Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hi, everyone. Uh Welcome to another lecture series on anatomy this time and we have Mr George West here joining us today to give you a lecture on upper limb. Um We're gonna wait a few minutes really quickly. Uh Just so everyone else can join uh that are latecomers, so bear with us for a minute, please. Yeah. Ok. Shall we start? Um again, once again, thanks for joining us again today. Our lecture series is sponsored by the MDU. Um at the end of the lecture series, you will get ac a certificate of attendance after you have filled out the feedback form approximately two hours to three hours after the lecture of the feedback. Uh the catch up content will be posted on our page. So you'll be able to uh see it again at a later date. If you do want to, I'll now leave you in the capable of hands. Oh, Doctor Mister West. Sorry. No worries. Thanks, Jerome. Um Can you hear me? Ok, Jerome? Yes, I can indeed. Quite fine. Fantastic. I wanna ask again. Um Hello to everyone. Thanks to Jerome and Me International for having me. Uh I'm George. I'm a current core surgical trainee um at Great Ormond Street Hospital, which is a pediatric hospital in London. Um I'm gonna be talking for around 45 minutes on upper limb anatomy. I'm really keen to have questions throughout. I want to know what level you guys are at. So in the poll, if you can just tell me what year you're currently studying or if you're qualified, um how far qualified you are. Um So if you could do that for me, that would be great. Uh Like I said, I'm really, really happy for questions throughout. Um And I'm gonna try and direct this at a kind of undergraduate level depending on where you are at. So, next slide, please, Jerome. So what I will and will not cover. So I'm gonna do a very brief discussion on the brachial plexus. Um Otherwise we'll be here all night and it's boring. Um I'm gonna talk about shoulder anatomy, um arm and forearm anatomy and then hand anatomy. So I'm gonna be working proximal to distal. Um I'm gonna attempt to link some clinical scenarios to help you guys in your training. Um But what I won't focus on um is the roots, trunks, divisions and cords of the brachial plexus. I'm not gonna go into every knitting blood supply. Um And I'm not gonna go into origin and insertion into every little detail. It looks like most of you are undergraduates. So, what you need to know is brief anatomy in certain parts of the body and how pathology links next slide, please. Jerome. So, like I said, this lecture is a whistle stop top, whistle stop tour of the upper limb. Um Depending on what level you're at will depend on how in depth you need to know. I've just uh studied and passed on my MRC S exam. Um So I'm now currently a member of the Royal College of Surgeon once I pay my fees, um and the exam is heavily based on anatomy in order to do surgical training here in the UK. Um And it took me months to study for this exam. So, for example, that's why I've got a picture of the er, iceberg because this lecture is literally the tip of the iceberg. Um and you'll need to layer your learning. Er, but what I'd recommend is the best way to learn anatomy is to see it in the flesh. So, whether you're in year one, learning your anatomy and going to dissection, make sure you're applying yourself as much as possible or you're in year five and six and you wanna be a surgeon, get to theater, ask about the anatomy and learn how pathology links to each next slide, please. So before we begin, I just wanna go through basics because even up until the end of med school, I found this hard and it's just about kind of an anatomical plains, but I just wanna focus on proximal distal, ventral and dorsal proximal being close to you, distal being far away, uh ventral being on this side, dorsal be in the back. I'm sure you will know that. But if you've got any questions, pop them in the chat and we'll be able to go on. Um next slide, please. Dr So the brachial plexus is a very, very important bunch of nerves that does a lot for our upper limb. It essentially controls our upper limb and our upper limb is there for the coordination of our hand. And that's why we have evolved as humans because we can use our hands um for finer movements and touch and feel and for coordination. So we are gonna be focusing mainly on the main branches which are the musculocutaneous nerve, the median nerve, the ulnar nerve, the radial nerve and the axillary nerve. And these give rise um from the cords. The brachial plexus is a very, very, very complicated um structure to learn. But if you're an undergraduate, I think you should at least know the roots. So C five to T one and the terminal branches, if you're an undergraduate that wants to be a surgical trainee, the best way to do it is just hit youtube up and just keep going over and over and learning the structure. Knowing the course of the brachial plexus will allow you to understand pathology when you see it in real life, larking in A&E or what pathologies may present on the ward. Um Next slide, please, Jerry. So let's get into it. So the upper limb, the arm is connected to our axial skeleton via our clavicle. And the shoulder joint is the most proximal joint in our upper limb. And it is an articulation of three bones, the scapula, the clavicle and the humerus. So the scapula is a flat triangular bone that's located on the posterior aspect of the thorax. It's not actually connected itself to anything. So some people call it a floating bone or like when you hear it commonly, the wing bone, it articulates with the clavicle at the acromioclavicular joint with the humerus at the glenohumeral joint. That's a fancy way of saying your collar bone and your shoulder come together at that part. So your glenohumeral joint is your shoulder joint and your clavicle is your collarbone. There are some important landmarks I feel as an undergraduate you need to know on the scapula. And that is the acromial process which you can see where the clavicle articulates the coracoid process, which is the little so to speak, Noblet under that. And then the glenoid cavity, which is the whole one where the um shoulder joint sits where the humerus articulates. So moving on, I'll go back now and talk about the clavicle which