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Shortcut to Anatomy – 1st year Physical Therapy October 6 University Faculty of Physical Therapy For Physical Therapy students (I) Dr. Ahmed F. AlDomairy M...

Shortcut to Anatomy – 1st year Physical Therapy October 6 University Faculty of Physical Therapy For Physical Therapy students (I) Dr. Ahmed F. AlDomairy M.B.,B.Ch. M.Sc. (Dermatology & Venereology) M.Sc. (Anatomy & Embryology) M.D. (Anatomy & Embryology) Associate professor of Anatomy & Embryology Faculty of Medicine – October 6 University 2019-2020 1 Shortcut to Anatomy – 1st year Physical Therapy ACKNOWLEDGMENT I wish to express my deep gratitude & appreciation to my family, who played a remarkable role during the preparation and edition of this book, not to mention my whole life. I am also much obliged to my friends, colleagues and students who always provide me with faith, encouragement and everlasting support. As in all scientific work, it was a must to rely on previous anatomical references, to their authors; I wish to express my sincere appreciation. 2 Shortcut to Anatomy – 1st year Physical Therapy PREFACE This book is not a complete text and it wasn’t meant to be. However, putting Anatomy -the medical science of facts- in the most palatable and easy form was always my goal. Accordingly, reformulation of the well known anatomical information was the way. I hope that this book would be a module for such a target. 3 Shortcut to Anatomy – 1st year Physical Therapy VISION Faculty of Physical Therapy, October 6 University will be recognized as an accredited academic community at national, regional and international level. MISSION Prepare competent physical therapy graduates practicing efficiently at national and Arabic regional level through enhancing a sustained innovation in education, learning and research, as well as to contribute to society service in a framework of professional and moral ethics. 4 Shortcut to Anatomy – 1st year Physical Therapy COURSE SPECIFICATIONS Program (s) on which the course is given: Bachelor of physical therapy Course Coordinator: Dr. Ahmed F. AlDomairy Head of Departement: Prof. Dr. Kamal Asaad Ibrahim External Evaluator: Prof. Dr. Hany Shawky Nadim Date of last Revision: Aug 2019 (A) Basic Information: Title: Anatomy I Code: 111 Contact hours: 4 hours Lecture: 3 Tutorial : - Practical : 1 Total : 4 (B) Professional Information : 1) Overall aims: To inform the student with full anatomical knowledge of bones, muscles, joints, nerves and viscera of the body. Preparation of the student to deal with the different anatomical based clinical cases as pain, fructures, dislocations, sprains, lacerations Qualify the student to reach an accurate diagnosis and plan a prompt treatment, using an updated teaching facilities as well as multiple assessment methods. 2) Intended learning outcomes (ILO s): A) Knowledge and understanding: each student will be able to: K1) Identify each organ according to its characteristic features, and know the details of important features related to its structure and/or function. K2) Realize the anatomical changes occurring in an organ due to differences in sex and age. K3) Describe the structure of different joints and its related movements. K4) Recognize anatomical information related to different clinical situations. K5) Correlate the anatomical information of skeletal, articular and muscular systems to the nervous system B) Intellectual skills: student will be able to: I 1) Display mental correlation between academic knowledge and common clinical cases. I 2) Think critically about clinical problems through different case studies and assignments. I 3) Gather different alternatives to deal with case study modification and oral discussions. C) Professional and practical skills: student will be able to P1) Recognize different relationships in scientific and medical fields (colleagues, professors and supervisors) through direct contact and group searches. P2) Share in different scientific group projects with his colleaguesD) D) General and transferable skills: student will be able to G1) Use the internet and electronic sources to perform scientific presentations. G2) Show discipline in executing time limited scientific project. G3) Manage different obstacles during group based enterprise.3) Contents: 5 Shortcut to Anatomy – 1st year Physical Therapy 3) Contents: Wk Hr Lect Topic Pract Topic Terminology 1 4 4 - - Skin and fascia 2 4 2 Bones 2 Clavicle 3 4 2 Joints 2 Scapula Cartilage 4 4 2 2 Humerus Muscles 5 4 2 Pectoral 2 Ulna 6 4 2 Scapular Radius 7 4 2 Back 2 Hand 8 4 2 Axilla 2 Pectoral, scapular 9 4 2 Arm & Cubital fossa 2 Back & axilla 10 4 2 Front of forearm 2 Arm & cubital fossa 11 4 2 Hand 2 Forearm 12 4 2 Median & ulnar Ns 2 Hand Back of forehand 13 4 2 2 Nerves Radial N 14 4 2 Joints 2 Joints 15 4 2 Joints 2 Joints 4) Facilities required for teaching and learning 1) Lecture rooms 2) Museum and lab 3) Overhead projectors and data show 4) Computers 5) Cameras 5) Teaching and learning Methods: 1) Lectures using data show, computer and recent anatomy interactive programs 2) Practical classes using models, natural specimens and special cameras 3) Assignments 4) Self learning programs 6) Teaching and learning methods for students with learning difficulties: 1) Revisions for previous subjects 2) Assignments 3) Modified self learning programs 7) Student assessment : Method Schedule Weighting Midterm exam Middle of 1st term 25 Project Throughout the whole course 10 Attendance Throughout the whole course 5 Final written At the end of the course 40 Oral At the end of the course 20 Total 100 8) List of references: 8-1) Course Notes: Shortcut to anatomy 8-2) Essential Books (Text Book): Netter or McMinn atlas of anatomy 8-3) Recommended Book: Grays (for students), Last’s and Snell anatomy 8-4) Periodicals , Web sites, …… etc: Pubmed.org and Kenhub.com 6 Shortcut to Anatomy – 1st year Physical Therapy INDEX Page INTRODUCTION 9 Terminology 11 Skin & fascia 13 Bones 15 Joints 