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Upper Limb Anatomy Osteology Muscles NeurovasculatureOverview topics Surface anatomy Movements of the upper limbSurface anatomy of the upper limb Many uses clinically • Examinations • BP, pulses • Venepuncture Usually only see basics unless you have a gym rat for a patientMovements of the upper limb Shoulder Elbow Wrist DigitsShoulder movements? Flexion Extension Abduction Internal and External RotationElbow and Forearm Movements? Flexion Extension SupinationPalm ends posterior – pronation Palms ends anterior - supinationWrist Movements? Flexion Extension Ulnar and Radial deviation Pronation and supinationFinger Movements? Abduction, Adduction Opposition, RepositionWhen looking at the thumb, think of the joint angle and anatomical position Flexion = joint angle decreasing Abduction = movement away from midline of the bodyThe Upper Limb - Anatomy 1) Shoulder girdle 2) Arm 3) Forearm 4) Hand and Wrist 1 2 Shoulder Girdle 3 1) OsteoMovementints and 2) Muscles 3) Neurovasculature 4 4) Important Anatomical Areas1 Shoulder Girdle - Osteology Clavicle and Scapula • Functions • Landmarks • Joints and movementsClavicle From manubrium of sternum to acromion of scapula Anterior convex proximal 2/3 and distal concave 1/3 Functions • Attaches appendicular to axial skeleton • Transmits forces from UL -> fracture due to small size (80% in middle third) • Protects neurovasculature to UL Landmarks • 2 facets (sternal and acromial) • Shaft = attachment point for several muscles • deltoid, trapezius, subclavius, pectoralis major, sternocleidomastoid and sternohyoid • Ligament attachments • Conoid tubercle ‒ conoid ligament, Trapezoid line ‒ trapezoid ligament • Both together give the coracoclavicular ligament ‒spends weight of upper limb from clavicle Joints Lateral end moves Medial pulled • Sternoclavicular ‒ between manubrium of sternum and clavicle inferiorly due to superiorly by • Acromioclavicular - between the acromion of the scapula and the clavicle weight of arm sternocleidomastoidScapula Anterior Lateral Posterior Aka shoulder blade Function • Connects upper limb to trunk • Increases range of motion of the upper limb Landmarks - Attachment points for 17 muscles! • Anterior • Subscapular fossa ‒ subscapularis • Coracoid process - pectoralis minor, coracobrachialis, and the short head of the biceps brachii • Lateral • Glenoid fossa ‒ glenohumeral joint • Supraglenoid tubercle - long head of the biceps brachii • Infraglenoid tubercle ‒ lng head of the triceps brachii • Posterior • Spine • Acromion ‒acromioclavicular joint • musclesinous and Infraspinous fossae ‒ supraspinatus and infraspinatus Joints • Glenohumeral - between the glenoid fossa of the scapula and the head of the humerus. • Acromioclavicular - between the acromion of the scapula and the clavicle • Scapulothoracic ‒ but not really , between scapula and thoracic cageMovements Shoulder girdle involving joints scapulothoracic joint Joint Type Movement Sternoclavicular Saddle synovial Little Acromioclavicular Plane synovial Little, gliding Scapulothoracic - Elevation, depression, retraction, protraction, rotation Glenohumeral Ball and socket Abduction, adduction, synovial flexion, extension, int and ext rotation, horizontal add and abduction Movement of the scapula increases the range of motion of the upper limb2 Shoulder Girdle – Muscles Pectoral and shoulder musclesPectoral muscles serratus anterior, subclaviusminor, Muscle Origin Insertion Function Innervation Pectoralis Major • Clavicular head – anterior Both heads insert onto Adducts and medially rotates Lateral and medial pectoral surface of the medial clavicle intertubercular sulcus of the the upper limb and draws the nerves • Sternocostal head – anterior humerus scapula anteroinferiorly. The surface of the sternum, the clavicular head also acts superior six costal cartilages and individually to flex the upper the aponeurosis of the external limb. oblique muscle. th Pectoralis Minor 3-5 ribs Coracoid process of the scapula Stabilise scapula drawing it Medial pectoral nerve Winged Scapula anteroinferiorly Serratus Anterior several strips, originating from theic Costal surface of medial border Rotates the scapula, allowing Long thoracic nerve lateral aan erior paralysis scapula the arm to be raised over 90 degrees, also protracting the Disturbs scapulohumeral rhythm – loss of scapula, holding