is the long s sorry, back to that side. Sorry, jo um back to the er back to the clavicle. It's the s bone that's articulating with the scapula. Um And it's there that connects the sternum to your axial skeleton to the scapula. It provides support and stability of the shoulder joint. Um And it's very prone um to fracturing in high force injuries, but I won't be going into that today. It's also a landmark um for certain nerves, but we won't be going into that today because we haven't discussed the brachial plexus and last but not least the humerus, which is your upper arm bone or quite simply your arm bone. Um And it's the long bone of the upper arm extending from the shoulder to the elbow. Um It's proximal end, articulates with the scapular, like we've said. Um And notable features include, you've got the head of the humerus, you've got the anatomical and surgical necks, which I want to point out, but I can't. So, um can you see my mouse on not jo No, I can't unfortunately, fine. No worries. I'm just so I I'll come onto it when we go to the X rays. But essentially the points I want you to know of the humerus include the shaft, which is the obvious mid part of the humerus. But then you have the anatomical and surgical neck. Um The surgical uh neck being the part in which way you can see that dorsi inserting if that fractures and then you've got the anatomical neck being the bit where the ball joint is at the end of the humerus um this is really basic anatomy. I'm sure you know it all, but it's good to start on it. Um Next slide, please. So the shoulder joint sits nice and snug because of four muscles called the rotator cuffs. So these are our images. By the way from Grey's Anatomy, I should be saying that um and the, the little tables and some notes that I've gathered um throughout my MRC S revision. So the role of the rotator cuff in shoulder stability is to provide dynamic stabilization by maintaining the position of our humeral head. There's four muscles involved, the subscapularis, the supraspinatus, the infraspinatus and the teres minor people get freaked out by remembering these, they are hard to learn. But if you can recognize them anatomically and know the landmarks, it's really easy to remember. So if we start with subscapularis, if we remember that the subscapularis is the only rotator muscle rotator cuff muscle that is on the ventral side of the scapula, you will remember that that one's there and that's one out of four. It inserts into the humerus on the lesser trachaner and it provides internal rotation. OK. And it's p and it's provided neuro, it's nerve supply is via the brachial plexus from the upper and lower subscapular nerves. Personally, this is the level you need to know at MRC S level. What I want you to take from subscapular subscapularis. And undergraduate level is just to know that the subscapularis is present on the ventral scapula, the front of the scapula. Ok. You've then got supraspinatus and infraspinatus, which are really easy to identify anatomically on the back of the scapula. You have something called the spine of the scapula. Above that spine would be the stra Spinatus, uh fossa below that spine will be the infraspinatus fossa, which thus gives rise to the name for the supraspinatus. And the infraspinatus, both will insert into the greater tuberosity of the humerus and both will both will provide a bit of external rotation. But the main thing to take away about the uh the Spinatus is, is the supraspinatus gives a B duction and it initiates it 0 to 15 degrees. You then have the teres minor, which is a small muscle at the base of the scapula that will again insert into the greater tuberosity of the humerus and again provide support of external rotating arm which is provided by the axillary nerve. I need you to take away from this slide. Is that three out of four, provide external, one out the floor, uh four provide internal and one or one that does both is the supraspinatus. And that's a B duction to 0 to 15 degrees. Clinically, you can decide between a supraspinatus or a deltoid muscle tear depending on where they can a BD to a B duction being away ad duction being taught. That's abduction and abduction. Next slide please. Jerome. So, moving more distally over the corner of your shoulder sits the deltoid muscle. So it's situated on the lateral aspect. Its origin is the clavicle, acromium and spinal scapula. And is that is why it has three heads, which means it has three functions that's forward flexion. So in front of you extension behind you rotation and then she'll also of course, a B duction. Pardon me? Yeah, this is controlled by the axillary nerve, which is again one of our branches of our posterior called our brachial plexus. But please read up on that. So you know that the clinical significance of this is that the axillary nerve plays a major role in what we'll talk about some fractures in a minute. However, injuries to the axillary nerve will allow us to see a a dysfunction to the deltoid muscle, the b sensory dysfunction over what's called the regimental badge area, which is just a badge area here. So if you've got quite a nasty proximal humeral fracture in A&E, you will know that if there is sensory loss over the proximal um the proximal upper arm, you'll know that there is an axillary nerve disfunction. Um Cool. Is there any Q? There's no questions coming. If there is any questions, guys, please just message them in. Um And I'm happy uh to discuss OK. Right. Next slide, please. So you guys are gonna be doctors. So we need to think clinically anatomy is great. But what's the point of having anatomy? If we can't link it to pathophysiology and treatment. Um So why has the shoulder joint got such a high rate of dislocation compared to other joints? It's because we sacrifice range of movement for stability. You can move your arm much more than you can move your hip joint. And that's to provide us as humans to reach for things and do tasks and coordination. We have a, there's within the shoulder joint and within the population, we have high rates of dislocation because of this sacrifice. It's a although it's a complex ball and socket joint consisting of these um consisting of the bones we've spoke about. There is a shallow capsule in which the ball