17 Cartilage 19 Muscles 19 UPPER LIMB 21 Osteology 22 Pectoral muscles 35 Scapular muscles 35 Intermuscular spaces 37 Muscles of the back 37 Axilla 39 Brachial plexus 41 Axillary (circumflex) nerve 41 Muscles of the arm 43 Musculocutaneous nerve 43 Cubital fossa 45 Muscles of forearm (front) 47 Muscles of the palm of hand 49 Flexor retinaculum and carpal tunnel 49 Median nerve 51 Ulnar nerve 53 Muscles of forearm (back) 55 Extensor retinaculum 57 Anatomical snuff box 57 Radial nerve 59 Sternoclavicular joint 61 Acromioclavicular joint 61 Shoulder girdle 61 Shoulder joint 63 Elbow joint 65 Superior radioulnar joint 65 Middle radioulnar joint (Interosseous membrane) 65 Inferior radioulnar joint 65 Supination and pronation 67 Wrist (radiocarpal) joint 67 COMMUNICATION 70 7 Shortcut to Anatomy – 1st year Physical Therapy This page intentionally left blank 8 Shortcut to Anatomy – 1st year Physical Therapy INTRODUCTION 9 Shortcut to Anatomy – 1st year Physical Therapy Planes Movements 10 Shortcut to Anatomy – 1st year Physical Therapy TERMINOLOGY Anatomical position: all the anatomical descriptions are based on a position in which the man is standing, with his face & palms of hands directed forward & the feet are close to each other. Anatomical planes & directions: Median (sagittal) plane: a vertical plane which divides the body at the midline into Rt & Lt equal halfs. According to this plane & the planes parallel to it (paramedian or parasagittal planes) the body is divided into medial (near the midline) & lateral (away from midline). Coronal plane: a vertical plane which divides the body into anterior (in front of the plane) & posterior (behind the plane). Transverse (horizontal) plane: which divides the body into superior (upper) & inferior (lower) parts. Anatomical descriptions: In addition to the previous terms, others could be used as: Superficial & deep: near or away from the surface. External & internal: outside or inside. Proximal & distal: near or away from the trunk. Terms of movements: Flexion & extension: moving 2 ventral surfaces towards or away from each other. Adduction & abduction: movement towards or away from midline. Medial & lateral rotations: moving the anterior side towards or away from the midline. N.B.: other terms of movements may be used in specific sites. 11 Shortcut to Anatomy – 1st year Physical Therapy Skin and fascia 12 Shortcut to Anatomy – 1st year Physical Therapy SKIN & FASCIA SKIN Layers: it is formed of 2 layers: Epidermis: outer tough layer. Dermis: inner layer containing hair follicles, sweat glands, nerves, blood vessels & lymphatics. Functions: Protection from external environment. Sensations. Regulation of body temperature. SUPERFICIAL FASCIA ❖ Formed of loose connective tissue & fat. ❖ It also contains nerves, blood vessels & lymphatics, transmitting it to skin. ❖ It is abscent in specific sites, e.g.: eye lids & scrotum. Functions: Fat store. Regulation of body temperature (fat prevent heat loss). In females, it contains the mammary gland forming the breast. DEEP FASCIA ❖ It is formed of dense connective tissue, to surround the deeper structures. ❖ It is well developed in limbs, especially around the joints (to grasp the different structures passing) & in the palm of hand & sole of foot (for protection). ❖ It is poorly developed in sites which nead expansion, e.g.: face & thoracic & abdominal walls. 13 Shortcut to Anatomy – 1st year Physical Therapy long short flat irregular pneumatic sesamoid Growing long bone 14 Shortcut to Anatomy – 1st year Physical Therapy BONES Types of bones: Type Description Example Long A bone with a shaft (diaphysis) & 2 ends (epiphysis) Humerus & femur Short Small bone Carpal bones Flat A bone with 2 surfaces Scapula Irregular A bone which does not fit the previous 3 types Vertebrae Pneumatic Special type, which is filled with air Maxilla Sesamoid Special type, which is found in a tendon of a muscle Patella Ossification of bones: Membranous: a connective tissue membrane will ossify into bone (e.g.: clavicle). Cartilaginous: a membrane will be transformed into cartilage model which will ossify into bone (e.g.: all bones of the limbs except clavicle). Growing long bone ❖ During development of long bones, it is formed of a membranous model, which mostly changes to a cartilage. ❖ Before birth, the shaft is transformed into bone, it begins by a primary center of ossification. ❖ After birth, each end is transformed into bone, it begins by a secondary center of ossification. ❖ A disc of cartilage persists between the shaft and each end, it is called epiphyseal plate of cartilage. ❖ The epiphyseal plate of cartilage add new cells to the shaft, this will increase bone length. ❖ The newly formed part of the shaft (near epiphyseal plate of cartilage) is called metaphysis. ❖ Later, the epiphyseal plate of cartilage ossifies, this will stop bone lengthening. ❖ Usually the 2 epiphyseal plates of the same bone do not ossify at the same time. One (non growing) end ossifies around the age of 19 years in males (17 years in females). The other (growing) end will ossify around the age of 21 years in males (19 years in females) with variations. ❖ The bone is covered by a periosteum. Periosteum add new cells deep to it, causing an increase in bone width. ❖ The bone shows a cavity. This cavity is lined with endosteum and contains bone marrow, which is responsible for formation of blood cells. 