limb girdle 21 Vascular anastomosis around the scapula Circumflex Scapular Artery C. circumflex scapular artery - Dorsal scapular artery from thyrocervical trunk of subclavian (B) - Suprascapular artery from thyrocervical trunk of subclavian (A) - Subscapular artery and its thoracodorsal and circuflex scapular artery (C) of axillary artery C circumflex s... Upper limb girdle 22 Upper limb veins Axillary vein Is the continuation of the basilic vein or brachial venae comitantes which go together with brachial artery. After crossing of the first rib axillary vein becomes the subclavian vein.  Brachial plexus C circumflex s... 23 Spinal nerve structure Posterior root contains preganglionic sensory Posterior root fibers Spinal ganglion - Spinal nerve ganglion is Meningeal branch created by the bodies of Posterior branch sensory neurons Anterior root contains motoric Anterior branch Anterior root fibers and preganglionic sympathetic fibers grey communicating branch white communicating branch Spinal nerve trunk is the place of different fibers mixing  Brachial plexus 24 White communicating branch provides preganglionic Spinal nerve structure sympathetic fibers to the sympathetic ganglion; Posterior root Spinal ganglion Grey communicating branch provides postganglionic Posterior branch sympathetic fibers from Meningeal branch sympathetic ganglion to the Anterior branch spinal nerve trunk; Meningeal branch provides the Anterior root sensory and postganglionic white communicating branch sympathetic fibers sypplying grey communicating branch the spinal canal and spinal dura mater. Sympathetic ganglion  Brachial plexus 25 Posterior branch provides sensory and motoric fibers supplying the deep back Spinal nerve structure muscles and skin of the back. Spinal ganglion Posterior root Posterior branch Anterior branch provides Meningeal branch sensory, motoric and Anterior branch postganglionic sympathetic fibers. They take part in neural plexuses creation and supply Anterior root white communicating branch muscles and skin of the grey communicating branch limbs, chest and abdomen. Sympathetic ganglion  Brachial plexus C circumflex s... Brachial plexus components: 26 1. Plexus roots (anterior rami of the spinal nerves from C5 to T1 Location: posterior interscalene space 2. Trunks: upper, middle and Lower Location: Lateral to the interscalene space and above the clavicle 3. Anterior and Posterior divisions of each trunk Location: Posterior to the clavicle 4. Cords: Lateral, medial and posterior Location: In the axilla, posterior to the pectoralis minor muscle  Brachial plexus C circumflex s... Brachial plexus Supraclavicular part (short branches) 27 1. Dorsal scapular nerve (C3 – C5) Supply: - Levator scapulae muscle; - Rhomboid major muscle; - Rhomboid minor muscle; 2. Suprascapular nerve (C4 – C6) Supply: Supraspinatus muscle; Infraspinatus muscle 3. Long thoracic nerve (C5 – C7) Supply: Serratus anterior muscle 4. Subclavian nerve (C5, C6) Supply: Subclavius muscle  Brachial plexus Brachial plexus Infraclavicular part 28 Short branches: 1. Subscapular nerve (C5, C6 posterior cord) Supply: Subscapularis muscle; Teres major muscle; 2. Thoracodorsal nerve (C6 – C8 posterior cord) Supply: Latissimus dorsi 3. Medial and lateral pectoralis nerves (C5 – T1 medial and lateral cord) Long skin branches Supply: 4. Medial cutaneous brachial nerve (C8, T1 medial cord Supply: skin over the medial part of the arm Pectoralis minor muscle Pectoralis major muscle 5. Medial cutaneous antebrachial nerve (T1, T2 medial cord) Supply: skin over the medial part of the forearm  Brachial plexus 1. Scalene syndrom 29 or cervical syndrom caused by the compression in the interscalene space usually by the presence of the cervical rib or ligamentous structure  Damage to the brachial plexus may present as pain, loss of sensation, and/or motor weakness. Clinical findings depend on the site of the lesion: - Upper plexus lesion (Erb – Duchenne palsy): usually affect the distribution of C5 – C6 nerve roots, with the deltoid and biceps, muscles affected, and sensory changes that extend below the elbow to the hand. Is apparent by the characteristic position (waiters tip position) in which the limb hangs by the side in medial rotation. It shows up after falling of the motorcycle or a horse and lands on the shoulder in the way that separates neck and shoulder or in infants when excessive streching of the neck occurs during delivery.  Brachial plexus 30  Lower plexus lesion (Klumpke’s palsy): usually affect the distribution of C8 – T1 nerve roots, with median and ulnar innervated muscles affected; hand weakness and sensory changes involve most of the palmar hand and ulnar aspect of the dorsal hand producing the claw hand.  Can show up when the upper limb is suddenly pulled superiorly – when person grasps something to break a fall or a baby’s upper limb is pulled excessively during delivery.  