sits which allows it to become in and out. Although it's not one singular uh one singular factor that leads to shoulder joint dislocation. Um Most people talk about um you rotate a cuff muscle tears that can cause shoulder joint dislocation, um a lax capsule within that and then a few ligaments if your ligaments have been torn, if you've got a shallowy glenoid cavity, um the presence of the quadrangular space, which is the space I won't be talking to you about today, but something you can go on and read about, um I just want you to take away from this side is that the shoulder joint is prone to dislocation because of its high range of movement. Ok. Next slide plays jerome. So we're moving into the arm now. So commonly anatomy. The arm is from the shoulder to the elbow and the elbow to the hand is the forearm. I want you to remember that in the anatomical position, uh we're looking um with our palms outwards too. So the anterior will be here. So the main bone of course is the humerus. We spoke about it already. Um And the humerus um is the long bone of the upper arm. It articulates with the scapula approximately. Um and then distally the radius and ulnar which forms the crucial joint of our elbow. Um Its proximal end is the head and the anatomical er and surgical neck we spoke about earlier which you can now see here, I forgot I had this slide and these landmarks are really important um to remember. Ok, um the distal end is called the capilla ventricular and that's what articulates with the ulnar and radius. Um And just understanding this is important because if you're ever an orthopedic health officer, you need to be able to tell your bosses in the morning after the trauma meeting where the fracture is and what it does. Um and what it's been doing to the patient. So, anatomically, um I want you to remember a few things from this image. So you've got the um head of the humerus which has got the anatomical neck and the surgical neck. It's called the surgical neck because it's more prone to fracture. So I want you to remember that. I also want you to remember uh the spiral groove that runs through the humerus. It's called the radial groove here, but most commonly is known as the spiral groove. And that's where your radial nerve sits. Ok. So if you get a fracture of that midshaft of the humerus, you'll have a radial nerve palsy. And then you've got the Condy area that you can just see demarcated on the left image with at and this is what's really common um fracturing kids and we're gonna discuss them in a sec. Um cool next slide theo So when you are all qualified, I don't know if you are qualified, but when you're up on the wards and you get a cool bleep that you've had a fall um on the Geriatrics ward. This is probably what you're going to see. OK. This is uh some uh ap radiograph images of proximal humoral fractures um commonly seen in the elderly and often due to very low trauma. So management will depend on multiple things, uh will depend on patient age. Uh scoring systems use fracture, displacement, bone quality, neurovascular um assessment. Um But what people don't realize is not that not all um proximal humeral fractures need to be surgically fixed, some can be conservative managed in a sling. Um The thing I want you to take away from when you think about a proximal humeral fracture is that I want you to get an X ray of the images, but also make sure you neuro neurovascular assess the patient because it's these fractures that lead to axillary nerve injuries and loss of deltoid function. And the deltoid muscle is what is the main A BD um of your shoulder joint D slide, please? J Sure, nice one. Thank you, mate. So on the other end of the arm is your supracondylar fractures um that are most common in the pediatric population. Um and they're often caused by falls onto an outstretched hand. Uh They typically occur above the elbow and they definitely, I shouldn't say definitely. Pardon me, they almost, nearly always lead to neurovascular complication. And that's because you need to know your anatomy. Um evaluation will involve making sure that you uh test neurovascular compromise and fracture stability. Uh management will depend on the degree of displacement and involvement of the surrounding structures. What you may see is neuropraxia, uh specific uh nerve palsies like radial nerve palsies, ulnar nerve palsies, median nerve palsies. Um just because of where, where the fracture is. Um you'll have media, you'll have the ulnar nerve. Um and you'll also have uh the ulnar nerve medially at, in the middle of the acute fos you may have the median nerve and actually you have the radial nerve coming round. So you need to make sure that you um examine the kids when they get this. So, next slide please, Jerome, we're now gonna go into a few ques uh a a few discussions on the muscles of the arm just to make sure there's no questions, no um fine. So the upper arm plays a crucial role in arm movement and stability. Uh You've got the base er, the biceps brachii originating from the scapula and inserting to the radius, er which is your primary flexor. You've got the triceps, which is located on the posterior aspect, which has got the long head and the lateral and medial head. So there's three heads, hence triceps and that's the main exe uh main extensor. And then we've also got the brachialis and brachoria um er in which we will er, sorry, the brachial, er sorry, the brachialis and the coracobrachialis part of my language. Um And we will talk about that next slide, please. The before we go on, um I just want you to realize that the nerve supply of the arm. So the upper arm is mostly two nerves you ha uh in motor, in motor sense, you've got the radial nerve, which is the extensor. So for anyone that goes gym, when you're doing your tricep, pull downs and you're extending your arm, that is your radial nerve. When you're doing your bicep curls into you, that is your musculocutaneous nerve and that is flexion of your anterior compartment. Sensation goes back to this lovely picture that we all saw in first year in medical school, just learn your dermatomes. They are learn them now because when you are neurologically assessing someone or seeing someone on an orthopedic ward. You need to make sure you can tell