Gross Anatomy 1 Midterm Study Guide PDF

Gross Anatomy 1 Midterm Study Guide Power point list: Shoulder, Dermatomes, Axilla & Brachial Plexus, Arm, Ant. & Post. Forearm, Wrist & hand, Upper Limb Neuropathies 1. Rotator Cuff: Know muscles (4), innervations, origins, insertions & actions. Subscapularis...

Gross Anatomy 1 Midterm Study Guide Power point list: Shoulder, Dermatomes, Axilla & Brachial Plexus, Arm, Ant. & Post. Forearm, Wrist & hand, Upper Limb Neuropathies 1. Rotator Cuff: Know muscles (4), innervations, origins, insertions & actions. Subscapularis o O: subscapular fossa scapula o I: lesser tubercle humerus o IN: upper and lower subscapular nerves o A: medial rotation of the humerus Supraspinatus o O: supraspinatus fossa of scapula o I: superior facet of greater tubercle o IN: suprascapular nerve o A: initiates abduction of humerus at glenohumeral joint, laterally rotates humerus when decelerating the arm in a throwing motion Infraspinatus o O: infraspinatus o I: middle facet greater tubercle o IN: suprascapular nerve o A: lateral rotation of humerus Teres minor o O: middle part of lateral border of the scapula o I: inferior facet of greater tubercle o IN: axillary nerve o A: lateral rotation of the humerus 2. Brachial plexus: Spinal roots (spinal levels) to terminal branches, including secondary branches off spinal roots, trunks, & cords. Review power point “Axilla & Brachial Plexus” Netter Atlas brachial plexus image, brachial plexus lab videos 3. Anatomical spaces: Triangular space, Quadrangular space, Triangular interval, Deltopectoral Triangle, Cubital fossa, Anatomical Snuffbox, Know contents & anatomical boarders of each. Triangular space o Teres minor, teres major, triceps long head o Circumflex scapular artery Quadrangular space o Teres minor, teres major, triceps long head, triceps lateral head o Axillary nerve o Posterior humeral circumflex artery Triangular interval o Teres minor, teres major, triceps lateral head o Radial nerve o Profunda brachii artery Deltopectoral triangle  o Deltoid o Clavicle o Pectoralis minor o Contents: ▪ Cephalic vein ▪ Thoracoacromial trunk artery (branch off axillary artery) ▪ Lateral pectoral nerve Cubital fossa o Brachialis tendon- floor o Bicipital aponeurosis- roof o Brachioradialis- lateral border o Pronator teres- medial border o Contents: ▪ Brachial vein ▪ Median nerve ▪ Medial epicondyle ▪ Brachial artery Anatomical snuff box o Lateral border- abductor pollicis longus (most lateral) o Lateral border- extensor pollicis brevis o Medial border- extensor pollicis longus o Contents: radial artery 4. Arm: Anterior comp. (3 flexors), Posterior compartment (1 extensor- 3 bellies) Origins, insertions, actions, and innervations Anterior: o Biceps brachii ▪ O: long head- supra glenoid tubercle; short head- coracoid process scapula ▪ I: radial tuberosity and bicipital aponeurosis ▪ IN: musculocutaneous nerve ▪ A: when elbow is extended it is a simple forearm flexor As elbow approaches 9- degrees of flexion and power is needed against resistance o Supination- primary forearm flexor o Pronation- primary supination Long head- stabilizer of the gleno-humeral joint o Coracobrachialis ▪ O: coracoid process (scap) ▪ I: medial middle humerus ▪ IN: musculocutaneous nerve ▪ A: flexes and adducts humerus at the gleno-humeral joint; resists dislocation of the shoulder. With deltoid and long head triceps o Brachialis ▪ O: distal half of anterior humerus ▪ I: ulnar tuberosity and anterior surface coronoid process ▪ IN: musculocutaneous nerve ▪ A: flexes forearm at elbow in any position ▪ Primary elbow flexor  Posterior: triceps