Brachial plexus 31 Brachial plexus Infraclavicular part Long branches: 1. Musculocutaneous nerve (C5 – C7 lateral cord) Supply: Coracobrachialis muscle Biceps brachii muscle Brachialis muscle - Lateral antebrachial cutaneous nerve Supply: skin over the lateral part of the forearm 2. Axillary nerve (C5, C6 posterior cord) Supply: Deltoid muscle; Teres minor muscle; - Superior lateral cutaneous brachial nerve Supply: skin over the lateral part of the arm  Brachial plexus: axillary 32 nerve The axillary nerve (C5 and C6) is usually injured during fracture of the neck of humerus. It may also be damage during dislocation of the glenohumeral joint and compression from the incorrect use of crutches. The result is the deltoid athrophies which produce flattened contour of the shoulder and also loss of sensation over the lateral side of the proximal part of the arm.  Brachial plexus: musculocutaneus nerve 33 Musculocutaneous nerve (C5 – C7) injury in the axilla can be caused by the weapon such a knife. It may result in paralysis of the anterior flexors muscles. Weak flexion and supination are still possible thanks to forearm muscles. Loss of sensation may occur on the lateral surface of the forearm.  Brachial plexus : radial nerve34 Brachial plexus Infraclavicular part Long branches: Radial nerve (C5 –T1 posterior cord) Supply: Triceps brachii muscle Anconeus muscle Supinator muscle Brachioradialis muscle Extensor carpi radialis longus muscle Extensor carpi radialis brevis muscle Extensor digitorum muscle Extensor digiti minimi muscle Extensor carpi ulnaris muscle Extensor pollicis longus muscle Extensor pollicis brevis muscle Extensor indicis muscle Abductor pollicis longus muscle  Brachial plexus : radial nerve 35 Brachial plexus Infraclavicular part Long branches: - Inferior lateral cutaneous brachial nerve Supply: skin over the lateral part of the arm - Posterior cutaneous brachial nerve Supply: skin over the posterior part of the arm - Posterior cutaneous antebrachial nerve Supply: skin over the posterior part of the forearm - Superficial branch of the radial nerve Supply: skin over the dorsal part of hand 2 and ½ digits radial side  Brachial plexus: radial nerve 36 Radial nerve (C5 – T1) injury superior to the origin its branches to triceps results in paralysis of extensor muscles of arm and forearm and loss of sensation at the posterior skin areas of the arm and forearm. Injury at the level of the radial groove causes uncomplete paralysis of triceps but paralysis of the forearm extensors. The clinical sign is the wrist –drop – inability to extend the wrist and the fingers. Partly flexed position of the wrist.  Upper limb girdle 37 Axillary lymph nodes Lie in the fat tissue of the axillary cavity. They drainage the upper limb, anterior wall of the thorax (breast – 75% of the lymph) and the back. These lymph nodes can be divided into 5 groups: - Apical (subclavian) lymph nodes connect with supraclavicular lymph nodes - Central lymph nodes – receive the lymph from other groups - Lateral (humeral) lymph nodes – receive most of the upper limb drainage - Posterior (subscapular) lymph nodes drainage the upper back - Anterior (pectoral) lymph nodes drain the breast and anterior trunk  Upper limb girdle C circumflex s... 38 Axillary lymph nodes enlargement An infection in the upper limb can cause the axillary nodes to become tender and inflamed. Lymphangitis (inflamation of the lymphatic vessels) can produce warm, red, tender streaks in the skin of the limb. Infections of the pectoral region, breast and superior part of the abdomen. In metastatic cancer of the apical group the nodes usually adhere to the axillary vein. Apical lymph nodes enlargement can obstruct the cephalic vein.  Upper limb girdle 39 Axillary lymph nodes dissection Removing and examining the lymph nodes is important in determining the degree of the cancer and is likely to have metastasized. After removing of the axillary lymph nodes lymphatic drainage of upper limb may be impeded resulting in lymphedema. During axillary lymph nodes dissection two nerves may be injured: long thoracic nerve – supplying the serratus anterior muscle what results in wing scapula Thoracodorsal nerve – supplying the lattissimus dorsi muscle resulting in medial rotation and adduction of the arm are weakened.  Arm 40 Muscles of the arm: Anterior compartment muscles: Generally flexors of the shoulder and elbow joints Supinators of the forearm (biceps brachii) Coracobrachialis muscle Origin: coracoid process Insertion: medial surface of the shaft of humerus 1/3 part Movements: flexion and adduction of the arm Innervation: musculocutaneous nerve  Arm 41 Muscles of the arm: Biceps brachii muscle Origin: long head – supraglenoid tubercle, short head coracoid process Insertion: radial tuberosity, aponeurosis connects to the forearm fascia Movements: flexion and supination of the forearm at the elbow joint, flexion of the arm Innervation: musculocutaneous nerve Brachialis muscle Origin: distal half of anterior humerus Insertion: Ulnar tuberosity Movements: flexion of the forearm Innervation: musculocutaneous nerve  Arm 42 Muscles of the arm: Biceps tendinitis Inflamation of the tendon is the result of repetitive microtrauma e.g. in sports involving throwing. A tight intertubercular groove may irritate and inflame the tendon, producing tenderness and crepius. Dislocation of long head of biceps tendon. May be produced after traumatic separation of the proximal epiphysis of the humerus in young person. Usually there is popping or catching sensation is felt during arm rotation.  