your boss where the neurological deficit is. Next slide, please. So let's dive into some of the muscles now. So, uh this picture is from teach me anatomy and again, the tales from my uh revision note. So the anterior compartment er of your arm. So remember we're in the anatomical position, er, anterior compartment is the, the most superficial muscle is your bicep rachi and it's responsible for elbow flection, but also forearm supination. So, if you flex your elbow joint and move your thumb inwards, you can feel your bicep uh tense a little bit. It consists of two heads, long head and short head with the long head originating from the solenoid and the short head, er originating from the coracoid process and both inserting into the radial tuberosity and it's controlled by the musculocutaneous nerve. Next slide, please. Jerome, you've also got two small muscles that no one ever talks about. Um And I feel need more credit and that's your brachialis and your coracobrachialis, coracobrachialis. It's really easy to remember it's origin because it's from the coracoid process and it goes into the mid humerus and it also does a bit of flexion and ad duction and it's your musculocutaneous nerve too. You've got your brachialis muscle, which is from your anterior humerus to your ulnar tubs and it also flexes your forearm. Some people remember it by the pneumonic BBC. I don't want you to learn that it's jaw innervation. I just want you to learn that it's musculocutaneous nerve. So you've got the three muscles of flexion, which is your bicep brachii, your brachialis and your coracobrachialis. Next slide, please j in your posterior compartment of your arm is a big muscle called tricep brachy. And it's a large muscle that has got three heads. You've got the long head, the lateral head and the medial head. Um it extends the elbow joint, aiding, pushing or straightening the arm and it's innervated by the radial nerve. Ok. So I just want you to remember that your tricep push downs is your radial nerve arm. Anatomy is pretty easy. Right. Right. Next one, please. Dr I lied a little bit. I said I wouldn't go into um full blood supply. But I, what I want you to know is that you've got the axillary artery that gives off five branches, er, the superior thoracic artery, the thoraco cranial, the lateral thoracic artery, the subscap and then it gives off your anterior and posterior circumflex humeral arteries too. But then it goes and changes into the brachial artery. The brachial artery is what um is the pulse you can just build just above your anterior cubital fossa, which then splits into your radial and ulnar arteries. Um This artery is vital for the blood supply of your upper arm and your lower arm. And I think that as a undergraduate medical student and an E years doctor, I think you should know that the main artery is the axillary artery that goes to the upper arm. And the axillary artery is what comes from the Subclavian. Thank you, Jerome. Next slide. Am I talking too fast? Dr, by the way, I'm getting stuck into it and enjoying it, but it's easy for me. No, it's not. It's perfect. Fine, fine. No worries, we'll continue. So we're still working proximal to distal. So we're now at the anterior cubital fossa. And as house officers, you'll get to love the anterior cubital fossa because all you'll be doing is not saving lives every day, but taking blood tests and this is one of the main sites. I mean, superficially, we're using the media cital vein, but we're not seeing anatomy, but it's good to know the er the anatomy of the er anterior cubes fossa cos there's a lot of important structures that go through this place um through this part of the body. Um it's bounded laterally by the brachia rais, which is the muscle will go into a bit, which is the muscle that supernate the forearm and also known as the beer drinking muscle um medially by the pronator Teres, which says what it does on the tin it pronate. Um and then you've got a floor, which is the brachialis muscle, which is the muscle. We spoke about the flexor of the arm. It's contents of what are important and commonly assessed the MRC S level. And that's the contents from medial to lateral are the median nerve, the brachial artery and the biceps tendon. So if you were to take anything away, forget the anatomy, just know that there, you've got the median nerve, the brachial artery and the biceps tendon. Next slide, please. Oh, I told you this is a wh stop. So I'm getting worn out talking this far. So if you've got any questions, please go ahead and ask, but I'm gonna continue um going into the forearm now. So osteology wise, bone wise, er the forearm is made of two bones. You've got the radius and the ulnar um and they connect your elbow to your wrist, the radius is on the thumb side and the ulnar is on your pinky side. Ok. Uh These bones play a crucial movement of your forearm um and also stabilize your forearm. They also help us pronate and supinate. Um And the, and the ulnar is to kind of support a muscle in which also gives that uh big thick um kind of elbow. The electro uh sorry, your electron process fractures of these bones, of course, are common from result of falling or trauma and fracture pattern can vary. Unfortunately, as much as I love it to be, this Lector is not on fractures, so I won't go into it. But what I want you to take away from this slide is knowing that the electron on process is part of the ulnar. The radius has got a head that rotates within this. And you've got the styloid process of the radius uh distally and the head of the ulnar distally. Next slide, please. Right. Um Now we're to the juicy bit. Jerome knows me. I like images and, and cheesy chat. So now we're getting to the real juicy part of anatomy of the upper arm. So the forearm, I do not expect anyone at undergraduate level to be able to name all muscles of the forearm. But to know that there's different com compartments that are prone to different types of pathology such as compartment syndrome. Um to know that the nerves play a different role in each compartment is what I do expect at undergraduate level. OK? So the forearm is divided first official into anterior and posterior compartment. The anterior compartment, we call it the flexor compartment, cos it flexes the digits