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Upper Limb Anatomy Ms SamanthaSharkey ST3Trauma& Orthopaedics LeedsGeneralInfirmary • Brief overview of upper limb anatomy • Bones & Joints • Neurovascular structures • Muscle compartments Aims of the • Relevance in clinical practice Session • Whatis NOT covered • Brachial plexus,spaces/intervals,extensor compartments of wrist The Clavicle • S-shaped bone usually split into 1/3rds • 80% fractures occur in the middle 1/3 • Land pull of pec major, medial end is displaced by SCM • Aacromion distallyhe sternum proximally and the • Cligaments) attach distallyconoid and trapezoid • Main surrounding structures at risk – lung, brachial plexuss, subclavian vessels, apex ofScapula • Triangular shapedbone with 4main processes: • Spine • Glenoid • Acromion • Coracoid process • Origin or insertion of 18muscles • Associatedinjuries in 80-95% • Usually highenergy mechanismThe Shoulder • Usually refers to the glenohumeral joint but examinationshould alsoinclude: • Sternoclavicular joint • ACjoint • Majority of movementis at the glenohumeral joint but 1/3scapulothoracic • Circumduction • Forward flexion, extension,abduction, adduction, IR,ERGlenohumeral Stability • Staticrestraints: • Glenohumeralligaments • socket depth)tsfor 50%of • Glenohumeralarticulation& joint capsule(lax) • Negativeintra-articularpressure • Dynamic restraints: • Rotatorcuff muscles • Longhead of biceps tendon(from supraglenoidtubercle) Rotator CuffMuscles Muscle Origin Attachment Innervation Action Supraspinatous Supraspinousfossa Greatertuberosity Suprascapularn Initiationof abduction(isolated to 15 degrees) Infraspinatous Infraspinousfossa Greatertuberosity Suprascapularn ER Subscapularis Subscapularfossa Lesser tuberosity Upper& lower IR subscapularn TeresMinor Posteriorsurface Greatertuberosity Axillaryn ER ofscapulaProximal Humerus • GreaterTuberosity: • Supraspinatous(superiorfacet), (inferiorfacet)middlefacet),teresminor • LesserTuberosity: • Subscapularis • Blood supply • Proximalhumeralcircumflexartery • Thoughtto bemain blood supply • Ascendingbranchofanterior humeral circumflexartery • Becomes arcuatearteryas penetrates boneof humeralhead • Mostcommonassociatedinjuryis axillary nerve injury • Found5-7cmdistalto the tip ofacromionShaft Humerus • Laterally • Deltoid tuberosity (roughened surface where deltoid attaches) • Anteriorly • Coracobrachialis • Deltoid • Brachialis • Brachioradialis • Posteriorly • Triceps • Spiral Groove • Aka radial groove • Depression which runs diagonally down posterior surface of humerus • Radial n and profunda brachii artery lie withinDistal Humerus • Medial Epicondyle • Larger of 2 • Commonflexor origin • Closely associatedwith ulnar n • Lateral Epicondyle • CommonextensororiginClinical applications of distal humerus bony landmarks • C R I T O L • Assessingradiographs • Anteriorhumeral line • Shouldintersectmiddle 1/3 capitellum • Radiocapitellar line • Radial neck • ShouldintersectcapitellumHumerusElbow Joint • Made up of 2 articulating surfaces: • Trochlear notch of ulna and trochlea of distal humerus • Radial head and capitellum of distal humerus • Nb. Proximal radio-ulnar joint within elbow joint capsule but often considered separate • Ligaments: • Radial collateral ligament: lateral epicondyle and blending with annular ligament • Lateral ulnar collateral ligament: lateral epicondyle to supinator crest of proximal ulna -> Lateral Collateral Ligament Complex • Ulnar collateral ligament: medial epicondyle to coronoid process and olecranon • Annular ligament: from proximal radial ulnar jointElbow Joint • Hinge Joint • Movements: • Extension • Tricepsbrachii • Anconeus • Flexion • Brachialis • Bicepsbrachii • Brachioradialis • radioulnarjointsfrom movementat the proximal Posterior Compartment Muscle Origin Attachment Innervation Action Triceps Longhead:infraglenoid Olecranon Radialn Elbowextension brachii tubercle process Lateral & Medialheads: posteriorsurface