it against the power, flexion and abduction, pain, fatigue of ribcage – winged scapula First costochondral joint (between Inferior surface middle third Anchor and depress clavicle Nerve to subclavius Subclavius – small rib and costal cartilage) clavicle directly under clavicle Push on wall to exacerbateShoulder muscles Extrinsic muscles – trapezius, latissimus dorsi, levator scapulae, rhomboids Thoracolumbarfascia Muscle Origin Insertion Function Innervation Trapezius Skull, nuchal ligament and Clavicle, acromion, and the • Upper fibres of the trapezius Accessory nerve the spinous processes of C7- scapula spine elevate the scapula and rotates it T12 during abduction • Middle fibres retract the scapula • Lower fibres pull the scapula inferiorly Latissimus dorsi from the spinous processes converge into a tendon that Extends, adducts, and medially Thoracodorsal nerve of T7-T12, iliac crest, attaches to the intertubercular rotates the upper limb thoracolumbar fascia and sulcus of the humerus the inferior three ribs the transverse processes of medial border of the scapula Elevates the scapula. Dorsal scapular nerve. Levator the C1-C4 vertebrae Scapulae spinous processes of T2-T5 medial border of the scapula, Retracts and rotates the scapula Dorsal scapular nerve Rhomboid vertebrae (4 vertebrae) between the scapula spine and Major inferior angle Rhomboid spinous processes of C7-T1 medial border of the scapula, Retracts and rotates the scapula Dorsal scapular nerve vertebrae (2 vertebrae) at the level of the spine of Minor scapula Shoulder muscles Intrinsic muscles – Deltoid, Teres Major, Supraspinatus, Infraspinatus, Subscapularis, Teres Minor Rotator cuff pull on humeral head ‒> stability glenohumeral joint Muscle Origin Insertion Function Innervation Deltoid lateral third of the clavicle, the deltoid tuberosity on the •Anterior fibres – flexion and medial rotation. Axillary nerve acromion and the spine of the lateral aspect of the humerus •Posterior fibres – extension and lateral rotation. scapula •Middle fibres – the major abductor of the arm • Rotator cuff allows you to lift your (takes over from the supraspinatus, which abducts the first 15 degrees). arm posterior surface of the inferiors medial lip of the lude tear Adducts and extends at the shoulder, and medially Lower subscapular nerve Teres Major angle of the scapula intertubercular groove of the rotates the arm. and d ghumerus n (repetitiv stress) • Symptoms include pain on movement Rotator Cuff – supraspinous fossa of the greater tubercle of the Abduction of the upper limb at the shoulder. It Suprascapular nerve scapula and prehumerusatient sleeping on performs the first 0-15 of abduction, and assists Supraspinatus shoulder, grinding or cracking the deltoid muscle for 15-90o infraspinous fossa of the scapula greater tubercle of the Laterally rotates the arm Suprascapular nerve RC – Infraspinatus sensatihumerusoving arm and limited mobility RC – Subscapularis subscapular fossa, on the costal lesser tubercle of the humerus Medially rotates the arm Upper and lower surface of the scapula • Treat with rest, NSAIDs, physio, subscapular nerves surgery if severe RC – Teres Minor posterior surface of the scapula, greater tubercle of the Laterally rotates the arm Axillary nerve adjacent to its lateral border humerus Shoulder Girdle - Neurovasculature 3 Axilla forms a gateway for the the upper limblar structures to • Brachial plexus and nn • Subclavian aa and branches • Veins covered at the end • Subclavian = first artery of the upper limb • R ‒ branches from brachiocephalic trunk Shoulder – • L ‒ branches directly from aorta • 3 key divisions Arterial Supply 1. origin of the subclavian artery to the medial border of the anterior scalene. 2. posterior to the anterior scalene. 