Arm 43 Muscles of the arm: Rupture of tendon of long head of biceps Usually the tendon is torn from its attachment to the supraglenoid tubercle. The rupture is associated with snap or pop. The detached muscle belly forms a ball near the center of the distal part of the anterior aspect of the arm (Popeye deformity). Shows up in weight lifters or after prolonged tendinitis.  Arm 44 Muscles of the arm: Posterior compartment muscles: Generally extensors of the arm and forearm 1. Triceps muscle Origin: Long head – infraglenoid tubercle Lateral head – posterior humerus superior part over the radial groove Medial head – posterior humerus inferior part below the radial nerve groove. Insertion: Olecranon posterior surface Movements: extension of the arm at the shoulder, extension of the forearm at the elbow joint Innervation: radial nerve  Arm 45 Muscles of the arm: Posterior compartment muscles: Generally extensors of the arm and forearm 2. Anconeus muscle Origin: lateral epicondyle of humerus Insertion: Posterior surface of ulna and olecranon Movements: extension of the elbow (week) Innervation: radial nerve  Arm 46 Arteries and nerves of the arm Anterior compartment contains flexor muscles and elements located at the medial bicipital groove: brachial artery, brachial vein, median nerve medial cutaneous brachial and antebrachial nerve, ulnar nerve at upper part. Over the groove and fascia basilic vein. At the lateral bicipital groove lies musculocutaneous nerve, over the groove and fascia cephalic vein.  Arm 47 Arteries and nerves of the arm Posterior compartment contains extensor muscles and elements located at the radial groove: radial nerve and deep brachial artery and deep brachial veins. Both compartments are separated by two intermuscular septas.  Arm 48 Arteries of the arm Brachial artery begins under the tendon of the pectoralis major muscle Branches: Deep brachial artery -- middle collateral artery -- radial collateral artery Superior ulnar collateral artery Inferior ulnar collateral artery Radial artery and ulnar artery  Arm 49 To stop bleeding from the brachial artery the best place to compress the brachial artery is medial to the humerus near the middle of the arm. Thanks to anastomosis around the elbow brachial artery may be clamped distal to the origin of the deep brachial artery without producing tissue damage. Ulnar and radial arteries will still receive sufficient blood by the anastomoses around elbow. However sudden, complete occlusion of the brachial artery may cause surgical emergency. Muscles can tolerate up to 6 hours of ischaemia then produce a flexion deformity as a result of irreversible necrosis of forearm flexor muscles.  Arm 50 Veins of the arm Brachial veins are venae comitantes of the brachial artery. They are deep veins which go together with deep arteries. Superficial veins present at the arm are the continuation of the veins which start at the hand. Basilic vein goes along medial surface of the arm over the fascia reaching one of the brachial veins. Cephalic vein goes along lateral surface of the arm over the fascia then along deltoid pectoral groove and reaches axillary vein.  Arm 51 Venipuncture in cubital fossa This is common site for sampling and transfusion. Usually the median cubital vein is selected. The vein is crossing the bicipital aponeurosis which separates it from the underlying brachial artery and median nerve. Median cubital vein is also used for the introduction of cardiac catheters to secure blood samples from the great vessels and chambers of the heart and for coronary angiography.  Arm 52 Deep tendon reflexes Muscle stretch reflex is dependend of Intact efferent (sensory) nerve fibers Normal functional synapses in the spinal cord at the appropriate level Intact efferent (motor) nerve fibers Normal functional neuromuscular junctions on the tapped muscle Normal muscle fiber functioning (contraction) Reflexes involve only several spinal cord segments. If there is pathology at the level tested, the reflex may be weak or absent. For the arm, the following segmental levels are for those reflexes Biceps brachii reflex (C5 and C6) Triceps brachii reflex (C7 and C8)  Forearm Muscles of forearm – anterior copartment 53 Superficial flexors 1. Pronator teres Origin : humeral head – medial epicondyle of humerus ulnar head – coronoid process of ulna Insertion: pronator tuberosity Actions: weak flexion of the elbow joint, pronation of forearm Innervation: median nerve (C6, C7) Fig. 1 3. Flexor carpi radialis Origin: medial epicondyle of humerus Insertion: Base of II metacarpal bone Actions: flexion and abduction of the wrist joint (hand) Innervation: Median nerve (C6, C7) Fig. 