of humerusabove& below spiralgroove Anterior Compartment Muscle Origin Attachment Innervation Action Biceps brachii Long head: Radial Musculocutaneous n Elbow flexion supraglenoid tuberosity Forearm tubercle supination Short head: Assists with coracoid process shoulder flexion Brachialis Medial & lateral Ulnar Musculocutaneous n Elbow flexion surfaces of tuberosity humeral shaft Coracobrachialis Coracoid Medial Musculocutaneous n Shoulder process humeral shaft flexion at level Weak adductor deltoid of shoulder tubercle Ulna • Stabilising boneof theforearm • Proximalulna has a numberof bonylandmarks: • Olecranonprocess • Coronoidprocess(partoftrochlearnotch) • Trochlearnotch • Radial notch • Ulnar tuberosity • Distalulna muchsmaller in diameter • Distalprojection=ulnar styloidprocess • Articulates with ulnarnotch of theradiusto formDRUJ • Proximal& DistalRadio-UlnarJoint disruptiondue to fracturegiveriseto specific fracturepatterns • Monteggia – proximalulna fracture • Galeazzi–distalradiusfracture Radius • 2 longbonein forearm • Pivotsaroundulnaduringpronationand supination • 4 sitesof articulation: • Radiocapitellarjoint • Proximalradio-ulnarjoint • Distalradio-ulnarjoint • Radiocarpaljoint • Proximally: • Radialhead • Radialneck • Radialtuberosity • Distallyalsohad radialstyloidandulnar notch • Radialheight = 13mm(<5mmaccepted) • Radialinclination = 23 (+/- 5 accepted) Normal Wrist • Palmar tilt = 11degrees (<5 dorsal angulation Radiograph accepted)Anterior Forearm • Split intoSuperficial, Intermediateand Deep Compartments Anterior Forearm - Superficial Muscle Origin Attachment Innervation Action Flexor carpi Humeral head: Pisiform, hook of Ulnar n Flexion & adduction ulnaris medial hamate & base of wrist epicondyle 5 metacarpal Ulnar head: olecranon Palmaris Longus Medial Flexor Median n Contributes to grip (85%) epicondyle retinaculum strength by flexing hand at wrist nd rd Flexor Carpi Medial Base 2 & 3 Median n Flexion & abduction Radialis epicondyle metacarpals of wrist Pronator Teres Medial Midshaft of Median n Pronation of forearm epicondyle & radius coronoid processAnterior Forearm - Intermediate • Sometimes classed as superficial • Median n and ulnar artery Muscle Origin Attachment Innervation Action pass between 2 heads and Flexor Digitorum Medial Middle Mediann Flexes travel posteriorly Superficialis epicondyle& phalangesof MCPJs, • Tendons travel through radius(2 4 fingers PIPJs & heads) wrist carpal tunnel AnteriorForearm - Deep Muscle Origin Attachment Innervation Action Flexor Digitorum Ulna & Distal phalanges Radial ½: Median Flexion of MCPJ, Profundus interosseous of 4 fingers n (AIN) DIPJs, wrist membrane Ulnar ½: Ulnar n Flexor Pollicis Radius & Base distal Median n (AIN) Flexion IP and Longus interosseous phalanx of MCPJ of thumb membrane thumb Pronator Volar surface Volar surface Median n (AIN) Pronation of Quadratus distal ulna distal radius forearm • Extensors (except brachioradialis) Posterior • All innervated by radial n • Can be split into superficial and deep Forearm compartments Posterior Forearm - Superficial Muscle Origin Attachment Action Brachioradialis Lateral supracondylar ridge Distal radius Elbow flexion Extensor carpi radialis longus ERCL: lateral supracondylar 2nd& 3 metacarpals Extension & abduction of & brevis ridge wrist ECRB: lateral epicondyle Extensor Digitorum Lateral epicondyle Extensor hoods of fingers Extension MCPJ & IP joints of Communis fingers Extensor Digiti Minimi Extensor digitorum/lateral Extensor hood little finger Extension little finger & wrist epicondyle Extensor Carpi Ulnaris Lateral epicondyle Base 5 metacarpal Extension & adduction of wrist Anconeus Lateral epicondyle Lateral surface olecranon Assist with elbow extension and posterior surface of (final 15 degrees), elbow joint proximal ulna stabilizer, assists with pronation Posterior Forearm - Deep Muscle Origin Attachment Action Supinator Lateral epicondyle & Posterior radius