3. lateral border of anterior scalene to the lateral border of the first rib. • At the lateral border of the first rib, the subclavian artery enters the axilla -> axillary a • 3 Key divisions as well ‒ relation to pec minor 1. proximal to pectoralis minor 2. posterior to pectoralis minor 3. distal to pectoralis minor • Each division gives key branches then becomes brachial artery Division Branches First Superior thoracic artery Second Thoracoacromial artery Lateral thoracic artery Third Subscapular artery Anterior and posterior circumflex arteriesShoulder - Brachial Plexus • Union of anterior rami C5-8 and T1, passes between first rib and clavicle • DRAW, DRAW and DRAW AGAIN • There arenʼt just 5 branches of the brachial plexus • We all prefer the cleaner version but itʼs just not realistic • Use the M to find the branches and cords ‒ need Look for the M to know which cords the branches come from Branch Roots Cord Supplies Shoulder - Musculocutane C5, C6, C7 Lateral •Motor Functions: Innervates the brachialis, biceps brachii and ous •Sensory Functions: Gives off the lateral cutaneous branch of the forearm, which innervates the lateral half of the anterior forearm, and a small Brachial Plexus lateral portion of the posterior forearm Median C6 – T1 Lateral and •Motor Functions: Innervates most of the flexor muscles in the forearm, Medial the thenar muscles, and the two lateral lumbricals associated with the index and middle fingers. •Sensory Functions: Gives off the palmar cutaneous branch, which innervates the lateral part of the palm, and the digital cutaneous branch, which innervates the lateral three and a half fingers on the anterior (palmar) surface of the hand. Ulnar C8 and T1 Medial •Motor Functions: Innervates the muscles of the hand (apart from the thenar muscles and two lateral lumbricals), flexor carpi ulnaris and medial half of flexor digitorum profundus. •Sensory Functions: Innervates the anterior and posterior surfaces of the medial one and half fingers, and associated palm area. Axillary C5, C6 Posterior •Motor Functions: Innervates the teres minor and deltoid muscles. •Sensory Functions: Gives off the superior lateral cutaneous nerve of arm, which innervates the inferior region of the deltoid (“regimental badge area”). Radial C5 – T1 Posterior •Motor Functions: Innervates the triceps brachii, and the muscles in the posterior compartment of the forearm (which are primarily, but not exclusively, extensors of the wrist and fingers). •Sensory Functions: Innervates the posterior aspect of the arm and forearm, and the posterolateral aspect of the hand. Donʼt just learn the motor effects ‒ will get asked bothShoulder - Brachial Plexus Klumpke Klaw Shoulder Girdle – Anatomical Areas Axilla 4 • Quadrangular space Important areas • Superior ‒ inferior margin of teres minor. • Lateral ‒ surgical neck of the humerus. around the Not interesting because • Medial ‒ long head of triceps brachii. of what they are, • Inferior ‒ superior aspect of teres major. interesting because of shoulder • circumflex humeral arve and posterior what you find there • Triangular interval • Superior ‒ Inferior border of the teres major. • Lateral ‒ Shaft of the humerus and lateral head of the triceps brachii. • Medial ‒ Lateral border of the long head of the triceps brachii. • Contents = radial n, profunda brachii a • Axilla • Lateral wall ‒ formed by intertubercular groove of the humerus. • • Medial wall ‒ consists of the serratus anterior and the thoracic Triangular space wall (ribs and intercostal muscles). • Lateral ‒ medial margin of the long head of the triceps brachii. • Anterior wall ‒ contains the pectoralis major and the • underlying pectoralis minor and the subclavius muscles. Inferior ‒ superior margin of the teres major. • Posterior wall ‒ formed by the subscapularis, teres major and • Superior ‒ inferior border of the teres minor latissimus dorsi. (or subscapularis). • Contents = circumflex scapular artery and • Contains axillary artery, vein, brachial plexus, axillary lymph vein nodes and biceps brachii and coracobrachialis tendons 1 2 Arm 3 1) Osteology, Joints and Movement 2) Muscles 4 3) Neurovasculature 4) Important Anatomical Areas1 Skeleton – Arm Humerus • Functions • Landmarks • Joints and movementsProximal Humerus • Long bone forming arm • Landmarks • Head ‒ glenohumeral joint • Anatomical neck ‒ separates head from tuberosities • Greater tuberosity ‒ supraspinatus, infraspinatus, teres minor • Intertubercular sulcus ‒ tendon long head biceps brachii runs in, pectoralis major, teres major and latissimus dorsi insert on the lips of the intertubercular sulcus • Lesser tuberosity ‒ subscapularis • Surgical neck ‒ distal to tuberosities - axillary nerve and circumflex humeral vessels run here • Joint • Glenohumeral ‒ ball and socket synovial • Fracture risk ‒ surgical neck ‒ damage to axillary nerve leads to paralysis deltoid and teres minor muscles used in abduction -> poor abduction, and numbness regimental badge area “a lady between two majors”, with latissimus