15 Shortcut to Anatomy – 1st year Physical Therapy ❖ Suture Syndesmosis gomphosis Primary cartiliginous Secondary cartiliginous Hinge Pivot Modified hinge ellipsoid Saddle Ball & socket Synovial Joint features 16 Shortcut to Anatomy – 1st year Physical Therapy JOINTS Definition: meeting between 2 or more bones (or cartilages). Types: according to the tissue between the bones the joints is classified into: Fibrous: a fibrous tissue connect the 2 bones, further divided into: Type Features Example syndesmosis Allows minimal movement Inf tibiofibular joint Does not ossify with age suture Allows minimal movement Sagittal suture (in skull) Ossify with age Gomphosis Allows no movement Between teeth & gums Does not ossify with age Cartiliginous: a cartilage connect the 2 bones, further divided into: Type Features Example Primary Formed of hyaline cartilage Epiphyseal plate of cartilage cartiliginous Allows no movement Ossifies with age Usually found away from midline Secondary Formed of fibrocartilage Intervertebral disc cartiliginous Allows minimal movement Usually does not ossify with age Usually found in midline Synovial: the 2 bones are connected with a capsule filled with synovial fluid, further divided into: Type Features Example Plane Allows only gliding movement Acromioclavicular Hinge Uniaxial: allows only flexion & extension Elbow Pivot Uniaxial: allows only rotation Sup & inf radioulnar Modified hinge Biaxial: allows flexion & extension + minimal Knee rotation Ellipsoid Biaxial: allows flexion & extension + adduction & Wrist abduction saddle Multiaxial: allows flexion & extension + adduction Carpometacarpal of & abduction + minimal rotation thumb Ball & socket Multiaxial: allows flexion & extension + adduction Shoulder & abduction + rotation Hip Synovial Joint features: Articular cartilages: a layer of hyaline cartilage, covering the articular surfaces, for smooth movement. Capsule: it is formed of fibrous tissue, which connect the articular surfaces Synovial membrane: lines the capsule & covers intracapsular non articular structures. It makes the joint space closed & secretes synovial fluid, which is responsible for joint lubrication. Ligaments: strong fibrous tissue, for joint stability. These ligaments may be capsular (thickened part of capsule), intracapsular or extracapsular. 17 Shortcut to Anatomy – 1st year Physical Therapy Skeletal Cardiac Smooth Types of skeletal muscles 18 Shortcut to Anatomy – 1st year Physical Therapy CARTILAGE ❖ It is avascular dense connective tissue, with intercellular matrix. Types: Type Features Example Hyaline Large amount of matrix Epiphyseal plate of cartilage Articular cartilages Fibrocartilage (white) Little matrix Intervertebral discs Rich in collagen fibers Intraarticular cartilages firm Elastic (yellow) Rich in elastic fibers Auricle of ear maleable Epiglottis MUSCLES ❖ There are 3 main types of muscles Skeletal Smooth Cardiac Site Attached to skeleton Viscera except heart Heart Muscle fibers Striated Smooth Striated Innervation Somatic nerves Autonomic nerves Autonomic nerves Action voluntary Involuntary Involuntary SKELETAL MUSCLES Attachment of skeletal muscle: Origin: it is the beginning of the muscle, it is usually proximal & fixed. Insertion: it is the end of the muscle, it is usually distal & movable. Forms of attachments: Fleshy: the regular fleshy nature of the muscle. Tendon: cylindrical cord like fibrous tissue. Aponeurosis: flat sheet like fibrous tissue. Raphe: meeting of 2 muscles (usually in midline), in the form of a mixture of fleshy & tendinuous fibers. Types of skeletal muscles: Type Features Parallel The muscle fibers are parallel from origin to insertion Fusiform Parallel muscle fibers with central dilatation Triangular The fibers attaches by a wide origin & narrow insertion Circular The fibers forms a circle Unipennate The fibers attaches obliquely to the tendon from one side Pennate Bipennate The fibers attaches to the tendon from 2 sides Multipennate Union of many bipennate parts Circumpennate Circular arrangement of multipennate 19 Shortcut to Anatomy – 1st year Physical Therapy This page intentionally left blank 20 Shortcut to Anatomy – 1st year Physical Therapy UPPER LIMB 21 Shortcut to Anatomy – 1st year Physical Therapy This page intentionally left blank 22 Shortcut to Anatomy – 1st year Physical Therapy CLAVICLE (SUP) Ant surface Ant border Attached structure: Attached structure: Pectoralis major Deltoid Med end Related structure: Post border Lat end Sternum Attached structure: Related structure: Related joint: Trapezius Acromion process Sternoclavicular joint Related joint: Acromioclavicular joint CLAVICLE (INF) Conoid tubercle Attached structure: Conoid lig Impression for Trapezoid ridge costoclavicular lig. Subclavian goorve Attached structure: Attached structure: Trapezoid lig Subclavius 23 Shortcut to Anatomy – 1st year Physical Therapy SCAPULA (ANT) Coracoid process Attached structures: Pectoralis minor Biceps (short head) Supraglenoid tubercle Coracobrachialis Attached structures: Coracoclavicular, coracoacromial & Biceps (long head) coracohumeral ligs. Suprascapular notch Related structures: Suprascapular N. & Vs. Glenoid cavity Related structure: Head of humerus Related joint: Shoulder Infraglenoid tubercle Med border Attached structures: Attached structure: Triceps (long head) Serratus Ant Subscapular fossa Attached structure: Suscapularis Inf angle Attached structure: Serratus Ant 24  Shortcut to Anatomy – 1st year Physical Therapy SCAPULA (POST) Supraspinous fossa Attached structures: Supraspinatus Acromion process Attached structures: Deltoid Trapezius Med border Coracoacromial lig Attached structure: Related joint: Levator scapulae, Acromioclavicular joint Rhomboides minor & Rhomboides major Crest of spine Attached structures: Deltoid Trapezius Lat bordrer Attached structures: Teres minor Infraspinous fossa Attached structures: Inf angle Infraspinatus Attached structures: Latissimus dorsi Teres major 25 Shortcut to Anatomy – 1st year Physical Therapy Greater tubercle HUMERUS (ANT) Head Attached structures: Related structure: Supraspinatus Glenoid cavity Infraspinatus Related joint: Teres minor Shoulder Bicipital groove Anatomical neck Attached structures: Teres major Lattisismus dorsi Lesser tubercle Pectoralis major Attached structure: related structure: Subscapularis Biceps Surgical neck Related structure: Axillary N. (post) Ant & Post circumflex humeral As. Deltoid tuberosity Attached structure: Deltoid Coronoid fossa Radial fossa Related structure: Related structure: Coronoid process of ulna Head of radius Related joint: Related