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Upper Limb – Part 2 Bones, Muscles, Nerves & Vascular supply of the forearm and hand Devanshi Jimulia City and Sandwell Hospitals, Birmingham 9tApril 2022 @BRITISHINDIANMEDIC@BIMAIA@BINDIANMEDICS BIMA Anatomy Series Intercalated in Clinical Anatomy at Birmingham Foundation Year 1 Doctor BIMA Teacher Devanshi Jimulia F1 at Sandwell and West Birmingham Trust BIMA Anatomy SeriesComing up… Bones Muscles Nerves Vascular supply Spotter BIMA Anatomy SeriesBones Forearm Imaging Hand BIMA Anatomy SeriesThe Radius BIMA Anatomy SeriesThe Ulna BIMA Anatomy SeriesThe Hand BIMA Anatomy SeriesThe Carpal Bones BIMA Anatomy SeriesName the fracture BIMA Anatomy SeriesName the fracture BIMA Anatomy SeriesMuscles Hand Forearm BIMA Anatomy SeriesAnterior Compartment – Superficial Layer What is the origin of all four muscles in the superficial layer of the anterior compartment? Medial epicondyle BIMA Anatomy SeriesAnterior Compartment – Intermediate layer Which two structures pass between the two heads of the flexor digitorum superficialis? Median nerve and Ulnar Artery BIMA Anatomy SeriesAnterior Compartment – Deep Layer Deep Layer: Flexor digitorum profundus Flexor pollicus longus Pronator quadratus BIMA Anatomy SeriesPosterior Compartment – Superficial Layer 3+3+3+3: 3 Muscles of the wrist: Extensor carpi radialis longus Extensor carpi radialis brevis Extensor carpi ulnaris 3 Muscles of the fingers: Extensor digitorum Extensor indicis Extensor digiti minimi 3 Muscles of the thumb: Abductor pollicis longus Extensor pollicis longus Extensor pollicis brevis 3 Muscles - miscellaneous: Anconeus Supinator Brachioradialis BIMA Anatomy SeriesPosterior Compartment – Deep Layer 3+3+3+3: 3 Muscles of the wrist: Extensor carpi radialis longus Extensor carpi radialis brevis Extensor carpi ulnaris 3 Muscles of the fingers: Extensor digitorum Extensor indicis Extensor digiti minimi 3 Muscles of the thumb: Abductor pollicis longus Extensor pollicis longus Extensor pollicis brevis 3 Muscles - miscellaneous: Anconeus Supinator Brachioradialis BIMA Anatomy SeriesThenar Muscles BIMA Anatomy SeriesHypothenar Muscles What nerve supplies the hypothenar muscles? Ulnar Nerve BIMA Anatomy SeriesLumbricals What is the function of the lumbricals? Flexion at the MCP and extension of the IP joints of each digit. BIMA Anatomy SeriesInterossei Muscles What is the function of the palmar interossei? Adduction What is the function of the dorsal interossei? Abduction BIMA Anatomy SeriesOther Muscles in the Palm Palmaris brevis and adductor pollicis What is the function of the Palmaris brevis? Improving grip Which structure passes between the two heads of the adductor pollicis Radial Artery BIMA Anatomy SeriesNerves Nerves of the forearm and hand BIMA Anatomy SeriesMedian Nerve What are the roots of the median nerve? (C5) C6 to T1 What are the motor functions of the median nerve? Flexor and pronator muscles in the anterior forearm (except the flexor carpi ulnaris and part of the flexor digitorum profundus) Thenar muscles Lateral two lumbricals in the hand What are the sensory functions of the median nerve? Palmar cutaneous branch - lateral aspect of the palm Digital cutaneous branch - lateral three and a half fingers on the palmar surface of the hand. BIMA Anatomy SeriesRadial Nerve What are the roots of the radial nerve? C5 to T1 What are the motor functions of the radial nerve? Triceps brachii and the extensor muscles in the forearm. What are the sensory functions of the radial nerve? Innervates most of the skin of the posterior forearm Lateral aspect of the dorsum of the hand The dorsal surface of the lateral three and a half digits. BIMA Anatomy SeriesUlnar nerve What are the roots of the ulnar nerve? C8 and T1 What are the motor functions of the ulnar nerve? Innervates the muscles of the hand (apart from the thenar muscles and two lateral lumbricals) Flexor carpi ulnaris Medial half of flexor digitorum profundus What are the sensory functions of the ulnar nerve? Medial one and half fingers, and associated palm area BIMA Anatomy SeriesVascular supply Arteries Veins BIMA Anatomy SeriesArteries Radial artery – supplies the posterolateral aspect of the forearm. It contributes to anastomotic networks surrounding the elbow joint and carpal bones. Ulnar artery – supplies the anteromedial aspect of the forearm. It contributes to an anastomotic network surrounding the elbow joint. Also gives rise to the anterior and posterior interosseous arteries, which supply deeper structures in the forearm. BIMA Anatomy SeriesArteries Superficial palmar arch – located anteriorly to the flexor tendons in the hand and deep to the palmar aponeurosis. It gives rise to the digital arteries, which supply the four fingers. Deep palmar arch – located deep to the flexor tendons of the hand. It contributes to the blood supply to the digits and to the wrist joint. BIMA Anatomy SeriesVeins BIMA Anatomy SeriesSpotter Bones BIMA Anatomy SeriesSpotter Vascular supply What is 9? Cephalic vein What is 8? Median cubital vein BIMA Anatomy SeriesCase A cyclist has reported numbness and tingling over his 4th and 5th digits, in addition to weakness in abducting and adducting his fingers. A claw hand deformity arises due to damage to the Ulnar nerve causing paralysis of the lumbricals. - The combination of hyperextension at the MCP and flexion at the IP joints gives the hand its claw like appearance. - The Ulnar Paradox: The ulnar nerve also innervates the ulnar half of the flexor digitorum profundus muscle. If the lesion occurs more proximally, the flexion of the IP joints is weakened, which reduces the claw-like appearance of the hand. BIMA Anatomy SeriesCase Mrs C, a 55 year old female, with a history of RA, has complained of numbness and tingling in her lateral 3.5 fingers, which is worse at night. She finds it difficult to hold a pen. The carpal tunnel contains a total of 9 tendons and the median nerve: - The tendon of flexor pollicis longus - Four tendons of flexor digitorum profundus - Four tendons of flexor digitorum superficialis Compression of the median nerve within the carpal tunnel can cause carpal tunnel syndrome (CTS) Clinical features: numbness, tingling and pain in the distribution of the median nerve. The pain will usually radiate to the forearm. BIMA Anatomy SeriesTHANK YOU