3 5. Palmaris longus Origin: medial epicondyle of humerus Insertion: Palmar aponeurosis Actions: weak flexion of the elbow joint tightens the palmar aponeurosis Innervation: Median nerve (C7, C8) Fig. 5  Forearm Muscles of forearm – anterior compartment 54 Superficial flexors 2. Flexor digitorum superficialis Origin: humeral head – medial epicondyle of humerus Ulnar head: coronoid process of ulna Radial head: distal to the radial tuberosity Insertion: Bases of the middle falanges of digits from 2nd to 5th Actions: weak flexion of the elbow joint, flexion of the wrist joitn, flexion of the metacarpophalangeal (MCP) joint and interphalangeal (PIP) joints. Innervation: Median nerve (C8, T1) Fig. 2 4. Flexor carpi ulnaris Origin: humeral head - medial epicondyle of humerus ulnar head - olecranon Insertion: hook of hamate, base of 5th metacarpal Actions: flexion and adduction of wrist joint (hand) Innervation: Ulnar nerve (C7 – T1) Fig. 4  Forearm 55 Muscles of forearm – anterior compartment Deep flexors 1. Flexor digitorum profundus Origin: 2/3 proximal parts of ulna and interosseus membrane Insertion: bases of distal phalanges from 2nd to 5th digits Actions: Flexion of the wrist joint and flexion of MCP and PIP joints Innervation: Median nerve (to 2nd and 3rd digit) (C8 - T1) Ulnar nerve (to 4th and 5th digit) (C7 – T1) Fig.1 2. Flexor pollicis longus Origin: Mid 1/3 part of radius and interosseus membrane Insertion: Basis of distal phalanx of Thumb Actions: Flexion and Abduction of wrist joint (hand), Opposition of Carpometacarpal (CMC) joint of thumb, flexion of CMP and PIP joints of thumb. Innervation: Median nerve (C7, C8) Fig.2 3. Pronator quadratus Origin: Distal ¼ part of the ulna Insertion: Distal ¼ part of the radius Actions: Pronates hand Innervation: Median nerve (C7, C8) Fig. 3  Forearm 56 Muscles of forearm – lateral compartment 1. Brachioradialis Origin: Lateral surface of distal humerus, lateral intermuscular septum Insertion: Styloid process of radius Actions: Flexion of the elbow joint, semipronation Innervation: Radial nerve (C5, C6) Fig. 1 2. Extensor carpi radialis longus Origin: Lateral surface of humerus, lateral intermuscular septum Insertion: base of 2nd metacarpal bone Actions: flexion of the elbow joint, extension and abduction of the wrist joint Innervation: Radial nerve, deep branch (C6, C7) Fig. 2 3. Extensor carpi radialis brevis Origin: lateral epicondyle of humerus Insertion: base of the 3rd metacarpal bone Actions: flexion of the elbow joint, extension and abduction of the wrist joint Innervation: Radial nerve, deep branch (C6, C7) Fig. 3  Forearm 57 Muscles of forearm – posterior compartment 1. Extensor digitorum Origin: Lateral epicondyle of humerus Insertion: dorsal digital expansions of the 2nd to 5th digits Actions: Extension of the wrist joint, extension of MCP, PIP and DIP joints of the 2nd to 5th digits, abduction of the fingers Innervation: Radial nerve – deep branch(C7, C8) Fig. 1 2. Extensor digiti minimi Origin: Lateral epicondyle of humerus Insertion: dorsal digital expansion of the 5th digit Actions: extension and abduction of the wrist joint, extension of MCP, PIP and DIP joints of the 5th digit, abduction of the 5th finger Innervation: Radial nerve, deep branch (C7, C8) Fig. 2 3. Extensor carpi ulnaris Origin: humeral head - lateral epicondyle of humerus, ulnar head – dorsal surface of the ulna Insertion: base of the 5th metacarpal bone Actions: extension and adduction of the wrist joint Innervation: Radial nerve, deep branch (C7, C8) Fig. 3  Forearm 58 Muscles of forearm – posterior compartment 1. Supinator Origin: Lateral epicondyle of humerus, olecranon of ulna, lateral collateral ligament and annular ligament of the radius Insertion: radius proximal part Actions: Supination of the forearm Innervation: Radial nerve – deep branch(C6, C7) Fig. 1 2. Abductor pollicis longus Origin: Dorsal surfaces of radius and ulna, interosseus membrane Insertion: basis of 1st metacarpal bone Actions: Abduction of the wrist joint, Abduction of MCP joint of thumb Innervation: Radial nerve, deep branch (C7, C8) Fig. 2 3. Extensor pollicis brevis Origin: Posterior surface of the radius and interosseus membrane Insertion: base of the proximal phalanx of the thumb Actions: Abduction of the wrist joint, extension of the CMC and MPC joints of the thumb Innervation: Radial nerve, deep branch (C7, C8) Fig. 3  Forearm 59 Muscles of forearm – posterior compartment 4. Extensor pollicis longus Origin: Posterior surface of the ulna and interosseus membrane Insertion: base of the distal phalanx of the thumb Actions: Abduction and extension of the wrist joint, adduction of the CMC and extension of the MPC and PIP joints Innervation: Radial nerve, deep branch (C7, C8) Fig. 4 5. Extensor Indicis Origin: posterior surface of the ulna, Insertion: dorsal digital expansion of the 2nd digit Actions: Extension of the wrist joint, extension of the MCP, PIP and DIP joints of the 2nd digit Innervation: Radial nerve – deep branch(C7, C8) Fig. 5  Brachial plexus: median