joint: Elbow joint Elbow joint Medial epicondyle Attached structure: Lateral epicondyle Common flexor origin (ant) Attached structure: Related structure: Common extensor origin Ulnar N. (post) & Ulnar collateral As. Trochlea Capitulum Related structure: Related structure: Trochlear notch of ulna Head of radius Related joint: Related joint: Elbow joint Elbow joint 26 Shortcut to Anatomy – 1st year Physical Therapy HUMERUS (POST) Surgical neck Related structure: Axillary N. (post) Ant & Post circumflex humeral As. Spiral grove Related structure: Radial N. Profunda A. Olecranon fossa Medial epicondyle Related structure: Related structure: Olecranon process of ulna Ulnar N. (post) & Ulnar Related joint: collateral As. Elbow joint 27 Shortcut to Anatomy – 1st year Physical Therapy ULNA (ANT) Olecranon process Related structure: Olecranon fossa Related joint: Radial notch Elbow joint Related structure: Head of radius Related joint: Trochlear notch Sup radioulnar joint Related structure: Trochlea Supinator fossa Related joint: Attached structure: Elbow joint Supinator Coronoid process Ulnar tuberosity Related structure: Attached structure: Coronoid fossa Related joint: Brachialis Elbow joint Interosseous border Attached structure: Interosseous membrane Head Related structure: Ulnar notch (circumference) Triangular articular disc (inf) Styloid process Related joint: Attached structure: Inf radioulnar joint Med collateral lig 28 Shortcut to Anatomy – 1st year Physical Therapy ULNA (POST) Olecranon process Attached structure: Triceps Radial notch Related structure: Head of radius Related joint: Sup radioulnar joint 29 Shortcut to Anatomy – 1st year Physical Therapy RADIUS (ANT) Head Related structures: Capitulum Neck Radial notch Related structure: Related joints: End of brachial A. Elbow joint Sup radioulnar joint Radial tuberosity Attached structure: Biceps Interosseous border Attached structure: Interosseous membrane Pronator tuberosity Attached structure: Pronator teres Ulnar notch Related structure: Head of ulna Related joint: Inf radioulnar Inf surface of lower end Styloid process Related structure: Attached structure: Scaphoid & Lunate Lat collateral lig Related joint: Wrist 30 Shortcut to Anatomy – 1st year Physical Therapy RADIUS (POST) Dorsal tubercle Styloid process Attached structure: Lat collateral lig 31 Shortcut to Anatomy – 1st year Physical Therapy HAND (ANT) 32 Shortcut to Anatomy – 1st year Physical Therapy HAND (POST) 33 Shortcut to Anatomy – 1st year Physical Therapy Pectoralis major Pectorlais minor Subclavius Serratus anterior Deltoid Supraspinatus Infraspinatus Teres minor Teres major Subscapularis 34 Shortcut to Anatomy – 1st year Physical Therapy PECTORAL MUSCLES Muscle Origin Insertion Action NS Pectoralis Clavicular head Bicipital groove Adduction shoulder Med & lat major Medial ½ of Med rotation shoulder Pectoral Ns front of clavicle Flexion shoulder Sternocastal head ½ breadth of sternum upper 6 costal Cartilages Pectoralis ribs 2-5 near Coracoid process Depression of scapula minor costal cartilages protraction of scapula Subclavius 1st rib Inf surface of clavicle Fixation of clavicle N to (subclavian groove) during shoulder subclavius movements Serratus 8 digitations Med border of scapula Up rotation of scapula N to anterior from upper 8 ribs (ant lip) → elevation of arm > serratus ant - 1st digit → sup angle 90° - 2-3 → med border protraction of scapule - 4-8 → inf angle fixation of scapula (paralysis leads to winging of scapula) SCAPULAR MUSCLES Muscle Origin Insertion Action NS Deltoid lat 1/3 of clavicle Deltoid Abduction (15-90°) Axillary N (ant border) tuberosity ant fibers: flexion & acromion (outer med rotation border) post fibers: extension crest of spine of & lat rotation scapula (lower border) Supraspinatus Supraspinous fossa Greater Abduction (0-15°) Suprascapular N tuberosity Infraspinatus Infraspinous fossa Greater Lat rotation Suprascapular N tuberosity Adduction Teres minor Lat border of scapula Greater Lat rotation Axillary N (upper 2/3 of post tuberosity Adduction aspect) Teres major Post surface of Bicipital Med rotation Lower scapula (above inf groove Adduction subscapular N angle) Extension Subscapularis Subscapular Fossa Lesser Flexion Upper & lower tuberosity Adduction subscapular Ns 35 Shortcut to Anatomy – 1st year Physical Therapy Scapular spaces Trapezius Latissimus dorsi Levator scapulae Rhomboides minor Rhomboides major 36 Shortcut to Anatomy – 1st year Physical Therapy INETERMUSCULAR SPACES Boundaries Space Contents Sup Inf Med Lat Triceps Quadrangular Teres minor Teres major Humerus Axillary N (long head) Triceps Upper triangular Teres minor Teres major (long head) Triceps Lower tringular Teres major Humerus Radial N (long head) MUSCLES OF THE BACK Muscle origin Insertion Action NS Sup nuchal line Lat 1/3 of Up rotation of scapula → Spinal (med 1/3) clavicle (post elevation of arm > 90° accessory N Trapezius External border) Retraction of scapula + C3-4 occipital Acromion Upper fibers → elevation of protuberance (med border) scapula Ligamentum Crest of spine Lower fibers → depression nuchae (sup border) of scapula C7 spine All thoracic spines Iliac crest Bicipital groove Adduction N to Lumbar fascia Med rotation latissimus Lower 6 thoracic Extension dorsi Latissimus spines Elevation of trunk to fixed dorsi Lower 3 ribs arm Inf angle of scapula (post) C1-4 vertebrae Med border of Elevation of scapula N to Levator scapula (above Retraction of scapula rhomboides scapulae spine) Rhomboides C7-T1 vertebrae Med border (at Elevation of scapula minor spine ) Retraction of scapula Rhomboides T2-5 vertebrae Med border Down rotation of scapula major (below spine) 37 Shortcut to Anatomy – 1st year Physical Therapy Axilla 38 Shortcut to Anatomy – 1st year Physical Therapy AXILLA Definition: pyramidal space between upper parts of arm & chest. Boundaries: Apex (cervico axillary canal): Connection between neck & apex of axilla. Transmits vessels & nerves to upper limb. It is bounded by: - Medial: 1st rib. - Anterior: clavicle. - Posterior: scapula. Ant wall: Pectoralis Major. Clavipectoral fascia. Subclavius. Pectoralis minor. Post wall. Subscapularis. Latisimus dorsi. teres major. Med wall Upper 5 ribs & intercostal muscles. Upper part of serratus anterior. Lat Wall Upper part of shaft of humerus. Coracobrachialis. Biceps. Contents: Axillary A. Axillary V. Brachial plexus. Axillary lymph nodes. 