o Long head ▪ O: infraglenoid tubercle of scap ▪ I: olecranon process of ulna ▪ IN: radial nerve ▪ A: stabilizes the gleno-humeral joint and extends humerus at gleno- humeral joint o Lateral head ▪ O: posterolateral surface of humerus and later intermuscular septum ▪ I: olecranon process of ulna ▪ IN: radial nerve ▪ A: extends forearm at elbow o Medial head ▪ O: posteromedial surface of humerus and medial intermuscular septum ▪ I: olecranon process of ulna ▪ IN: radial nerve ▪ A: extends forearm at elbow 5. Forearm: Ant. comp. (8 flexors) & Post. comp. (12 extensors) Know specific compartment muscles, origins, insertions, actions & nerve Innervations Anterior: o Pronator teres ▪ O: humeral head- medial epicondyle; ulnar head- coronoid process ▪ I: mid lateral surface of radius ▪ IN: median nerve ▪ A: pronation of forearm, rotation of radius on ulna, turning the palm medially ▪ Weak pronator o Flexor carpi radialis ▪ O: medial epicondyle ▪ I: base of 2nd and 3rd metacarpal ▪ IN: median nerve ▪ A: flexes carpometacarpal joint and the hand at the wrist Radial deviation (abduction) with ECRB and ECRL Steadies hand with flexor carpi ulnaris o Palmaris longus ▪ O: medial epicondyle ▪ I: flexor retinaculum and palmer aponeurosis ▪ IN: median nerve ▪ A: tenses palmar aponeurosis and weakly flexes wrist ▪ Often absent unilaterally and bilaterally o Flexor carpi ulnaris ▪ O: medial epicondyle; medial olecranon process, posterior border of ulna ▪ I: pisiform; hamate’ base of 5th metacarpal ▪ IN: ulnar nerve (and cubital tunnel) ▪ A: flexes carpometacarpal joint Ulnar deviation (adduction) with ECU Steadies the wrist with FCR o Flexor digitorum superficialis  ▪ O: humeroulnar head: medial epicondyle, coronoid process of ulna; radial head- anterior surface of radius, distal to the radial tuberosity ▪ I: 4 tendons split to attach the medial and lateral sides of the bases of middle phalanges, digits 2-5 ▪ IN: median nerve ▪ A: flexes proximal and middle interphalangeal joints and the metacarpophalangeal joints ▪ Power grip muscle o Flexor digitorum profundus ▪ O: upper 3/4ths of anterior medial ulna and ulnar ½ of interosseous membrane ▪ I: its 4 tendons pierce the tendons of FDS at bases of middle phalynx to insert at bases of distal phalanges 2-5 ▪ IN: anterior interosseous and ulnar nerve ▪ A: flexes the distal interphalangeal joints after the proximal phalangeal joints are flexed by FDS. This is the gentle grip flexor. Weak wrist flexor o Pronator quadratus ▪ O: distal 1/4th anterior surface of ulna ▪ I: distal 1/4th anterior surface of radius ▪ IN: anterior interosseous nerve ▪ A: pronation of forearm o Flexor pollicis longus ▪ O: anterior surface of radius and interosseous membrane ▪ I: base distal phalanx of thumb ▪ IN: anterior interosseous nerve ▪ A: flexes interphalangeal joints and metacarpophalangeal joint of thumb Posterior: o Anconeus ▪ O: lateral epicondyle of humerus ▪ I: lateral olecranon and shaft of the ulna. Joint capsule of the elbow ▪ IN: radial nerve ▪ A: assists triceps brachii to extend joint capsule of the elbow during extension of the forearm o Brachioradialis ▪ O: upper 2/3rd of lateral supracondylar ridge of humerus ▪ I: lateral aspect of the styloid process of the radius ▪ IN: radial nerve ▪ A: flexes in a semi prone forearm o Extensor carpi radialis longus ▪ O: lower 1/3rd of lateral supracondylar ridge of humerus ▪ I: base of 2nd metacarpal ▪ IN: radial nerve ▪ A: extends the wrist. When acting in unison with FCR, it will abduct or radially deviate the hand. Will fix the wrist when acting synergistically with ECU o Extensor carpi radialis brevis ▪ O: lateral epicondyle humerus ▪ I: base of 3rd metacarpal ▪ IN: deep branch radial nerve ▪ A: assists ECRL to extend wrist o Supinator ▪ O: lateral epicondyle humerus, radial head collateral ligament, supinator and crest and fossa of ulna ▪ I: lateral surface proximal 1/3rd of radius  ▪ IN: deep branch radial nerve ▪ A: supinates forearm from pronated position o Extensor digitorum ▪ O: lateral epicondyle of humerus by common extensor tendon ▪ I: dorsal digital expansions of medial 4 digits to DIPs ▪ IN: posterior interosseous nerve ▪ A: extends metacarpal phalangeal and interphalangeal joints o Extensor digiti minimi ▪ O: medial belly of extensor digitorum ▪ I: dorsal digital expansions of little finger via 1 or 2 tendons ▪ IN: posterior interosseous nerve ▪ A: assists extensor digitorum at 5th digit o Extensor carpi ulnaris ▪ O: lateral epicondyle of humerus ▪ I: medial side base of 5th metacarpal ▪ IN: posterior interosseous nerve ▪ A: acts with FCU, to adduct or ulnar deviate hand. Acting with ECRU and ECRB, will fix the wrist. It can also extend the wrist o Abductor pollicis longus ▪ O: posterior surfaces of radius, ulna, and interosseous membrane ▪ I: base 1st metacarpal and trapezium ▪ IN: posterior interosseous nerve ▪ A: abducts and extends the thumb o Extensor pollicis brevis ▪ O: posterior surface of radius and interosseous membrane ▪ I: base of proximal phalanx of thumb ▪ IN: posterior interosseous nerve ▪ A: extends metacarpophalangeal joint, extends carpometacarpal joint o Extensor pollicis longus ▪ O: posterior shaft of ulna and interosseous membrane ▪ I: base of distal phalanx, thumb ▪ IN: posterior interosseous nerve ▪ A: extends thumb at interphalangeal and metacarpophalangeal joints o Extensor indicis ▪ O: posterior surface of interosseous membrane; posterior surface of the ulna ▪ I: dorsal digital expansion of index finger ▪ IN: posterior interosseous nerve ▪ A: extends index finger. Assisting extensor digitorum 6. Dermatomes & cutaneous innervations for patient case scenario questions. Forester, Keegan Garrett dermatome mapping patterns Cutaneous nerve innervation mapping by area (medial, posterior, & lateral) for arm & forearm ****************Screenshot on ipad 7. Carpal tunnel syndrome: Know tunnel contents, signs, symptoms, causes Guyon’s tunnel: location, contents Canal of Guyon ▪ Ulnar nerve ▪ Ulnar vein  ▪ Ulnar artery Carpal tunnel syndrome ▪ May follow a healed fx of carpals ▪ May be assoc. with carpal arthritis ▪ Can be caused by hypothyroidism, amyloidosis, gout, diabetes, and subluxation ▪ Median nerve passes through the carpal tunnel along with tendons of the long finger flexors ▪ Passes under the flexor retinaculum ▪ Etiology is chronic compression ▪ Repetitive use ▪ Occurs from any lesion that: o Reduces size of tunnel (swelling) o Increases size of structures like fascia coverings in tunnel (most common) o Swelling of tendons or synovial sheaths ▪ Fluid retention, infection, excessive exercise or mvmt of fingers and wrist, repetitive use syndrome ▪ Most common etiology occupational stress ▪ Seen in computer operators, word processors, assembly workers, etc ▪ Effects women more than men ▪ Exacerbated during menopause or pregnancy ▪ Significant weight gain over a short time frame ▪ Initially sensory and subjective only ▪ Objective signs may never occur (or much later) ▪ Classic presentation → brachialgia, paresthetica, nocturna ▪ Patient awakens during the night with hand(s) paresthesia/pain ▪ Finger mvmt may be clumsy and difficult ▪ Whole limb may be painful, with symptoms radiating into arm and axilla 8. Upper Limb