Supination of posterior ulna (2 heads) forearm st Abductor Interosseous membrane Base 1 metacarpal Abduction of Pollicis thumb Longus Extensor Interosseous membrane & Proximal phalanx of thumb Extension of PollicisBrevis posterior surface of radius MCPJ and CMCJ of thumb Extensor Interosseous membrane & Distal phalanx of thumb Extension of Pollicis posterior surface of ulna CMC, MCPJ Longus and IPJ of thumb Extensor Interosseous membrane & Extensor hood of index finger Extension of Indicis posterior surface of ulna index finger PropriusHand& Carpal Bones Carpal Bones • Stop – Scaphoid • Letting– Lunate • Those– Triquetrum • People– Pisiform • Touch – Trapezium • The – Trapezoid • Cadaver’s– Capitate • H and- Hamate Kaewlai R, AveryLL, AsraniAV, AbujudehHH, SacknoffR, Novelline RA. MultidetectorCTofcarpal injuries:anatomy, fractures, andfracture- dislocations.Radiographics.2008Oct;28(6):1771-84.doi:10.1148/rg.286085511. PMID:18936035 Carpal Tunnel • Floor: • Carpal arch • Laterally scaphoid& trapezium tubercles • Medially hook of hamate& pisiform • Roof: • Flexor retinaculum • Entrance is atlevel of distalwrist crease • Contents: • 4xFDPtendons, 4xFDS tendons,FPL & mediann ThenarEminence(Mediann) Muscle Origin Attachment Action Opponens Pollicis Tubercle of Radial margin of Opposition st trapezium & 1 MC flexor retinaculum Adbuctor Pollicis Tubercles of Radial margin of Abduction of Brevis scaphoid & proximal phalanx thumb trapezium & of thumb flexor retinaculum Flexor Pollicis Tubercle of Base proximal Flexion MCPJ Brevis trapezium & phalanx of thumb flexor retinaculum HypothenarEminence(Ulnarn) Muscle Origin Attachment Action Opponens Digiti Hook of hamate & Medial margin of 5th Opposition Minimi flexor retinaculum MC Abductor Digiti Minimi Pisiform & FCU tendon Base proximal phalanx Abduction of little of little finger finger Flexor Digiti Minimi Hook of hamate & Base proximal phalanx Flexes MCPJ of little Brevis flexor retinaculum of little finger finger IntrinsicHand Muscles • Lumbricals: • Palmaris Brevis: • 4lumbricals (1 per finger) • Small thin muscle in subcutaneous • Originatefrom FDPtendons tissueof hypothenar eminence • Pass dorsally andlaterally around • Wrinkles skinof hypothenar eminence each finger and insert into extensor improvegrip strengthvature and hoods • Innervated by ulnar n • Flexion at MCPJ and extensionat IPJ • Radial2 – median n, ulnar 2 – ulnar n • AdductorPollicis: • Interossei: • Large triangular musclewith 2heads • Palmar (x3)–adduction (PAD) throughwhich radial artery passes to • Dorsal(x4)– abduction (DAB) form deep palrdrarch • Originatefrom metacarpaland insert • capitate& 2 /3 MCther head from into extensorhood and proximal • Adduction of thumb phalanxof samefinger • Flexion of MCPJ and extensionatIPJ • Innervated by ulnar nVascular Structures • Axillary Artery • Brachial Artery • RadialArtery • Ulnar Artery • Superficial & Deep Palmar arches • DigitalarteriesAxillary Nerve • C5 andC6 nerve roots • Derived from the posterior cord of brachial plexus and located posterior to axillary artery andanterior to subscapularis • Passes to the surgicalneck of humerus where it divides intoits terminal branches • MotorFunction: Teres minor and deltoid • SensoryFunction: Skin over lower deltoid (”regimental badge area”) via upper lateral cutaneous nerve of armMusculocutaneousNerve • C5-C7nerve roots • Terminal branch of lateral cord of brachial plexus emergingatinferior border of pec minor • Leaves axilla and pierces coracobrachialis and passingdown flexor compartmentof upper arm superficial to brachialis and deep to biceps brachii. Pierces deep fascia lateral to biceps to emergelateral to biceps tendon and brachioradialis to continue intoforearm as the lateral cutaneous nerve. • MotorFunctions: Biceps brachii, brachialis, coracobrachialis • SensoryFunction: Skin of anterolateral aspect of forearm (via lateral cutaneous nerve of forearm)MedianNerve • C6-T1 nerve roots • Derivedfrom