39 Shortcut to Anatomy – 1st year Physical Therapy Brachial plexus Axillary nerve 40 Shortcut to Anatomy – 1st year Physical Therapy BRACHIAL PLEXUS Stage Formation Branches Roots Ant rami of C5,6,7,8,T1 N to rhomboids (C5) N to serratus ant (C5,6,7) Trunks Upper: union of C5 & C6 N to subclavius (upper trunk, C5,6) Middle: C7 Suprascapular N (upper trunk, C5,6) Lower: union of C8 & T1 Divisions Each trunk divides into ant and post divisions Cords Lat (C5,6,7): union of ant divisions of 1) Lat pectoral N (C5,6,7) upper & middle trunks 2) Lat root of median N (C5,6,7) 3) Musculocutaneous N (C5,6,7) Med (C8,T1): ant division of lower 1) Med pectoral N (C8,T1) trunk 2) Med root of median N (C8,T1) 3) Med cutaneous N of arm (C8,T1) 4) Med cutaneous N of forearm (C8,T1) 5) Ulnar N (C7,8,T1) Post (C5,6,7,8,T1): union of the 3 post 1) Upper subscapular N (C5,6) divisions 2) Lower subscapular N (C5,6) 3) Axillary N (C5,6) 4) N to latissimus dorsi (C6,7,8) 5) Radial N (C5,6,7,8,T1) N.B.: Branches of brachial plexus supply all the muscles of upper limb except trapezius. The ulnar N receives fibers of C7 from the median N. AXILLARY (CIRCUMFLEX) NERVE Root value: C5,6. Begining: from post cord of brachial plexus. Course and Relations:  It passes post to axillary A.  Passes through quadrangular space.  Passes post to surgical neck of humerus. Branches and Distribution: Ant branch: ant part of deltoid. Post branch: Post part of deltoid & teres minor. Upper lat cutaneous N of arm: supply skin over deltoid. End: deep to deltoid by dividing into ant and post branches. Injury of axillary nerve: Causes: fracture surgical neck of humerus or dislocation of shoulder. Motor: Paralysis of deltoid → loss of abduction 15-90°. Sensory: loss of sensation over the deltoid 41 Shortcut to Anatomy – 1st year Physical Therapy Biceps Coracobrachialis Brachialis Triceps Musculocutaneous N 42 Shortcut to Anatomy – 1st year Physical Therapy MUSCLES OF THE ARM Muscle Origin Insertion Action NS Long head (lat): Radial flexion shoulder Musculocutaneous N supraglenoid tuberosity Flexion elbow tubercle → Supination. Biceps bicipital groove short head (med): Coracoid process Coracoid process Med border Flexion shoulder Musculocutaneous N Coracobrachialis of humerus (pierces the muscle) (middle) Lower ½ of shaft Ulnar Flexion elbow Musculocutaneous N Brachialis of humerus tuberosity Radial N (lat fibers) (front) Long head: Olecrenon Extension elbow Radial N Infraglenoid process tubercle Lat head: back of humerus above Triceps radial groove Med head: back of humerus below radial groove MUSCULOCUTANEOUS NERVE Root value: C5,6,7. Origin: lat cord of brachial plexus. Course & relations:  It descends lateral to axillary A.  Pierces coracobrachialis.  Passes between coracobrachialis & biceps then between biceps & brachialis.  Appears lat to biceps & continue as lateral cutaneous N of forearm. Branches: A) Muscular: Coracobrachialis. Each head of biceps. Brachialis. B) Cutaneous: lat cutaneous N of forearm (terminal branch): supply corresponding skin. 43 Shortcut to Anatomy – 1st year Physical Therapy Cubital fossa 44 Shortcut to Anatomy – 1st year Physical Therapy CUBITAL FOSSA Definition: triangular space in front of elbow. Boundaries: Base: imaginary line between 2 humeral epicondyles. Med: pronator teres. Lat: brachioradialis. Roof: Skin. Superficial fascia containing med & lat cutaneous Ns of foream, bicipital aponeurosis & superficial veins (site of injection). Deep fascia. Floor: Med: brachialis. Lat: supinator. Contents: Brachial A and its 2 terminal branches: ulnar & radial. Lat: biceps tendon and radial N. Med: median N. 45 Shortcut to Anatomy – 1st year Physical Therapy Flexor digitorum Pronator teres Flexor carpi radialis Palmaris longus Flexor carpi ulnaris superficialis Flexor digitorum profundus Flexor pollicis longus Pronator quadratus 46 Shortcut to Anatomy – 1st year Physical Therapy MUSCLES OF FOREARM (FRONT) Muscle Origin Insertion Action NS Pronator Humeral head: med Lat surface of pronation teres supracondylar ridge radius (middle) Ulnar head: coronoid process Flexor carpi CFO 2nd & 3rd FW radialis metacarpal Abduction wrist Palmaris CFO Palmar FW longus apponeurosis (may be (apex) Median N absent) Flexor Humero-ulnar head: Med 4 fingers FW digitorum CFO & coronoid (middle Flexion of med 4 superficialis process phalanges) fingers Radial head: ant (metacarpophalangea oblique line l & proximal interphalangeal joints) Flexor carpi Humeral head: CFO Pisiform then to: FW Ulnar N ulnaris Ulnar head: olecranon Hamate Adduction wrist process & post border 5th metacarpal Flexor Upper ¾ of ulna (ant Med 4 fingers FW Med ½: ulnar digitorum surface) (distal Flexion of med 4 N profundus phalanges) fingers (all joints) Lat ½: ant interosseous N Flexor Upper ¾ of radius (ant Distal phalanx of FW pollicis surface) thumb Flexion thumb (all Ant longus joints) interosseous Pronator Lower ¼ of ulna (ant Lower ¼ of Pronation (median) N quadratus surface) radius (ant surface) CFO = common flexor origin (front of med epicondyle). FW = flexion wrist. 47 Shortcut to Anatomy – 1st year Physical Therapy Flexor retinaculum & carpal tunnel Abductor pollicis brevis Flexor pollicis brevis Opponens pollicis Adductor pollicis Abductor digitiminimi Flexor digitiminimi Opponens digitiminimi Palmaris brevis Lumbricals Palmar interossei Dorsal interossei 48 Shortcut to Anatomy – 1st year Physical Therapy FLEXOR RETINACULUM AND CARPAL TUNNEL Definition: flexor retinaculum is thickened deep fascia ant to wrist joint. Carpal tunnel is the space between flexor retinaculum and carpal bones. Attachement: Lat: scaphoid (tubercle), trapezium (crest). Med: pisiform, hamate (hook). Structures passing superficial: 1) Ulnar N. 2) Ulnar A. 3) Palmis longus. Structures passing deep: 1) Flexor digitorum superficialis. 