dorsi attaching between teres major on the medial lip and pectoralis major laterallyShaft of Humerus • Landmarks • Deltoid tuberosity ‒ deltoid attachment • Radial groove - shallow depression that runs diagonally down the posterior surface of the humerus ‒ find radial nerve and profunda brachii artery • Muscles attaching along the shaft of the humerus • Anteriorly ‒oracobrachialis, deltoid, brachialis, brachioradialis • Posteriorly ‒ medial and lateral heads of theiceps brachii • Fracture risk • Mid shaft fracture = radial groove -> damage to profunda brachii artery and radial nerve ‒> poor extension of wrist ‒> wrist drop, also sensation posterior surface hand and posterior side of proximal ends of the lateral 3 and a half fingers Distal Humerus • Landmarks • Medial and Lateral supraepicondylar ridges (Lat being site of common origin of the extensor muscles of the forearm) • Medial and Lateral epicondyles (palpable areas elbow), ulnar nerve passes along a groove in the larger medial epicondyle posteriorly • Trochlea ‒ medial, extends onto posterior aspect • Capitulum ‒ lateral, articulates with radius • 3 fossae - accommodate bones of forearm in flexion and extension • Coronoid ‒ coronoid process of ulna • Radial ‒ anterior border head of radius • Olecranon ‒ olecranon of the ulna • Joints • Humeroradial • Ulnohumeral • Proximal radioulnar • Fractures ‒ supracondylar (just above elbow joint) • FOOSH • Damage to brachial artery , uncontrolled ischaemic flexion • Anterior interosseus nerve , ulnar, radial ‒ weak OK sigm2 Muscles – Arm Coracobrachialis, Triceps Brachii Arm muscles Biceps brachii, brachialis, coracobrachialis and triceps brachii Muscle Origin Insertion Function Innervation Biceps Brachii – 2 headed, • Long head - from the supraglenoid Both heads insert distally into the Supination of the forearm. Musculocutaneous nerve. tubercle of the scapula radial tuberosity and the fascia of Also contributes to flexion The bicep tendon reflex tests gives off bicipital aponeurosis = • Short head - from the coracoid process of the forearm via the bicipital at the elbow and the spinal cord segment C6. CT sheet (roof bicipital the scapula aponeurosis shoulder aponeurosis) coracoid process of the scapula muscle passes through the axilla, Flexion of the arm at the Musculocutaneous nerve Coracobrachialis and attaches the medial side of shoulder, and weak the humeral shaft, at the level of adduction the deltoid tubercle medial and lateral surfaces of the humeral Ulnar tuberosity, just distal to the Flexion at the elbow Musculocutaneous nerve, Brachialis deep to the biceps shaft elbow joint with contributions from the brachii, and is found more distally radial nerve than the other muscles of the arm. It forms the floor of the cubital fossa. Triceps Brachii • Long head originates from the Distally, the heads converge into Extension of the arm at the Radial nerve. Triceps tendon infraglenoid tubercle of the scapula. one tendon which inserts onto the elbow reflex tests C7 (posteriorly ), 3 heads • Lateral head originates from the humerus olecranon of the ulna (superior to the radial groove). • Medial head originates from the humerus (inferior to the radial groove). Arm - Neurovasculature 3 Brachial artery and branches Nerves of the upper Brachial Artery arm • Continuation of axillary artery past lower border • Dermatomes ‒ C4-T2, some maps are different of teres major but there are general rules especially in your neuro exam • Main branch • Profunda brachii immediately distal to teres major • Axillary ‒ (with radial n) supplying posterior upper arm and • Sensory - regimental badge area elbow anastomotic network • Motor ‒ Teres minor and deltoids • Brachial artery proper descends down the arm • • Musculocutaneous ‒ Moves through the cubital fossa, underneath the • Motor - coracobrachialis, biceps brachii and the bicipital aponeurosis -> terminates by bifurcating brachialis into the radial and ulnar arteries • Radial ‒ • Motor ‒ triceps brachii Sensory innervation arm Arm – Anatomical Areas Cubital Fossa 4 Ulnar Tunnel Cubital Fossa Ulnar Tunnel • Medial wall ‒ medial epicondyle of the humerus. • Lateral border ‒ medial border of the brachioradialis muscle. • Medial border ‒ lateral border of the pronator teres muscle. • Lateral wall ‒ olecranon of the ulna. • Superior border ‒ horizontal line drawn between the epicondyles of the • Floor ‒ elbow joint capsule