nerve Brachial plexus Infraclavicular part 60 Long branches: Median nerve (C6 – T1 lateral and medial cord) Supply: Pronator teres muscle Pronator quadratus Palmaris longus Flexor carpi radialis Flexor pollicis longus Flexor digitorum superficialis Flexor digitorum profundus (part)  Brachial plexus: median nerve Brachial plexus Infraclavicular part 61 Long branches: Median nerve (C6 – T1 lateral and medial cord) Supply: Abductor pollicis brevis Opponens pollicis Flexor pollicis brevis (superficial head) First and second lumbricals - Palmar branch of the median nerve -- Common palmar digital nerves 3 ----Proper palmar digital nerves Supply: skin over the palmar side of hand 3 and ½ digit Brachial plexus: median nerve 62 Injuries and chronic comression of the median nerve in the carpal tunnel. Compression and entrapment of the nerve within the carpal tunnel can have various causes such as fractures and dislocations of the carpal bones, inflammatory changes in the tendon sheats, muscles variants, and connective tissue proliferation due to endocrine hormonal changes Sign: sensory disturbances, chiefly affecting the tips of the index and middle fingers and thumb due to increased carpal tunnel pressure resulting from prolonged flexion or extension of the wrist during sleep. Chronic or severe damage leads to motor deficits involving the thenar muscles with preservation of thenar sensation and positive bottle sign. Brachial plexus: median nerve 63 Proximal median nerve lesion -Traumatic injury caused by fracture or dislocationn of the elbow joint - Chronic pressure injury from an anomalous supracondylar process connected to the medial epicondyle by a ligament, pressure form a tight bicipitals aponeurosis or pronator teres syndrome in which the nerve is squized between two heads of the pronator teres Typical „hand of benediction” when fist closure is attempted, with incomplete pronation, loss of thumb opposition, impaired grasping ability, atrophy of the thenar muscles and sensory disturbances affecting the radial part of the palm and radial 3 ½ digits. The patient also has positive „bottle sign” in which the fingers and thumb cannot be fully close around a cylindrical object due to weakness of the abductor pollicis brevis. Brachial plexus: median nerve 64 Carpal tunnel  Brachial plexus: ulnar nerve 65 Brachial plexus Infraclavicular part Long branches: Ulnar nerve (C8, T1 medial cord) Supply: Flexor carpi ulnaris Flexor digitorum profundus (part) Palmaris brevis Flexor digiti minimi Abductor dogiti minimi Adductor pollicis Flexor pollicis brevis (deep head)  Brachial plexus: ulnar nerve 66 Brachial plexus Infraclavicular part Long branches: Ulnar nerve (C8, T1 medial cord) Supply: Plamar and dorsal interosseus muscles Third and fourth lumbricals - Palmar branch of the ulnar nerve -- Common digital palmar nerve ---- Proper digital palmar nerve Supply: skin over the hand 1 and ½ digit palmar side -- Dorsal branch of the ulnar nerve Supply: skin over the hand 2 and ½ digit dorsal side Brachial plexus: ulnar nerve 67 Proximal ulnar nerve lesion -Traumatic lesions, usually occuring at the elbow joint due to the exposed position of the nerve in the ulnar groove, displacement of the nerve from its groove, or articular injuries due to fractures. - Chronic pressure on the nerve in the ulnar groove due to degenerative or inflammatory changes in the elbow joint, or chronic traction on the nerve caused by repetitive flexion and extension at the elbow joint (sulcus ulnaris syndrom - possible compression between the tendons of origin of flexor carpi ulnaris (cubital tunnel syndrome -Symptoms: claw hand caused of the atrophy of the innerossei muscles and sensory disturbances  Brachial plexus: ulnar nerve 68 Midlevel ulnar nerve lesion -Traumatic lesions, at the wrist - Chronic compression of the nerve in the ulnar tunnel, a fibroosseus canal between the palmar carpal ligament, pisiform bone and flexor retinaculum Signs: claw hand and sensory disturbances that spare hypothenar region Distal ulnar nerve lesion Compression of the deep branch of the ulnar nerve in the palm due to chronic pressure Signs: claw hand with no sensory disturbances  Brachial plexus: radial nerve 69 Midlevel radial nerve lesion Chronic compression of the radial nerve in its passage throuh the lateral intermuscular septum and in the radial tunnel. Signs: dropped wrist with sensory disturbances Distal radial nerve syndrom Compression of the deep branch of the radial nerve at its entry into the supinator canal. Signs: No typical wrist drop and no sensory distrurbances involving the hand. There are aplsies involving the extensor pollicis brevis and longus, Trauma to the deep radial branch abductor pollicis longus, extensor caused by a fracture or dislocation of the digitorum, extensor indicis and radius extensor carpi ulnaris Signs: no wrist dropand no sensory disturbances Forearm 70 Elbow joint dislocation: -Posterior dislocation - posterior dislocation with coronoid process fracture - posterior dislocation with lateral epicondyle fracture - anterior dislocation of radius and ulna with fracture of olecranon Forearm 71 Radial neck fracture During passive flexion of the elbow blocked flexion or crepitus is indication for excision of fragments or, occasionally, entire radial head.  