the medialandlateralcords • Course: • Travelslateralto brachialartery then crosses mediallyhalfwaydown the arm • Entersanteriorcompartmentof forearm viacubitalfossa • Travelsbetween FDPand FDS • Givesoff AIN andpalmarcutaneousbranchbefore enteringthe carpal tunnel • Terminatesby dividingintorecurrent branchandpalmardigitalbranch • Motor function:Pronatorteres, flexor carpiradialis,palmarislongus,FDS, lateral2 lumbricals,thenarmuscles. • oflateral3 ½ digits.ect of the palmand the palmarsurface and fingertips MedianNerve • 2 commonsites of injury/compressionare at the elbow and within the carpal tunnel • Clinical signs of median nerve injury: • “Hand of benediction” • Supination,ulnar deviation and weakflexion of wrist(if proximal lesion) • Loss of sensationover median nerve distribution(palm sparedin CTS) • Wasting of thethenar eminence • Associatedsigns of AINinjuryAnterior Interosseous Nerve • Exitsfrom anterolateralaspectof mediannerve 4-6cm distalfrom the elbow (junctionof middleto proximal 1/3 of forearm) • andulnabetween FDPand FPLmbrane betweenradius • Supplies½ FDP (alongwithulnarnerve), FPL and pronatorquadratus • AIN injuryleadsto inabilityto perform OK sign due to inabilitytoflexIP jointof thumband DIPof index fingerRadial Nerve • C5-T1nerve roots • Derived from the posterior cord • Course: • Arises in the axilla,posterior to the axillary artery andexits inferiorly via the triangular space • Descends down the arm in the radial groove wrapping around the humerus laterally and travelling anterior to the lateral epicondyle • It enters the forearm throughthe cubital fossaand terminates by dividing into two branches; the deep branch (becomes the PINafter piercing the supinator muscle) and the superficial branchRadial Nerve • MotorFunction: Triceps brachii, brachioradialis, extensor carpi radialis, supinatorand the extensor muscles of the posterior forearm • SensoryFunction: Radial Nerve • Clinicalsignsof palsydependon leveloflesion • Axilla • Unableto extend atthe elbow,wrist orfingers • Loss ofsensationoverlateraland posteriorarm, posteriorforearm anddorsal surface of lateral3 ½ digits • In radialgroove • Weakened elbowextensionbut not lost, evidenceofwrist-drop and inability to extend atfingers • Normalsensationto lateralandposteriorarm and posteriorforearm but loss ofsensationto dorsalsurface oflateral3 ½ digitsand associatedarea on dorsum ofthe hand • Forearm • Superficialbranch– loss ofsensory supplyto dorsalsurface of lateral3 ½ digits andassociatedarea ondorsum of the hand • PIN – Loss ofextensionof the fingers butno wrist-dropUlnarNerve • C8-T1 nerve roots • Derivedfrom the medialcord • Course: • Descendsdown medialaspect of upperarm • Passes posteriorto medialepicondyleof humerus • In forearm, piercesthe two headsof flexorcarpi ulnarisandtravelsdeep to the muscle alongsidethe ulnagivingoff3 mainbranches;muscularbranch,palmar cutaneousbranchanddorsalcutaneousbranch • Travelssuperficiallyto the flexor retinaculum,medialto the ulnarartery, through Guyon’scanalto enterthe handwhere it terminatesgivingrise to the superficial anddeep branchesUlnarNerve Motor Function: muscular branch supplies flexor carpi ulnaris and medial ½ FDP,deep branch supplies hypothenar muscles,medial 2 lumbricals, adductorpollicis, interosseousmusclesand palmaris brevis Sensory Function: UlnarNerve • ProximalLesion: • Flexion of wrist can occur but is accompanied byradial deviation • Loss of adduction andabduction of fingers • Movementof 4 and 5 digits and thumbis impaired • Positive Froment’s sign • Loss of sensationover entire ulnar nerve distribution • DistalLesion: • Ulnar “claw” hand • Loss of adduction andabduction of fingers • Movementof 4 and 5 digits and thumbis impaired • Positive Froment’s sign • Loss of sensationof palmarside of medial 1 ½fingers • Teach me anatomy • Orthobullets • Aclands Video Atlas • Ken Hub • Funky Professor videos • Theatre Useful ResourcesThankyou! Anyquestions? samantha.sharkey1@nhs.net