2) Flexer digitorum profundus. 3) Median N. 4) Flexor pollicis longus. 5) Flexor carpi radialis (in special compartement). Applied anatomy: Carpal tunnel syndrome: compression of median N in carpal tunnel (usually due to carpal bone dislocation, inflammation of tendons or overstreched hand). MUSCLES OF THE PALM OF HAND Group Muscle Action NS Abductor pollicis Abduction of thumb Median N: brevis Thenar Thenar Flexor pollicis brevis Flexion of thumb 1st (lat) 2 Opponens pollicis Opposition of thumb lumbricals Abductor digitiminimi Abduction of little finger Ulnar N: Flexor digitiminimi Flexion of little finger supplies Hypothenar other Ms Opponens Opposition of little finger digitiminimi Adductor pollicis Adduction of thumb Palmaris brevis Increase concavity of hand → firm grip writing position of med 4 fingers 4 lumbricals Flexion of metacarpophalangeal joint Extension of interphalangeal joints 4 Palmar interossei Adduction of all fingers except middle (1st may be absent) Writing position 4 Dorsal interossei Abduction of middle 3 fingers Writing position N.B.: adduction & abduction of fingers is along a line of the 3rd finger. 49 Shortcut to Anatomy – 1st year Physical Therapy Median N 50 Shortcut to Anatomy – 1st year Physical Therapy MEDIAN NERVE Root value: C5,6,7,8,T1. Beginning: by 2 roots, Lat root from lat cord & med root from med cord of brachial plexus. Course and relations:  Descends lat to axillary & brachial A.  At the middle of the arm it crosses the brachial A & passes med to it to enter the cubital fossa.  Leaves cubital fossa by passing between 2 heads of pronator teres.  Descends between flexor digitorum superficialis (superficial) & flexor digitorum profundus (deep).  Passes deep to flexor retinaculum to the hand then divides into terminal branches. Branches: Site Motor Sensory At axilla Pronator teres Flexor carpi radialis At cubital fossa Palmaris longus Flexor digitorum superficialis Ant interosseous N: supplies: Palmar cutaneous branch Flexor digitorum profundus (lat ½) → lat 2/3 of palm (ant) At forearm Pronator quadratus Flexor pollicis longus Thenar Lat 3½ fingers (ant) At hand Lat 2 lumbrical Injury of median nerve: (Ape like hand) A] Injury above cubital fossa: Motor: Paralysis of pronator teres & quadratus → loss of pronation. Paralysis of wrist flexors except flexor carpi ulnaris → weak flexion accompanied by adduction. Paralysis of flexor pollicis longus & brevis → loss of thumb flexion. Paralysis of opponens pollicis → loss of opposition (Ape like hand). Sensory: loss of sensation of ant side of lat 2/3 of hand & lat 3½ fingers. B] Injury at wrist: Cause: carpal tunnel syndrome due to compression by inflammation, bone dislocation or overstretch by extended hands (e.g.: typewriters). Motor: loss of opposition (Ape like hand). Sensory: loss of sensation of ant side of lat 3½ fingers. 51 Shortcut to Anatomy – 1st year Physical Therapy Ulnar nerve 52 Shortcut to Anatomy – 1st year Physical Therapy ULNAR NERVE Root value: C7,8,T1. Beginning: from med cord of brachial plexus. N.B.: med cord of brachial plexus does not contain C7, it reaches the ulnar nerve through lat root of median nerve. Course and relations:  Descends med to axillary & brachial A.  At mid arm it passes to post compartment.  Passes post to med epicondyle.  Passes between 2 heads of flexor carpi ulnaris to forearm.  Descends between flexor carpi ulnaris (superficial) & flexor digitorum profundus (deep).  Passes superficial to flexor retinaculum to the hand. Branches: Site Motor Sensory At axilla & arm Flexor carpi ulnaris Palmar & dorsal cutaneous At forearm Flexor digitorum profundus (med ½) branches → med 1/3 of hand (ant & post) Hypothenar Med 1½ fingers (ant & post) Adductor pollicis At hand Palmaris brevis Med 2 lumbricals Palmar & dorsal interossei Injury of ulnar nerve: (partial claw hand) A] Injury above the elbow: Motor: Paralysis of flexor carpi ulnaris → weak flexion of wrist accompanied by abduction. Paralysis of med 2 lumbricals → clawing of ring & little fingers (partial claw hand) = extension of metacarpophalangeal and flexion of interphalangeal joints. Paralysis of interossei → loss of adduction and abduction of med 4 fingers. Paralysis of adductor pollicis → loss of adduction of thumb. Sensory: loss of sensation of med 1/3 of hand & med 1½ fingers (ant & post). B] Injury at wrist: differs in: Motor: No affection of wrist flexion Claw hand is more severe due to further flexion by flexor digitorum profundus (ulnar paradox). Sensory: loss of sensation of med 1½ fingers (ant and post). 53 Shortcut to Anatomy – 1st year Physical Therapy Extensor carpi Extensor carpi Extensor Extensor carpi Anconeus Brachioradialis Extensor digitorum radialis longus radialis brevis digitiminimi ulnaris Supinator Abductor pollicis longus Extensor pollicis brevis Extensor pollicis longus Extensor indicis 54 Shortcut to Anatomy – 1st year Physical Therapy N.B.: complete claw hand: (clawing of med 4 fingers) occurs due to injury of both median & ulnar nerves or injury of lower trunk or med cord of brachial plexus. MUSCLES OF FOREARM (BACK) Muscle Origin Insertion Action NS Anconeus Lat epicondyle (post) Post surface of Extension elbow ulna (upper ¼) Radial N Brachioradialis Lat supracondylar ridge Lower end of Initiate supination and radius (lat pronation surface) Extensor carpi Lat supracondylar ridge 2nd metacarpal EW radialis longus Abduction wrist Extensor carpi CEO 3rd metacarpal EW radialis brevis Abduction of wrist Extensor CEO Med 4 fingers EW digitorum (extensor Extension of med 4 expansion) fingers (all joints) Extensor digiti CEO Little finger EW minimi (extensor Extension little finger expansion) (all joints) Post interosseous (Radial) N Extensor carpi CEO 5th metacarpal EW ulnaris post border of ulna Adduction wrist Supinator Supinator crest & fossa upper 1/3 of Supination radius (post, lat & ant surfaces) Abductor pollicis Post surface of radius, 1st metacarpal Abduction thumb longus ulna & interosseous membrane (upper 1/3) Extensor pollicis Post surface of radius Proximal phalanx Extension thumb brevis (middle 1/3) of thumb (metacarpophalangeal joint) Extensor pollicis Post surface of ulna Distal phalanx of EW longus (middle 1/3) thumb Extension thumb (all joints) Extensor indicis Post surface of ulna Index (extensor EW (below extensor pollicis expansion) Extension index (all longus) joints) CEO = common extensor origin (front of lat epicondyle). EW = extension wrist. Extensor expansion: the tendons expand over the proximal phalanges of fingers, divide into 3 slips & insert into middle & distal phalanges. 