and then the posterior compartment, we call it the extensor cos it extends the digits, ok? You've then annoyingly got it divided into superficial and deep. There are five muscles in the superficial flexor compartment of the anterior forearm. And then what I want you to remember that the anterior forearm, the flexor compartment is mainly supplied by the median nerve except two things. And that's the ulnar half of the uh of flex to profundus which and the flexor car ulnaris. Another thing I want you to remember is that Palmaris Longus. So if you can all just kind of pinch your hands together, now, some people may, or some people may not have a tendon present just in the middle of their forearm that is Palmaris Longus and it's actually absent in 15% of the population. It can be used for tendon grafts. Um, and it doesn't actually provide much significance any more. Um, I've just noticed a, a mistake on my slide. I'm gonna say er flex, it's flexor, er Carpe, sorry, it's flexor digitorum profundus that the old and a half is supplied to in the anterior compartment. It's only all median nerve I will in the slides that we send out. I will make sure I change that next slide, please. Dr So we now have the deep flexors which are very easy to remember. There's only three and that's three muscles and it's the muscle of flexor digitorum profundus, flexor pollicis, Longus and pronator quadratus. These muscles are flexors of the digits um and are supplied by the median nerve. We'll come on to the flexors of the fingers in a bit more. But all I want you to take away at this level is the um there are 55 in the superficial flexors and uh three in the deep flexor. And what I also want you to take away is is that almost all of the flexors in the forearm arise from the medial epicondyle, which will come become significant when we talk about a pathology in a bit. Um Just out of curiosity, um is anyone post graduate and sitting the MRC exam? Because if they are messaging the in the comments, and I will go into a bit more de about details about the muscles of the forearm. Uh Next uh what before we move on? I just want to, I don't know why I put it on this slide. I must have been having been thinking um when we talk about Longus versus Brevis, longus means a long tendon and it's a tendon that goes into a muscle. I'm not, but they require deep info on our uni, right? OK. Let's go back and go into deep info. Then uh previous slide, please. Right. No. Previous. Thank you, mate. So five muscles in the forearm. Ok. All forearm, uh sorry, in the superficial flexor of the forearm, all forearm muscles by your supers and pronators, either flex er will flex the wrist or digit. So your forearm muscles you can see, control your fingers. They don't do anything. You can't bend your forearm in half, can you? So I want you to remember and they all arise, arise from the medial epicondyle and will insert into either your phalanges or the bones of your hand. Um I want you to remember that they're all median nerve except flexor, carpi, ulnaris, your flexi carpi, ulnaris that stands for flexor. Carpi means wrist and Latin ulnaris means ulnar side. Ok. So learning Latin, which I'm sure that some uh European medical schools are very eager for you to understand Latin should come natural. And I want you to learn about um Longus and brevis. Longus being the tendon be muscle and brevis being a short muscle present in the um in the uh part of the body it acts on next slide, please. Jerome. Uh So in this, they want the location, nurse supply on the origin location. A they want the location, nurse supply along with the origin and insertion. Wow. OK. I will do that from now on. You're more than welcome to have access to these slides. I don't know if you can send them out. Um I, the best way to learn origins and insertions is to get to the anatomy lab dissect. Um see it in real life or get to the theater origins and, and insertions are easy to learn as you layer your learning and we'll go through them now and we'll start talking more about them. So you've got your deep flexors of your forearm and this is your flexor digitorum profundus, which or originates from your anterior and medial ulnar and it goes into the base of the distal phalanges and it flexes your distal interphalangeal joint and that's your media arterial to or and nerve. Ok. Depending on where it is in the hand. Um You then got your median nerves control on the flexor pois longus, which means flexion of the thumb. And that's the anterior and lateral radius, base of the distal phalanges, uh flexes the IP joint of the thumb and again, median nerve and then pronator quadratus, which is a small muscle that helps pronate your wrist, uh distal ulnar intervolar radius, pronating the hand, median anterior and torosus nerve. Next slide please. Dr So the finger is a very complicated mechanism that I've been on plastics, jobs that even consultants are still learning about and senior registrars I should say. Uh but what I want you to take away is that you've got the flexor T tutor and Profundus and the flexor tutor superficialis, the profundus flexing the er distal um the distal inter joint and the superficialis flexing the proximal joint. The way it works is that flexor digitalis tendons, splits and inserts on either side of the phalanges to allow the distal er sorry, the er flexor digitorum performers to go through and flex the distal end. Next slide, please. Dr So we're now changing side um to the superficial extensors of the arm. OK. And I want you to remember that I mentioned that they're gonna originate from the opposite side. So they're now on the lateral epicondyle of the humerus. So you can see all the extensor digital minima come from the lateral side of the humerus. So you've got seven muscles, it's very difficult to learn, the more you go over it, the more you'll remember it. So you've got the brachial radialis, er, which er helps in flexion of the forearm, but also supination, that's a bit wrong. You've also got the extensor carpi, radialis, longus and brevis. So there are two muscles along on a short one that extend the wrist at the radial side and they go into the second metacarpal and third metacarpal space uh base respectively. You've got the anconeus, which is a very small