Forearm 72 Elbow tendinitis or lateral epicondylitis tennis elbow „tennis elbow” may be follow repetitive use of the superficial extensor muscles of the forearm. The symptom is pain felt over the lateral epicondyle and radiating down the posterior surface of the forearm. Lateral epicondylitis is caused by repeated forcefull flexion and extensionof the wrist what strain the attachment of the common extensor tendon. Forearm 73 Measuring the pulse rate The common place for measuring the pulse rate is where the radial artery lies on the anterior surface of the distal end of radius. When measuring the radial pulse rate, the pulp of the thumb should not be used because it has its own pulse  Arteries of Forearm 74 Arteries of the forearm Radial artery - Radial recurrent artery - palmar carpal branch - superficial palmar branch -Dorsal carpal branch -- Dorsal metacarpal arteries -- Dorsal digital arteries - Princeps pollicis artery - Radialis indicis artery - Deep palmar arch -- Palmar metacarpal arteries -- Perforating branches  Arteries of the Forearm 75 Arteries of the forearm Ulnar artery -Ulnar recurrent artery - Common interosseus artery -- Posterior interosseus artery -- Recurrent interosseus artery -- Anterior interosseus artery - Palmar carpal branch - Dorsal carpal branch - Superficial palmar arch -- Common palmar digital arteries -- Proper palmar digital arteries Veins of the forearm 76 Deep veins of the upper limb - Subclavian vein - Axillary vein - Brachial veins - Ulnar veins - Eadial veins - Anterior interosseus veins - Posterior interosseus veins - Deep palmar venous arch - Palmar metacarpal veins  Forearm clinics 77 Colles fracture Fracture of the distal radius (about 80% of forearm fractures results from a fall at an outstretched hand. Colles fracture produce typical dinner- fork deformity.  Forearm clinics 78 Scaphoid bone fracture Scaphoid bone is the most often fracture bone of the wrist and may be injured after falling at extended wrist. Fracture of the middle third (waist) of the bone is the most common. You can expect pain and swelling at the anatomical snuffbox. Healing depends on good blood supply from the palmar carpal branch of the radial artery. Loss of the blood supply can provide to the osteonecrosis of the bone. Hand: thenar and hypothenar 79 muscles 1. Abductor pollicis brevis Origin: scaphoid and trapezium bone, flexor retinaculum Insertion: Base of the proximal phalanx of the thumb Action: abduction of the thumb Innervation: median nerve (C8-T1) fig 1 2. Adductor pollicis Origin: transverse head: palmar surface of the third metacarpal oblique head: capitate bone, base of second metacarpal Insertion: base of the proximal phalanx of the thumb Action: opposition of the CMC joint and flexion of MCP joint of the thumb Innervation: Ulnar nerve (C8 – T1) fig 2  Hand: thenar and hypothenar 80 muscles 3. Flexor pollicis brevis Origin: superficial head: flexor retinaculum deep head: capitate and trapezium bone Insertion: Base of the proximal phalanx of the thumb Actions: Flexion and opposition of the CMC joint and flexion of MCP joint of the thumb Innervation: median nerve (C8-T1) superficial head ulnar nerve (C8, T1) deep head fig. 3 4. Opponens pollicis Origin: Trapezium bone Insertion: radial border of the 1st metacarpal bone Actions: opposition of the CMC joint of the thumb Innervation: Median nerve (C8 – T1) Fig. 4  Hand: thenar and hypothenar 81 muscles 5. Abductor digiti minimi Origin: pisiform bone Insertion: proximal phalanx and dorsal digital expansion of the 5th digit Actions: MCP joint of the little finger, flexion and abduction of the little finger Innervation: Ulnar nerve (C8, T1) Fig. 5 6. Flexor digiti minimi Origin: Hook of hamate, flexor retinaculum Insertion: Ulnar border of 5th metacarpal Actions: opposition of the little finger Innervation: Ulnar nerve (C8 - T1) Fig. 6 Palmaris brevis (not shown) Origin: Ulnar border of palmar aponeurosis Insertion: Skin of the hypothenar eminence Action: Tightens the palmar aponeurosis Innervation: Ulnar nerve (C8, T1) Fig. 7 Hand: the metacarpal muscles 82 1. First through four lumbrical muscles Origin: radial sides of the tendons of flexor digitorum profundus Insertion: - first lumbrical: dorsal digit expansion of the 2nd digit; - second lumbrical: dorsal digit expansion of the 3rd digit - third lumbrical: dorsal digit expansion of the 4th digit - fourth lumbrical: dorsal digit expansion of the 5th digit Actions: flexion of the MCP joint of the 2nd through 5th digits, Extension of the PIP and DIP joints of the 2nd through 5th digits Innervation: Median nerve C8, T1 (1st and 2nd lumbricals); Ulnar nerve C8, T1 (3rd and 4th lumbricals) Fig. 1 Hand: the metacarpal muscles 83 2. First through fourth dorsal interossei Origin: By two heads from adjacent sides of the 