55 Shortcut to Anatomy – 1st year Physical Therapy Extensor retinaculum Snuff box 56 Shortcut to Anatomy – 1st year Physical Therapy EXTENSOR RETINACULUM Attachments: Lat: ant border of radius (lower part). Med: triquetrum and pisiform. Structures superficial to it: superficial radial N Structures deep to it: 6 compartements (from lat to med) Compartment Contents Abductor pollicis longus 1 Extensor pollicis brevis Extensor carpi radialis longus 2 Extensor carpi radialis brevis 3 Extensor pollicis longus Extensor digitorum Extensor indicis 4 Post interosseous N Ant interosseous A 5 Extensor digitiminimi 6 Extensor carpi ulnaris ANATOMICAL SNUFF BOX Boundaries: Lat: Abductor pollicis longus & extensor pollicis brevis (1st compartment of extensor retinaculum). Med: extensor pollicis longus (3rd compartment of extensor retinaculum). Floor: styloid process of radius & scaphoid bone. Roof: superficial fascia containing superficial radial N. Contents: Radial A. Ext carpi radialis longus and brevis (2nd compartment of extensor retinaculum). 57 Shortcut to Anatomy – 1st year Physical Therapy Radial nerve 58 Shortcut to Anatomy – 1st year Physical Therapy RADIAL NERVE Root value: C5,6,7,8,T1. Begining: from post cord of brachial plexus. Course and relations:  Lies post to axillary and brachial A.  Passes in lower triangular space.  Runs in spiral groove.  Descends in cubital fossa between brachialis and brachioradialis & divides into 2 terminal branches. Branches: Site Motor Sensory At axilla Triceps (long head) Post cutaneous N of arm Triceps (med head) At spiral Triceps (med head) Lower lat cutaneous N of arm groove Triceps (lat head) Post cutaneous N of forearm Anconeus Between Brachialis (lat fibers) brachialis & Brachioradialis bracioradialis Extensor carpi radialis longus Terminal Post interosseous N: supplies: Superficial terminal branch: extensor carpi radialis brevis supply skin of dorsum of hand (lat extensor digitorum 2/3) & lat 3½ fingers extensor digitiminimi extensor carpi ulnaris abductor pollicis longus extensor pollicis brevis extensor pollicis longus extensor indicis supinator Injury of radial nerve: (wrist drop) A] Injury above spiral groove: Motor: Paralysis of triceps & anconeus → loss of elbow extension. Paralysis of muscles of back of forearm → wrist drop. Paralysis of fingers extensors → fingers drop. Sensory: loss of sensation of 1st interdigital cleft (post). B] Injury in Spiral Groove: differs in: No loss of elbow extension. C] Injury of Posterior Interosseous N: differs in: No loss of elbow extension. Weak extension of wrist (only by extensor carpi radialis longus). No sensory loss. 59 Shortcut to Anatomy – 1st year Physical Therapy Sternoclavicular joint Acromioclavicular joint 60 Shortcut to Anatomy – 1st year Physical Therapy STERNECLAVICULAR JOINT Type & variety: synovial, saddle. Articular surfaces: clavicle (sternal end) & sternum (clavicular notch). Capsule: attached to margins of articular surfaces. Intracapsular structures: cartilaginous articular disc Synovial Membrane: Lines the capsule. Covers intracapsular non articular structures. Ligaments: Costaclavicular. Interclavicular. ACROMIOCLAVICULAR JOINT Type: synovial, plane. Articular surfaces: clavicle (acromial end), acromion (clavicular facet). Capsule: Attached to the margin of articular surfaces. Synovial membrane: Lines the capsule. Covers intracapsular non articular structures. Ligaments: Coracoclavicular ligament - 2 parts: conoid & trapezoid. - Strong ligament transmits upper limb weight to the clavicle & axial skeleton. SHOULDER GRIDLE Definition: Movement of scapula and clavicle through sternoclavicular and acromioclavicular joints. Movement & muscles: Elevation: trapezius (upper fibers), levator scapulae, rhomboids minor & major. Depression: trapezius (lower fibers) & pectoralis minor. Protraction: serratus ant & pectoralis minor. Retraction: trapezius, levator scapulae, rhomboids minor & major. Up (lat) rotation (elevation of arm ˃ 90°): trapezius & serratus ant. Down (med) rotation: pectoralis minor, rhomboids minor & major. 61 Shortcut to Anatomy – 1st year Physical Therapy Shoulder joint 62 Shortcut to Anatomy – 1st year Physical Therapy SHOULDER JOINT Type and variety: synovial (ball& socket). Articular surfaces: scapula (glenoid cavity) & humerus (head). Capsule: Attachements: at the margins of articular surfaces except inferiorly where it reaches surgical neck. Intracapsular structures: Labrum glenoidal: fibrocartilage ring attached to the margin of glenoid cavity to deepen it. Long head of biceps Synovial membrane: Lines the capsule. Covers the intracapsular non articular structures (labrum glenoidal & long head of biceps). Ligaments: Coracohumeral ligament: from coracoid process to greater tuberosity. Glenohumeral ligament: from glenoid cavity to lesser tuberosity. Coracoacromial ligament: from coracoid to acromial processes. The 2 processes & the ligament form coracoacromial arch. It prevents sup dislocation. Transverse humeral ligament: between greater & lesser tuberosities. It controls the movement of the long head of biceps. Movements and muscles: Flexion: pectoralis major, deltoid (ant fibers), biceps & coracobrachialis. Extension: deltoid (post fibers), teres major & latismus dorsi. Adduction: pectoralis major, latismus dorsi & teres major (TLP). Abduction: 0-15°: supraspinatus. 