muscle that everyone forgets about. Um, and it's um to extend the forearm uh with the radial nerve. Again, you've got extension to tutor, which does what it says on the tin and extend your fingers and it goes into the extensor aponeurosis, something that I won't be speaking about today. You've got extensor digiti minimi, which is a common extensive tendon of your little finger, extensor digiti minimi. Um And it's, er, goes into er, the space over the little finger and then you've got extensor carpi ulnaris which extends um the wrist on the ulnar side, going into the fifth metacarpal space. All of these are controlled by the radial nerve. So, if you've got as a kid with a supracondylar fracture, as mentioned earlier and they can't extend, you know, they've wiped out their radial nerve. Next slide, please. You've then got five more muscles in the deep extensors of the forearm. And that's the supernate, the abductor, poly longus, the extensor pollicis, brevis, extensor, polys Longus and extensor in extensor indices again, all controlled by the radial nerve. Um but the deeper extensors not originating from the lateral epicondyle, except the sator, the finger extensors or thumb extensors, so to speak, come from the dorsal ulnar or radius and go into the respective phalanges. They're going to act on thumb movements will come on to in a bit. So I'm not gonna cover them now. But if you've got any questions, please put them in the chat. So clinically this links next slide, please. Um er, extra bonus point if anyone can name the golfer on the left. Um er, so this is uh clinically this links to golfer elbow and tennis elbow, things that people get often confused with. So tennis elbow is lateral epicondylitis and it's pain and tenderness on the outside of the elbow and that's worse by gripping or lifting objects and it's associated with activities involving repetitive wrist extension. So if you're thinking about a tennis swing, you're pushing your wrist out and that's why you get that pain. But golfer elbow is medial epicondylitis which presents with pain and tender on the medial side of the elbow. And that's cos you're flexing the wrist when you swing. I don't know if anyone plays golf. I do and I'm woeful. Um, but um you get a bit of pain here if you flex your wrist. So if I want you to take anything away, if your early years, um clinically, just know the difference between golfer elbow and tennis, elbow and have it as a differential depending on where the pathology is in the arm. Next slide, please. Doro. So we're now on to hand bones and this can be very complicated. There are certain pneumonics I won't go through, but I can't say, am I wrong? Cos it might get me kicked off of metal, but it, the whole hand consists of 27 bones completely. And you've got, um, your metacarpal bones, you've got your hand bones, you've got the phalanges, but I want you to try and remember the carpal bones if you can, er, because one specific carpal bone is really po uh prone to fracture. So you've got the scaphoid, the lunate, the triquetrum and the pisiform, you've got the trapezium, the trapezoid, the hamate and the, er, and the capitate, I've missed out. Pardon me? But what I want you to remember and somehow some people will remember because they get confused with the teeth. Just know that the trapezium is under the thumb. So the M for M and you'll remember in what way around the triquetra is down by, on the base and you know, the trapezoid is up there and they do actually come in alphabetical order if you think of it that way bones are important, include the scaphoid and the trapezium and the, and the, er, sorry and the pisiform and the hamate cos this is where your flexor and extensor. Um, sorry, your flexor retinaculum attaches. Next slide, please. Dr So the anatomical snuffbox is a very important landmark. It's called the anatomical snuffbox. Cos back in the day when people used to snort tobacco, that's where they used to put um the er tobacco. So the anatomical snuffbox, if there is tenderness there after a fall on an outstretched hand, it is a scaphoid fracture until proven. Otherwise, it also may take time to show on the x-ray. The reason we worry about a scaphoid fracture is that the blood supply of the scaphoid works from dorsal uh sorry, from distal to proximal. So you'll get a vascular necrosis of the bone. It's important to know the boundaries anatomically of the anatomic snuffbox and it's to remember that I call it the Brevis sandwich. So you've got the extensor pollicis brevis. Um So you'll have the extensor pollicis Longus on the ulnar side, you'll then have the extensor pollicis Brevis in the middle and the abductor pollicis Longus on the outside, you'll have the scaphoid um at the base. OK. Um And it's important to know that the catholic vein also runs through there, common vein that we kind of sometimes take blood or cannulate. Um Next side, please. Jo another very, very, very important thing to know as an undergraduate is the sensory supply of the hand. So it's governed by the ulnar median and radial nerve. Um The ulnar nerve supplies sensation to the medial aspect of the hand, including the pinky and half the ring finger. When the median nerve innervates the palmar aspect to the thumb, index, middle and ring finger. Meanwhile, the radial nerve sorry the half of the ring finger. And then meanwhile, the radial nerve, primary fire sensation to the dorsal of the hand and the thumb. Please do remember this. It comes up in exams all the time. Um And you need to know it clinically. Next slide, please j So we're getting even deeper now um into the intrinsic muscles of the hand. There's loads of intrinsic muscles, but they're, they're broadly divided by the Thenar. Can you still see me? Dr? Yeah, I can all my thing just crashed for some reason, but at least I'm back fine. So er thenar muscle, hypothenar lumbar call it into rossi. Um They all originate within the hand themselves, control finger and thumb movements. There's even more muscles control in thinking er er finger and thumb movements. OK. Um Next slide, please. So the Thenar eminence, which is the muscle side of the thumb on uh on the um on the anterior part is called uh we call them the loaf muscles, but this is the oath. Um and they are three