Neuropathies Saturday night palsy, Claw hand, bottle sign, Erb’s Palsy, Klumpke’s Palsy Waiter’s tip, Wrist drop, Sign of Benediction, Thoracic outlet, Nevins Synd. ▪ Saturday night palsy o Neurapraxia ▪ Bottle sign o AKA Simian hand o If lesion is distal to forearm: part unable to oppose thumb o Grasping becomes difficult o When patient attempts to approximate thumb to 5th digit: side of thumb will touch digit, not tip o Due to inadequate pronation of thumb o Atrophy of thenar eminence ▪ Klumpke’s palsy o Dererine – Klumpke o “Claw hand” deformity o Most commonly involves T1, lesser C8 o Less common than upper lesion o Motor deficit of intrinsic hand muscles o Long finger and wrist flexors may be affected o Triceps is usually spared ▪ Waiters tip o AKA Erb – Duchenne palsy o More common than lower lesions  o Involves C5 & 6 spinal roots o Motor and sensory deficits exhibited o Abductor and external rotators of humerus o Flexors of humerus o Brachioradialis, ECRU and scapular muscles, teres minor and major, rhomboid major and minor o Paresis or paralysis ▪ Wrist drop o Distal lesion o Result of pressure on the axilla ▪ Sign of Benediction o AKA Preacher’s hand o High lesion (above elbow) prevents a part from making fist o Flexion of fingers will occur only by those muscles innervated by the ulnar nerve ▪ FDP, FCU, 3rd and 4th lumbrical ▪ Thoracic outlet syndrome o Non-descript, non-anatomic term o Controversial with respect to diagnosis and management o Vascular and neurogenic aspects o Over diagnosed o Mechanical causes: ▪ Physical trauma ▪ Repetitive strain injuries – computer workers/sports ▪ Anatomical defects – cervical ribs ▪ Nevins syndrome o AKA interosseous syndrome o Pure motor branch of median nerve passes through region of anterior interosseous o Common with forearm fractures o Commonly seen spontaneously o Patient will not be able to flex distal thumb and index finger to produce an “O” o “ok” sign 9. Intrinsic hand muscles: Innervations & organizational divisions of hand (thenar, Central & hypothenar groupings, specific innervations & actions), “Short LLoaf” ▪ Thenar muscles → recurrent median nerve o Abductor pollicis brevis o Flexor pollicis brevis o Opponens pollicis ▪ “Central group” muscles → deep branch ulnar nerve o Adductor pollicis o 1,2,3,4 lumbricals ▪ 1 and 2 go with recurrent median nerve o 4 dorsal interossei o 3 palmar interossei ▪ Hypothenar muscles → deep branch ulnar nerve o Abductor digit minimi o Flexor digiti minimi o Opponens digiti minimi ▪ Short lloaf → recurrent median nerve o 1st and 2nd lumbricals o Opponens pollicis  o Abductor pollicis brevis o Flexor pollicis brevis ▪ Palmaris brevis muscle → superficial branch ulnar nerve 10. Blood Vessels: Profunda brachii a., brachial a., axillary a. (3 parts & branches), Ant. & Post. humeral circumflex a., circumflex scapular a., radial a., ulnar a., cephalic & basilic veins 11. Classifications of Peripheral nerve injuries (3 types) 1) Neurapraxia ▪ Mildest form ▪ Interruption of nerve conduction without loss of continuity of axon ▪ SS- transient motor paralysis o Little or no sensory or autonomic dysfunction ▪ TX- removal of compression o Complete recovery expected ▪ Saturday night palsy/crutch/park bench 2) Axonotmesis ▪ Moderate injury ▪ Involves axonal degeneration ▪ Loss of continuity of axon and myelin o Epineurium, perineurium preserved ▪ SS- motor, sensory, and autonomic paralysis ▪ TX and prognosis- recovery if compression is removed in a timely fashion and if axon regenerates, treatment may be needed 3) Neurotmesis ▪ Most severe ▪ Nerve is completely disrupted by contusion, traction, or