and medial collateral humerus. ligament of the elbow. • Roof ‒ bicipital aponeurosis, fascia, subcutaneous fat and skin. • Roof ‒ ligament spanning between the medial • Floor ‒ brachialis (proximally) and supinator (distally). epicondyle and olecranon ‒ cubital tunnel • Contents = radial nerve, biceps tendon, brachial artery, median retinaculum nerve • Contents = ulnar nerve • Roof contains median cubital vein ‒ common venepuncture site 1 2 Forearm 3 1) Osteology, Joints and Movement 2) Muscles 3) Neurovasculature1 Forearm - osteology Radius and ulna • Functions • Landmarks • Joints and movementsRadius • Long bone • Parallel to ulna ‒ pivots around giving pronation/supination • 4 articulation points • Radiocapitellar joint • Proximal and distal radioulnar joints • Radiocarpal joint ‒ scaphoid, lunate, triquetrum • Joints strapped by many ligaments • Landmarks • Head ‒ concave disc • Neck ‒ between head and tuberosity • Radial tuberosity ‒ attachment biceps brachii • Shaft ‒ middle has attachment pronator teres • Styloid process • Ulnar notch -> distal RU jointUlna • Long bone, medial to radius, acts as stable bone radius pivots around • Landmarks • Proximally • Olecranon ‒ part of trochlear notch, tip of elbow, triceps brachii attachment • Coronoid process ‒ part of trochlear notch • Trochlear notch ‒ articulates with trochlea humerus • Radial notch ‒ lateral surface TN, articulates w radius • Tuberosity of ulna ‒ brachialis attachment • Shaft ‒ attachment site many muscles and interosseus membrane • Distal - Smaller than proximal end • Ulnar styloid process • Head ‒ distal radioulnar joint Joints • Proximal radioulnar joint ‒ pivot synovial - articulation between the head of the radius and the radial notch of the ulna • Elbow ‒ hinge synovial • Distal radioulnar joint - articulation between the ulnar notch • 2 articulations, 1 joint of the radius and the ulnar head ‒ • Trochlear notch of the ulna and the trochlea of the • Interosseus membrane humerus • Head of the radius and the capitulum of the humerus • Holds the radius and ulna together during pronation and supination of the forearm, providing addition stability. • Many ligaments to stabilise • Acts as a site of attachment for muscles in the anterior and • Flexion, extension posterior compartments of the forearm. • Transfers forces from the radius to the ulna.2 Forearm - muscles Anterior and Posterior Compartments Anterior Compartment Muscles Superficial - flexor carpi ulnaris, palmaris longus, flexor carpi radialis, pronator teres Muscle Origin Insertion Action Innervation FCU • humeral head - from the medial passes into the wrist and Flexion and adduction Ulnar nerve epicondyle of the humerus with attaches to the pisiform bone, at the wrist the other superficial flexors hook of hamate, and base of • ulnar head - from the olecranon the 5th metacarpal of the ulna. PL -absent in medial epicondyle flexor retinaculum of the wrist Flexion at the wrist Median nerve about 15% of the population FCR medial epicondyle base of metacarpals II and III Flexion and abduction Median nerve at the wrist PT one from the medial epicondyle, mid-shaft of the radius Pronation of the Median nerve and the other from the coronoid forearm process of the ulnaAnterior Compartment Muscles Intermediate – flexor digitorum superficialis Muscle Origins Insertion Action Innervation FDS • one from the splits into four tendons at the Flexes the MCP joints Median nerve medial wrist, which travel through and PIP joints at the 4 epicondyle of the the carpal tunnel, and attach fingers, and flexes at humerus to the base of the middle the wrist. • other from the phalanx of the four digits radius Lateral Anterior Compartment Muscles Deep - flexor digitorum profundus, flexor pollicis longus, and pronator quadratus Medial Muscle Origins Insertion Action Innervation FDP Ulna and associated At the wrist, it splits into four • Only muscle that can flex • Medial half – interosseous membrane tendons, that pass through the carpal the DIP of the fingers ulnar nerve tunnel and attach to the distal • Flexes at • Lateral half – phalanges of the four fingers metacarpophalangeal Ant interosseus joints and at the wrist branch median FPL anterior surface of the base of the distal phalanx of the Flexes the interphalangeal Median nerve radius and surrounding thumb joint and (anterior interosseous membrane metacarpophalangeal joint of interosseous