muscles controlled by the median nerve and control uh control the thumb. So there's three muscles you've got the Opponens pollicis, which is the largest of the Thenar muscles and lies at the base. It's attachments are, it originates from the tubercle of the uh trapezium. Um and the flexi flexor retinaculum inserting onto the first met uh metacarpal. Pardon me, it opposes the thumb, hence the name opponent's po and of course, is innervated by the media nerve. You also got the abductor po brevis, which forms the anterior lateral aspect of the thenar eminence overlying the opponent's po. Um and this again originates from but the of another carpal bone uh the scaphoid um and then again, the flexorum and it'll attach to the lateral side of the proximal phalanx of the thumb. Um It's innervation again is the median nerve and of course, a B ducts the thumb and you then have the flexor po brevis um which is the medial aspect of the thenar eminence and is associated again with the trapezium and attached to the flexor retinaculum. OK. And it's a short flexor of the thumb. Any questions about that? It's very complicated. But just remember that you've got the loath muscles, the lateral two lumbrical, they're also for trouble, but we'll, we'll go on to that in a second. Uh This is often forgot about um the adduct poly cyst because it's an anomaly. It ad ducts and brings the thumb in and it's controlled by the ulnar nerve. I had this question in my exam a few weeks ago. They asked me what thumb muscle was controlled by the ulnar nerve and it's the AUC polycysts. It's uh got two heads and a oblique transverse, it extends from the third metacarpal to the capitate bone and the f and the base of the first proximal phalanx and it ad ducts the thumb. OK. So brings it in to the carpometacarpal joint. Next slide, please. Jerome. So the thumb's complicated. I don't expect you to know this completely. But what I want you to know is the thumb can do many things. A B duction, ad duction or position extension, flexion. And there's just want you to remember two flexion and two extension. I want you to remember that it's mostly it's controlled by all ulnar nerves. So you need to think about this when doing your hand exam. Um And I need you to remember that you have multiple different muscles. I didn't, uh we're gonna go through uh the, the way I remember to remember where they are on uh the, on the hand. But what most people remember is only the anterior compartment of thing because your ex er your extensor is posteriorly. And then it's easy to remember the anterior part. I was just read. That sounds really complicated. But what I'm gonna repeat again is the extensor d muscles again, are on your posterior side and they're really easy to remember cos it's just extensor poly longus and Brevis. And on this side, you've got the rest of your thenar muscles plus a duct poly. Next slide, please. You've then got your hypothenar muscles which are the muscles that control your little finger they're controlled by the ulnar nerve and a very strong muscles. Um, a study done back in 2010. I found that people with no little finger had 50% less grip strength. So, if you ever get tortured and need to lose a finger, don't lose your little finger. It's one of the most controlling fingers of your hand. Um, you've got three muscles here. You've got the Opponens Digiti Minimi. Um, you've got the abductor Digiti Minimi and the flexor digiti Minimi. Again, the opponent of digit eny is what opposes the little finger attaches from the sorry, originates from the hook of the hamate and inserts into the medial margin of the fifth metacarpal. It's innovation is the older nerve. You then have the A BD Digiti Minimi, um which is er attachment from the pisciform of the tendon and the flex Carpia and the flexor carpi ulnaris and attached to the proximal phalanx of the little finger. Um And that A B ducts a little finger and again is the ulnar nerve. You have the, the flexor minimi um Brevis or uh you can just remember it's flexity minimi and that flexes your finger and again is on the hook of the hamate and goes into the metacarpal. Next slide, please. Jerome. So the way I remember it is the same, the same from the three musketeers is you can remember where they are on the hand by remembering that there's three muscles in the thenar eminence and three muscles in the hypothenar eminence. One for all and all for one. And if you remember that you'll be able to remember the positioning of the muscles within the hand and it works both ways. Next slide, please. Jerome, I'm conscious on time for our viewers. So we've then got the lumbrical er which are four small intrinsic muscles of the hand originating from the flexor is torn, the fundus tendons and inserted into the extensor hoods of the fingers. They will flex the metacarpophalangeal joints but also extend the interphalangeal joints enabling precise finger movements and grip modulation. Um dysfunction of these will lead to dysfunction of hand grip. Uh The lateral two lumbrical are the l in the loaf muscles controlled by the median. So it it's innervation is split from the median and the ulnar. Next slide, please. Jane, you've then got your interossei muscles. I just I realized what this is actually looks like a rude gesture. So I apologize from this picture from teaching anatomy, but you've got the palmar interossei and dorsal interossei. And these are involved with ad duction and A B duction of your heart of your fingers. Pardon me? And I want you to remember pad and dab so palmer into OSI um will add up and dorsal inter OSI will A B duck to bring you together and it's one way to test these is via the ulnar nerve. So when you do your upper limb neuro exam and you're testing that you're testing your sore arthriti and the the stability of the ulnar nerve. Next slide, please. So, of course, we can't talk about the hand without talking about the carpal tunnel. Um The carpal tunnel is a narrow passageway that exists on the anterior surface of the forearm and goes into the hand houses the median nerve tendons. Um It has four tendons of flexor digitorum superficialis, the floor of tendons of flexor digitorum profundus, uh flexor pollicis, longus, flexor carpi, radialis. Um And of course, the median nerve repetitive