1st through 5th metacarpals Insertion: Dorsal digital expansion of the 2nd through 4th digits, base of proximal phalanx - First interosseus: radial side of the 2nd proximal phalanx - Second interosseus: radial side of the 3rd proximal phalanx - Third interosseus: ulnar side of the 3rd proximal phalanx - Fourth interosseus: ulnar side of the 4th proximal phalanx Actions: flexion of the MCP joints of the 2nd through 4th digits, extension and abduction of the PIP and DIP of the 2nd through 4th digits Innervation: Ulnar nerve (C8, T1) Fig. 2  Hand: the metacarpal muscles 84 3. First through third palmar interossei Origin: - First interosseus: ulnar side of the 2nd metacarpal bone - Second interosseus: radial side of the 4th metacarpal bone - Third interosseus: ulnar side of the 5th metacarpal bone Insertion: Dorsal digital expansion and base of the proximal phalanx of the associated finger Actions: flexion of the MCP joints of the 2nd, 4th and 5th digits, extension and adduction of the PIP and DIP of the 2nd, 4th and 5th digits Innervation: Ulnar nerve (C8, T1) Hand: carpal and digital tendon 85 sheats Hand: carpal and digital tendon sheats 86 Dorsal tendon compartments for the extensor tendons First tendon compartment: Abductor pollicis longus Extensor pollicis brevis Second tendon compartment: Extensor carpi radialis longus and brevis Third tendon compartment: Extensor pollicis longus Fourth tendon compartment: Extensor digitorum Extensor indicis Fifth tendn compartment: Extensor digiti minimi Sixth tendon compartment: Extensor carpi ulnaris Hand: dorsal digital expansion 87  Arteries Radial artery of the hand 88 Dorsal carpal branch - Dorsal metacarpal arteries - Dorsal digital arteries Princeps pollicis artery Radialis indicis artery Deep palmar arch - Palmar metacarpal arteries - Perforating branches Ulnar artery Dorsal carpal branch Deep palmar branch Superficial palmar arch -Common palmar digital arteries - Proper palmar digital arteries  Arteries of the hand 89 Laceration of palmar arches Bleeding is usually profuse when the palmar arches are lacerated. It may not be sufficient to ligate only one forearm artery when the arches are lacerated, because these vessels usually have numerous communications in the forearm and hand. The better option is to compress the brachial artery.  Arteries of the hand 90 Ischaemia of digits Intermittent bilateral attacks marked by cyanosis and often accompanied by paresthesia and pain, is characteristically brought on by cold and emotional stimuli. When the cause of the condition is idiopathic or primary, it is called Raynaud syndrome connected with overactivity of the sympathetic system narrowing the arteries of the hand. Venous supply of the upper limb: 91 superficial veins Dorsal venous network of the hand \Superficial palmar venous arch Venous supply of the upper limb: 92 superficial veins Superficial veins of the upper limb -Cephalic vein - Accessory cephalic vein - Basilic vein - Median cubital vein - Median antebrachial vein - Median cephalic vein - Median basilic vein Lymph vessels of the upper limb 93 Upper limb skin innervation 94 Skin innervation of the upper limb Posterior cutaneous nerve of the arm – radial nerve; Posterior cutaneous nerve of the forearm – radial nerve; Lateral cutaneous nerve of the arm – axillary nerve; Lateral cutaneous nerve of the forearm – musculocutaneous nerve; Medial cutaneous nerve of the arm – medial cord; Medial cutaneous nerve of the forearm – medial cord; Hand – Dorsal surface: 2 ½ fingers radial side – radial nerve to the middle finger level 2 ½ fingers ulnar side – ulnar nerve to the middle finger level 3 ½ fingers radial side – median nerve 1 ½ fingers ulnar side – ulnar side Injuries of the fingers 95 Coach’s finger – dorsal dislocation of the joint Boutonniere deformity – dislocation or avulsion fracture of the middle phalanx with failure so that causing deformity and chronic pain  Injuries of the fingers 96 Swan neck deformity Dorsal dislocation with disruption of palmar volar and collateral ligaments. Injuries of the fingers 97 Mallet finger – usually caused by direct blow on extended distal phalanx with torn extensor digitorum tendon. Severe tension on long extensor may avulse part of the attachment to the base of the distal phalanx. In result it is impossible to extend the distal interphalangeal joint.  Injuries of the fingers 98 Boxer fracture – fracture of the metacarpal shaft at its distal end. Game keeper thumb – rupture of the medial collateral ligament with avulsion fracture.  Hand 99 Dupuytren contracture Disease of the palmar fascia and aponeurosis. The fibrous degeneration of the longitunal bands of the palmar aponeurosis on the medial side of the hand pulls the 4th and 5th into partial flexion at the metacarpophalangeal and proximal interphalangeal joints. In men over 50 years old. Cause is unknown.  Hand 100 Hand infections Because palmar fascia is thick and strong, swellings resulting from hand infections usually appear on the dorsum of the hand, where the fascia is thinner. Depending on the side of infection, puss will accumulate in the thenar, hypothenar, midpalmar or adductor compartments.  