lacerations ▪ Connective tissue coverings lose continuity ▪ Transection ▪ TX- surgery with unpredictable results o Recovery incomplete in most cases * Know examples & characteristics of each classification 12. Classification of Joints (Upper Extremity Joint Classification (reference guide) - Terminology definitions - Structure classifications - Function classifications - Specific structure & functional classifications of the upper extremity articulations for the following joints: sternoclavicular, acromioclavicular, glenohumeral, radiocarpal, humeral ulnar, humeral radial, proximal middle, and distal radioulnar joints, intercarpal, carpometacarpal (1-5 digits), metacarpophalangeal, interphalangeal 13. Arcade of Froshe: Deep radial nerve compression within supinator muscle 14. Arteries of the Hand Ulnar artery  Superficial Palmer Arch Common palmar digital arteries (3) Proper palmar digital arteries (3 pairs), digits 2-5 Radial artery Deep Palmer Arch Palmar metacarpal arteries Princeps pollicis Radialis indicis (Arises from radial artery, can arise from Princeps pollicis) Quiz #1, Quiz #2 review study guides Dry Lab: Upper Extremity Bone & Landmark study guide & notes Wet Lab: muscle, nerve, & vessel notes, outlines, lab videos (brachial plexus, axillary artery, post. shoulder spaces, ) Forearm Muscles & Nerves / Lab Identification list Anterior forearm / Flexors, Pronators (8) Muscle Innervation Pronator teres Median n. Flex. Carpi radialis Median n. Palmaris longus Median n. Flex. Carpi Ulnaris Ulnar n. Flex. Digitorum superficialis Median n. Flex. Digitorum profundus Ant. Interosseous / ulnar n. Pronator quadratus Ant. Interosseous n. Flex. Pollicis longus Ant. Interosseous n. Posterior Forearm / Extensors, Supinator’s (12) Muscle Innervation Anconeus Radial n. Brachioradialis Radial n. Ext. Carpi Radialis longus Radial n. Ext. Carpi Radialis Brevis Deep Radial n. Supinator (Arcade of Froshe) Deep Radial n. Ext. Digitorum Post. Interosseous n. Ext. Digiti Minimi Post. Interosseous n. Ext. Carpi Ulnaris Post. Interosseous n. Ext. Indicis Post. Interosseous n. Abductor Pollicis Longus Post. Interosseous n. Ext. Pollicis Brevis Snuff Box” Post. Interosseous n. Ext. Pollicis Longus Post. Interosseous n. Extremity Anatomy / Scott Meisel M.S., D.C.  Upper Extremity / Joint Classifications (Reference guide) Bone / Joint Structure Function Clavicle / Scapula Sternoclavicular diarthrodial / synovial saddle, with disc- plane pivot (Functions like a ball & socket jt.) Acromioclavicular diarthrodial/ synovial plane Coracoclavicular syndesmosis / 2-part ligament amphiarthrosis / stability Costoclavicular (1st rib) syndesmosis / ligament amphiarthrosis / stability Scapula Scapular-thoracic muscle & fascia / physiological jt. plane / glide Humerus / Scapula Glenohumeral diarthrodial /synovial ball & socket Elbow (humerus, radius, ulna) Humeral - radial diarthrodial / synovial hinge, pivot, glide Humeral - ulnar diarthrodial / synovial hinge (ginglymus) Radio-ulnar (proximal jt.) diarthrodial / synovial pivot (trochoid) Radio-ulnar (middle jt.) fibrosis syndesmosis amphiarthrosis Radio-ulnar (distal jt.) diarthrodial / synovial pivot (trochoid) Wrist Radio carpal diarthrodial / synovial condylar (ellipsoid) Intercarpal diarthrodial /synovial plane Hand /fingers Carpometacarpal diarthrodial / synovial plane (digits 2-5) st Thumb (1. Carpometacarpal) diarthrodial / synovial saddle (trapezium & base of 1st metacarpal) Metacarpal phalangeal diarthrodial / synovial condylar (ellipsoid) digits 1-5) Interphalangeal diarthrodial / synovial hinge Scott A. Meisel M.S., D.C.