15-90°: shoulder joint deltoid. N.B.: elevation of arm ˃ 90°: trapezius & serratus ant (shoulder girdle). Med rotation: pectoralis major, latismus dorsi, teres major (TLP), deltoid (ant fibers) & subscapularis. Lat rotation: infraspinatus, teres minor & deltoid (post fibers). Circumduction Stability: Weak joint due to shallow articular surfaces & weak ligaments. Mainly supported by rotator cuff muscles; supraspinatus (sup), infraspinatus and teres minor (post) & subscapularis (ant). It is also supported by coracoacromial arch (sup). Frequently dislocated inferiorly, usually with abducted arm. Its dislocation may lead to axillary nerve injury. 63 Shortcut to Anatomy – 1st year Physical Therapy Elbow joint Radioulnar joints 64 Shortcut to Anatomy – 1st year Physical Therapy ELBOW JOINT Types & variety: synovial, hinge. Articular surfaces: Trochlea of humerus with trochlear notch of ulna. Capitulum of humerus with head of radius (sup surface). Capsule: attached to margins of articular surfaces. Synovial membrane: Lines the capsule. Covers intracapsular nonarticular structures. Ligaments: Med (ulnar) collateral ligament: between med epicondyle & med margin of coronoid & olecranon processes. Lat (radial) collateral ligament: between lat epicondyle & annular ligament. Movements and muscles: Flexion: biceps, brachialis & brachioradialis. Extension: triceps & anconeus. SUPERIOR RADIOULNAR JOINT Type & variety: synovial, pivot. Articular surfaces: head of radius (circumference) & radial notch of ulna. Capsule: attached to margins of articular surfaces. Synovial membrane: Lines the capsule. Covers intracapsular non articular structures. Ligaments: Annular ligament: attached to margins of radial notch & surrounds head of radius. Quadrate ligament: between neck of radius & ulna. Movement: supination & pronation. MIDDLE RADIOULNAR JOINT (INTEROSSEOUS MEMBRANE) Type & variety: fibrous, syndesmosis. Attachment: interosseous borders of radius & ulna. Direction of fibers: med (from radius to ulna) & downwards. INFERIOR RADIOULNAR JOINT Type & variety: synovial, pivot. Articular surfaces: head of ulna and ulnar notch of radius. Capsule: attached to the margins of articular surfaces. Synovial membrane: Lines the capsule. Covers intracapsular non articular structures. Movement: supination and pronation. N.B.: triangular articular disc: attached between lower end of ulnar notch of radius & styloid process of ulna. It separates ulna from the carpal bones. 65 Shortcut to Anatomy – 1st year Physical Therapy Supination & pronation Wrist joint 66 Shortcut to Anatomy – 1st year Physical Therapy SUPINATION AND PRONATION Definition: Supination: is lat rotation of forearm so that the palm faces anteriorly & the thumb is directed laterally. Pronation: is med rotation of forearm so that the palm faces posteriorly & the thumb is directed medially. In both movements the radius moves while the ulna is fixed. Joints concerned: radioulnar joints. Muscles: Supination: biceps (with flexed elbow) & supinator. Pronation: pronator teres and pronator quadratus. N.B.: Brachioradialis initiates both movements. ❖ Supination is stronger than pronation, supination with semiflexed elbow is stronger than with extended elbow. Both due to the action of biceps). WRIST (RADIOCARPAL) JOINT Type & variety: synovial, ellipsoid. Articular surfaces: Proximal: lower end of radius & triangular articular disc. Distal: scaphoid, lunate & triquetrum. Capsule: attached to the margins of articular surfaces. Synovial membrane: Lines the capsule. Covers intracapsular non articular structures. Ligaments: Ant radiocarpal: between lower ends of radius & ulna & carpals (ant). Post radiocarpal: between lower ends of radius & ulna & carpals (post). Med (ulnar) collateral ligament: between styloid process of ulna & pisiform & triquetrum. Lat (radial) collateral ligament: between styloid process of radius & scaphoid & trapezium. 67 Shortcut to Anatomy – 1st year Physical Therapy 68 Shortcut to Anatomy – 1st year Physical Therapy Movements and muscles: Flexion: flexor carpi radialis, flexor carpi ulnaris, palmaris longus, flexor digitorum superficialis & profundus & flexor pollicis longus. Extension: extensor carpi radialis longus and brevis, extensor carpi ulnaris, extensor digitorum, extensor digitiminimi, extensor pollicis longus & extensor indicis. Adduction: flexior carpi ulnaris, extensor carpi ulnaris. Abduction: flexor carpi radialis, extensor carpi radialis longus & brevis. Circumduction. 69 Shortcut to Anatomy – 1st year Physical Therapy REFERENCES ❖ Kenhub.com (2019) ❖ Marieb EN, Wilhelm PB and Mallatt J (2012): Human Anatomy. 6th ed. Pearson education. San Francisco. ❖ Martini FH, Nath JL and Bartholomew EF (2012): Fundamentals of Anatomy and Physiology. 9th ed. Pearson education. San Francisco. ❖ McKinley M and O’Loughlin VD (2012): Human Anatomy. 3rd ed. McGrow Hill. New York. ❖ Shier D, Butler J and Lewis R (2001): Human Anatomy and Physiology. 9th ed. McGaw Hill. New York. ❖ Shuenke M, Schulte Eand Schumacher U (2006): Thieme atlas of anatomy. Georg Thieme Verlag, Stuttgurt, Germany, New York. ❖ Sinnatamby C.S. (2011): Last's anatomy; Regional and Applied. 12th ed. Churchill Livingstone imprint. Elsevier, London, UK. ❖ Snell R.S. (2012): Clinical Anatomy; by Regions. 9th ed. Lippincott. Williams and Wilkins imprint. Wolters Kluwer, Philadelphia, USA. ❖ Standring S (2015): Gray's anatomy; The Anatomical Basis of Clinical Practice. 41st ed. Churchill Livingstone imprint. Elsevier, London, UK. ❖ Tortora G and Nielsen MT (2012): Principles of Human Anatomy. 12th ed. John Wiley & Sons, Inc. Danvers. ❖ Whitaker RH and Borley NR (2005): Instant Anatomy. 2nd ed. 2000 reprinted 2005. Blackwell science publishing. Oxford, UK. To communicate with the author: E-mail: [email protected] Facebook: Ahmed F. AlDomairy 2011/15392 :‫رقم اإليداع بدار الكتب‬ 70