the thumb branch) PQ - found deep to thanterior surface of the anterior surface of the radius Pronates the forearm Median nerve tendons of the flexorulna (anterior digitorum profundus interosseous and flexor pollicis longus branch) Muscle Origins Insertion Action Innervation Posterior Compartment Muscles Brachioradi proximal distal end of the radius, Flexes at the Radial Extensor muscles – alis aspect of the just before the radial elbow superficial – Brachioradialis, lateral styloid process extensor carpi radialis longus and brevis, supracondylar extensor digitorum, extensor carpi ulnaris, ridge of humerus extensor digiti minimi, anconeus ECRL lateral metacarpal bones II and Extends and Radial nerve supracondylar III abducts the wrist ridge of the humerus ECRB lateral metacarpal bones II and Extends and Radial nerve epicondyle III abducts the wrist Extensor lateral tendon continues into in Extension of the Radial nerve digitorum - epicondyle the distal part of the digits at the IP (deep branch) main forearm, where it splits and MCP joints extensor of into four, and inserts into the fingers the extensor hood of each fingerPosterior Muscle Origins Insertion Action Innervatio n Compartment Muscles Extensor muscles – EDM lateral attaches, with the Extends the little Radial nerve epicondyle of extensor digitorum finger, and (deep superficial – Brachioradialis, the humerus. tendon, into the contributes to branch) extensor carpi radialis longus and brevis, extensor hood of the extension at the little finger wrist extensor digitorum, extensor carpi ulnaris, extensor digiti minimi, anconeus ECU lateral base of metacarpal V Extension and Radial nerve epicondyle of adduction of wrist (deep the humerus branch) Anconeus lateral posterior and lateral Extends and Radial nerve epicondyle part of the olecranon stabilises the elbow joint. Abducts the ulna during pronation of the forearm Muscle Origins Insertion Action Innervatio n Posterior Compartment Supinator One originates from the posterior surface of Supinates the forearm Radial nerve lateral epicondyle of the radius (deep branch) the humerus, the other Muscles from the posterior surface of the ulna. Extensor muscles – APL interosseous membrane lateral side of the base Abducts the thumb Radial nerve deep – and the adjacent posterior of metacarpal I (posterior surfaces of the radius and interosseous supinator, abductor pollicis longus, ulna branch) extensor pollicis brevis, extensor pollicis longus and extensor indicis EPB posterior surface of the base of the proximal Extends at the MCP and Radial nerve radius and interosseous phalanx of the thumb CMC joints of the thumb (posterior membrane interosseous branch) EPL posterior surface of the distal phalanx of the Extends all joints of the Radial nerve ulna and interosseous thumb thumb: CMC, MCP and (posterior membrane IP interosseous branch) EI posterior surface of the extensor hood of the Extends the index finger Radial nerve ulna and interosseous index finger (posterior membrane, distal to the interosseous extensor pollicis longus branch) Forearm - neurovasculature 3 Compartments Posterior • Bifurcation of brachial artery in cubital fossa -> Forearm arterial • Radial artery ‒ • Supplies the posterolateral aspect of the forearm and nerve supply • Contributes to anastomotic networks surrounding the elbow joint and carpal bones Radial and Ulnar aa • Pulse felt in distal forearm, lateral toR tendon • Ulnar artery ‒ • Supplies the anteromedial aspect of the forearm • Contributes to an anastomotic network surrounding the elbow joint . • Gives rise to the anterior and posterior interosseous arteries, which supply deeper structures in the forearm • Anastomose in hand • Nerves supplying the forearm • 3 main nerves running in forearm = median, ulnar, radial • Musculocutaneous -> lateral cutaneous nerve of the forearm ‒ lateral aspect forearm • Median ‒ majority anterior compartment forearm • Ulnar ‒ FCU, medial ½ FDP • Radial ‒ skin posterior forearm, extensor muscles forearm 1 2 Hand and Wrist 3 1) OstMovementJoints and 2) Muscles 3) Neurovasculature 4 4) Important Anatomical Areas1 Hand and Wrist - osteology Carpal bones, metacarpals and • Functions • Landmarks • Joints and movementsCarpal Bones – Wrist • Radiocarpal joint formed from radius, scaphoid and lunate • Ulna articulates with articular disc • All carpal bones articulate with metacarpals • Scaphoid most