strain injury, typing leads to thickening of this sheath and connected tissue which leads to if you just hit the next slide for me, please. Um Carpal tunnel syndrome, which is a very common condition that is noticed in orthopedics and hand surgery. Um, we essentially need a decompression by a fasciotomy. A really simple uh procedure done by hand surgeons and that's to decompress the median nerve. I'd expect you to be able to diagnose this at an undergraduate level in a hand exam. Um by a simple test such as Phalen test or reverse valence or Tinel sign by tapping on the median nerve. It's really common. You might see some hard skin in the area, but it's called by um uh repetitive hand movements. Uh Most can be done with antiinflammatory medications, the surgical, um, splinting, but surgical decompression may be needed next slide, please. Dr So you've got the blood supply of the hand. Uh which I know I said I wouldn't go into, but I'm gonna quickly say that you've got the radio and ulnar artery and these um will provide a collateral circulation. Hence why when we do an ABG, we're not too overly worried after doing an ISS test um that you're not gonna knock off blood supply to your hand because of course, our hand is the most uh distal aspect of our arm. Next slide, please. Jeron. Next slide. All right. Just let me one second. No worries. Yeah, sorry. I think my internet is just cutting out. I do apologize. No worries. I must apologize for my background. Everyone guys, this is the the messy doctor's office here at uh uh my trust. I shouldn't. But any questions guys, fire away. I'm happy to if we just go back one just to fine. So the allens test a test that you all need to do before taking the ABG just demonstrates there's a collateral circulation in the, in the hand. OK? You can do it and see the reperfusion. Next slide, please draw. So when testing the motor nerves of the hand, especially where I am now in ap population can be quite complicated but a simple way to do it is to test the ulnar nerve is get to a peace sign. A radial nerve is to extend the thumb or look I'm good er is doing animation power to the people. Median nerve gripping, uh sorry, flexing and the OK sign, which is again the median nerve, but the anterior enters branch branch I haven't focused on today. Uh but it is a branch of the hope um that, er, to control a lot of dr eminence, but it's not a level that I need to know from an R CFO, it's no median nerve. Ok. Fine. Remember this? It's great. It's impressive in front of, in uh in a kind of exam scenario, quickly getting a patient to piece the thumb up fist and OK. And you know, you're testing the distal nerve supply. Next slide, please. I'm not gonna go over this but know how to do an upper limb neurological exam. It's in flexion and extension. Um Testing C 52 with kind of the chicken poses as some people say a wrist flexion, extension, thumb and finger abduction, eight and eight abduction. Next slide, please. Jerome. Wow, that was a lot to take in. Um Here's my favorite picture of Hezbollah. Um and I er want you just to know that it takes a long time to learn about upper limb anatomy and that was 54 minutes that had gone by like that and for you to learn it, it will take hours, but please do keep going over it. Um Next slide, please drone the five key things I'd like you to take away if you were to learn anything. Is that the, the rotator cuff is made of four muscles and is the main stabilizer in the shoulder joint. Um in proximal midshaft and distal humeral fractures nerves and arterial damage can occur. I want you to remember that the musculocutaneous nerve is flexion of the arm and the radial nerve is extension of the arm. I want you to know the median nerve is a flexion of the forearm mostly and then radial is extension. And I want you to know how to test the nerves. So when you come to the ward, you'll know what to test next slide, please. Jerome. Thank you. I know that was fast. I was given a time slot. Um I'm happy to answer any questions, er, slash Jone. Provide my email if, er, people have any further questions about er, anything as we have much more comprehensive syllabus. Could you summarize the piano ecology requirements? So, I went to medical school here in Sheffield. We needed to understand where muscles were, don't get me wrong, but even origins and insertions are not needed to know up to the Fr CS level. I had three anatomy stations. I still do dissection once a week now. Um as a post graduate um in my course of surgical training and even now we don't need to know the insertion and origin unless anatomically required, uh procedure specific, don't get me wrong. Things like the coracoid process present under the achroma. Um I need to know what, er, go, er, what inserts us such as the bicep shorthead, the, er, the peck minor and the coracobrachialis, but little insertions that go into the humerus itself. I don't need to know, we needed to know the, er, rotator cuff origins and insertions, but we didn't know, need to know absolutely everything. A nerve supply was massive blood supply, not so much doing a comprehensive neurological exam examination is key in practice over here. Um, so it's quite important that you know how to test the nerve, test these nerves. Uh very specifically, absolutely fractures. Yep, I would love to spoke about an hour for fractures. You need to know absolutely every fracture, every complication, what to expect, how to assess it, how to manage it, who to call um how to image it. Yeah, so absolutely everything. OK. Um Yes, uh Bianca, um the recording will be made available. They will be um sent to you in about a couple of hours time. The feedback form will be also emailed to you straight after this lecture is done. Um So you can fill it out there and then a after you filled it out, you will get a certificate of attendance. Thank you so much for everyone joining in and a big thank you to uh Mr George West uh for giving this great presentation um do tune in next week uh for another lecture on anatomy. Again, we'll be holding it for the next six weeks in different locations in the body. Um Thank you so much for your time. I'm hoping that everyone enjoyed it. Um And we will see you next week at the same time on the same day. Thanks do.