Hand 101 Tenosynovitis Injuries such as puncture of a finger by a rusty nail can cause infection of the digital synovial sheaths. The digit swells and movement becomes painfull. Usually infection is usually confined to the infected finger. „Trigger finger” Back 102 Extrinsic muscles of the back Trapezius muscle Origins: Superior nuchal line (descending part) Spinous processes of C7 – T12 vertebras (transverse and ascending part) Insertion: clavicle – acromial end, acromion, spine of the scapula Action: elevates and depresses the shoulder and rotates the glenoid cavity superiorly Innervation: Accessory nerve CN XI (spinal part), spinal nerves C3, C4 cervical plexus. Back 103 Extrinsic muscles of the back Latissimus dorsi muscle Origins: spinous processes from T6 to T12, thoracolumbar fascia, iliac crest, inferior ribs from 9th to 12th. Insertions: Intertubercular groove of humerus. Action: extends, adducts, rotates medially, rises body toward arms. Innervation: Thoracodorsal nerve (C6 – C7, C8) Back 104 Rhomboid minor muscle Mięsień dźwigacz łopatki Mięsień równoległoboczny mniejszy Origin: spinous processes of C6 – C7 vertebras Insertion: Medial margin of the scapula below the spine Mięsień równoległoboczny większy Rhomboid major muscle Origin: spinous processes of T1 – T4 vertebras Insertion: Medial margin of the scapula below the spine Action: pulling the scapula toward the vertebral column Innervation: Dorsal scapular nerve Opracowanie: dr n. med. Renata Wilk  10 Back 5 Mięsień płatowaty głowy Mięsień dźwigacz łopatki Mięsień płatowaty szyi Levator scapulae muscle Origin: transverse processes (posterior tubercle) of C1 – C4 vertebras Insertion: Superior angle of the scapula, Medial margin of the scapula above the spine Action: Flexes the cervical vertebra and rotates it to the same side, working alone. Extens the cervical vertebra working together. Pulls up and directs the scapula medially http://www.winkingskull.com/dissector/popups/7c004_ m015.html Innervation: Dorsal scapular nerve Opracowanie: dr n. med. Renata Wilk Back Extrinsic muscles of the back 106 Serratus posterior muscles superior and inferior Origins: - superior – spinous processes of the C6, C7, T1, T2 vertebras; - inferior – spinous processes of the T11, T12, L1, L2 vertebras; Insertions: - superior - posterior parts of the ribs from 2nd to 5th - inferior – posterior parts of the ribs from 9th to 12th Actions: - superior – elevates the ribs (inspiration muscle) - inferior – depress the ribs (expiration muscle) Innervation: - superior – 2nd to 5th intercostal nerves - inferior - - 9th to 11th intercostals and subcostal nerve Back 107 Intrinsic muscles of the back are innervated by the posterior rami of the spinal nerves and control movement of vertebral column. Superficial layer Splenius muscles Origins: nuchal ligament and spinous processes of the C7 – T6 vertebrae Insertion: mastoid process of the temporal bone, superior nuchal line of occipital bone (splenius capitis), transverse processes of C1 - C3, C4 vertebras Actions: flexes the neck and rotates head, extends head and neck Back 108 Intermadiate layer Erector spinae muscles - Iliocostalis muscle - Longissimus muscle - Spinalis muscle Origins: posterior part of iliac crest, posterior surface of the sacral bone, spinous processes of the sacral and lumbar vertebras, supraspinous ligament Insertions: angles of the ribs lying above and cranium Actions: extend cervical vertebras and head, flex laterally the cervical part of the vertebral column. Back 109 Deep layers Transversospinalis Semispinalis Multifidus Rotatores Origins: transverse processes of C4 – T12 vertebrae (semispinalis), transverse processes of T1 – T3, C4 – C7 vertebrae (multifidus), transverse processes of the thoracic vertebrae Insertions: Spinous processes of more superior verterae Actions: Extension of head, cervical and thoracic region, rotation, stabilization of the vertebral column during movements Innervation: posterior rami of the spinal nerves  Suboccipital muscles Rectus capitis posterior major muscle Origin: posterior tubercle of the axis Insertion: Inferior nuchal line Rectus capitis posterior minor muscle Rectus capitis posterior minor muscle Origin: the spinous process of the atlas Rectus capitis posterior major muscle Insertion: Inferior nuchal line Obliquus Obliquus superior muscle superior muscle Origin: the transverse process of the atlas Obliquus Inferior Insertion: Inferior nuchal line muscle Obliquus Inferior muscle Origin: the spinous process of the axis Insertion: the transverse process of the atlas „Visible Body Human Anatomy Atlas” Action: extension in the atlantoaxial joint, working together, flexion in the joint to the same side and rotation to the opposite side, working unilaterally, stabilising the vertebral column Innervation: posterior branches of the spinal nerves: C1= suboccipital nerve, C2 - lesser occipital nerve) Opracowanie: dr n. med. Renata Wilk