injured ‒ FOOSH, pain tenderness anatomical snuffbox, retrograde blood supply means risk avascular necrosis • Form an arch coronally -> carpal tunnel bridged by retinaculum which median nerve passes in, irritation - > carpal tunnel syndrome DIP Metacarpals and PIP Phalanges • Metacarpals numbered 1-5, each with base, shaft and head • Proximal middle and distal phalanges but no middle in the MCP thumb • Proximal and distal interphalangeal joints CMC • IP = hinge joint = flexion, extension • MCP = condyloid = allow the movements of flexion, extension, abduction, adduction and circumduction2 Hand and Wrist - muscles Muscle Origins Insertion Action Innervation Muscles of the Hand – Intrinsic Thenar, Hypothenar, Lumbricals, Interossei, OP tubercle of the lateral margin of the firstOpposes the thumb, by Median trapezium, flexor metacarpal medially rotating and nerve (recurrent Palmaris Brevis, Adductor Pollicis retinaculum flexing the metacarpal branch) Extrinsic = muscles of forearm that insert onto hand- already covered APB tubercles of the lateral side of proximal Abducts the thumb Median scaphoid and phalanx of the thumb nerve (recurrent trapezium, flexor branch) retinaculum FPB tubercle of the base of the proximal Flexes the Median trapezium, phalanx of the thumb metacarpophalangeal nerve (recurrent associated flexor joint of the thumb branch), deep retinaculum head by deep branch ulnar ODM hook of hamate, medial margin of rotates the metacarpal Ulnar nerve. associated flexor metacarpal V of the little finger retinaculum towards the palm, producing opposition ADM pisiform and the base of the proximal Abducts the little finger Ulnar nerve tendon of the phalanx of the little flexor carpi ulnaris finger FDMB hook of hamate, proximal phalanx of the Flexes the Ulnar nerve adjacent flexor little finger metacarpophalangeal retinaculum joint of the little finger Muscle Origins Insertion Action Innervation Muscles of the Hand – Intrinsic Lumbricals Each from a pass dorsally and Flexion at the MCP Lat 2 = median Thenar, Hypothenar, Lumbricals, Interossei, tendon of the laterally around each joint and extension at Med 2 = ulnar Palmaris Brevis, Adductor Pollicis flexor digitorum finger, and inserts into the interphalangeal Extrinsic = muscles of forearm that insert onto profundus the extensor hood (IP) joints of each hand- already covered digit Dorsal Each from the extensor hood and Abduction of the Ulnar nerve Interossei lateral and medial proximal phalanx of digits. Assists in surfaces of the each finger flexion at the metacarpals metacarpophalangeal joints and extension at the interphalangeal joint Palmar from a medial or extensor hood and Adduction of the Ulnar nerve interossei lateral surface of proximal phalanx of digits. Assists in a metacarpal same finger flexion at the metacarpophalangeal joints and extension at the interphalangeal joints. PB palmar dermis of the skin on deepens the Ulnar nerve aponeurosis and the medial margin of curvature of the flexor the hand hand, improving grip retinaculum AP capitate and base of the proximal Adductor of the Ulnar nerve adjacent areas of phalanx of the thumb thumb metacarpals II and III Hand and Wrist - Neurovasculature 3 Palmar arches Nerves Venous drainageArterial Supply Nerve Supply to Hand Hand • Superficial and Deep Palmar Arches • Median nerve supplies • Hand has a rich arterial supply with • motor - thenar eminence, lumbricals many anastomoses • Branches of ulnar and radial arteries • sensory - radial three and a half fingers • Ulnar -> gives deep palmar arch on the palmar aspect and the nail beds branch, continues as superficial dorsally, radial two-thirds of the palm via • Radial -> crosses anatomical snuffbox palmar cutaneous continues as deep palmar arch • Ulnar nerve supplies • Superficial palmar arch ‒ • Majority intrinsic muscles hand ‒ thenar • in the hand and deep to the palmarendons and radial 2 lumbricals aponeurosis. It gives rise to the digital • Sensory branches - palmar and dorsal arteries, which supply the four fingers. side of the ulnar one and half fingers • Deep palmar arch ‒ located deep to • Radial nerve supplies the flexor tendons of the hand. It • sensation to the radial 3 and a half fingers digits and to the wrist joint.y to the and dorsal surface of the hand • Paired veins accompany arches, drained by cephalic and basilic Hand and Wrist – Anatomical areas Palmar arches Nerves Venous drainage 4 Anatomical Carpal Tunnel Snuffbox • Triangular depression found on the lateral aspect of the dorsum of the hand ‒ pain found here in scaphoid • Floor Laterally = scaphoid, trapezium fracture • Ulnar m(dial ) border: Tendon of the extensor pollicis • Floor Medially = hook hamate, pisiform longus. • Roof = flexor retinaculum • Radial l(teral ) border: Tendons of the extensor pollicis brevis and abductor pollicis longus. • Contents = 9 tendons and median nerve ‒ FPL, • Proximal border: Styloid process of the radius. FDP, FDS • Irritation -> compression median nerve -> Carpal • Floor : Carpal bones; scaphoid and trapezium. Tunnel Syndrome = tingling, pain, numbness, • Roof : Skin. weakness • cephalic veinradial artery, superficial branch radial nerve, Summary of the venous supply of the upper limb Superficial veins Deep veins • Major superficial veins are basilic and cephalic • Basilic arises from network in hand and ascends medially, combines with brachial -> axillary vein • Cephalic arises from network in hand, ascends antero-laterally, enters axilla, empties into axillary • Connect at elbow via median cubital vein ‒ most common site venupuncture Hand veins • Deep venous system found under deep fascia, share the name of artery they accompanySummary of the lymphatic drainage of the upper limb • The superficial lymphatic vessels of the upper limb initially arise from lymphatic plexuses in the skin of the hand and travel up the arm along the main superficial veins, deep lymphatics follow deep vessels • Majority drains to lymph nodes of the axillaQuestionsQuestion 1 • A 25-year-old man falls onto an outstretched hand playing rugby. He experiences dull pain in the radial wrist, swelling and tenderness of palpation in the wrist and just proximal to the dorsal side of the thumb on the hand. • What is the most likely injury? 1. Distal radius fracture 2. Scaphoid fracture 3. Hook of hamate fracture 4. Radial styloid fractureQuestion 2 • What nerve is most likely implicated in the aetiology of winged scapula? 1. Dorsal Scapular nerve 2. Short Thoracic nerve 3. Long Thoracic nerve 4. Accessory nerveQuestion 3 • A patient presents with weakened extension of the elbow wrist and fingers after sleeping overnight with their arm resting on a chair back. • Which labelled nerve was most likely compressed? • A • B • C • DQuestion 4 • Which muscle is not a part of the rotator cuff group • Supraspinatus • Infraspinatus • Subscapularis • Teres MajorQuestion 5 • A 50-year-old man cuts his hand slicing a tomato. He arrives at the hospital and on examination is unable to flex the last joint in his 2 nd digit. • What is the most likely tendon to have been severed • Flexor digitorum profundus • Flexor digitorum superficialis • Flexor carpi ulnaris • Flexor pollicis longusQuestion 6 • What structure is most likely to be damaged due to this fracture • Median nerve • Circumflex humeral artery • Ulnar Nerve • Axillary NerveQuestion 1 • A 25-year-old man falls onto an outstretched hand playing rugby. He experiences dull pain in the radial wrist, swelling and tenderness of palpation in the wrist and anatomical snuffbox (proximal to the dorsal side of the thumb). • What is the most likely injury? • Distal radius fracture • Scaphoid fracture • Hook of hamate fracture • Radial styloid fractureQuestion 2 • What nerve is most likely implicated in the aetiology of winged scapula? • Dorsal Scapular nerve • Short Thoracic nerve • Long Thoracic nerve • Accessory nerveQuestion 3 Saturday Night nerve palsy • A patient presents with weakened extension of the elbow wrist and fingers after sleeping overnight with their arm resting on a chair back. • Which labelled nerve was most likely compressed? • A - musculocutaneous • B - radial • C - median • D - ulnarQuestion 4 • Which muscle is not a part of the rotator cuff group • Supraspinatus • Infraspinatus • Subscapularis • Teres MajorQuestion 5 • A 50-year-old man cuts his hand slicing a tomato. He arrives at the hospital and on examination is unable to flex the last joint in his 2 nd digit. • What is the most likely tendon to have been severed • Flexor digitorum profundus • Flexor digitorum superficialis • Flexor carpi ulnaris • Flexor pollicis longusQuestion 6 • What structure is most likely to be damaged due to this fracture • Median nerve • Circumflex humeral artery – anterior and posterior aa • Ulnar Nerve • Axillary Nerve