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Ok. Um Right. I think we should make a stop. So, hello, everyone. Um My name is Abdul Krem. I'm the president of the in Rheumatology and Speak Society in Glasgow. Um Thanks for all for joining uh today. Basically, we gonna do this, this is the second part, second session of the M SK series. So last week we, we went over the um hand and rest, um anatomy can um slash, you know, P uh P and some questions at the end as well. Um And we're gonna, today, we're gonna be a second session, we're gonna go over the uh elbow and shoulder. Um And uh so if, if you're here uh on last week, you probably know, er, know how, how it goes. But basically, so I've got her with us. Uh So if I want those kind of kindly gonna be uh take us through this MS case series, um He's one of the, he's the one of the past presence of uh Gus of the society and he, he grown very fond of even after leaving the unit, he's still big part of it. So I do appreciate the, his help and t taking the team. Um, so once I'll hand over to her, uh, in a minute. So, but at any point you have any questions, please post them in the chats and do, let us know, um, we try to make it as, in attractive as, as, uh, as we can. Uh, but in the end of the day, you know, I take each, it's up to each one of you to kinda, to make it attract and, you know, if you, you know, and get involved. Um, but yeah, I'll hand over to her and, yeah, I hope, I hope you enjoy the session and, uh, yeah, cool. Yeah. Thank you. Hello, everyone. Um, yeah, so my name is her and this is our second, um, lecture that we've done. We did one previously last week, um, on the hand and wrist today we're gonna be focusing on the elbow and shoulder. Um, essentially these lectures. Uh, if you haven't really, you know, revised much for kind of limbs and back. Um, and I guess a few of your, your anatomy stuff, uh, they should be able to cover you, um, with what you should know for your exams at least. Um, yeah. So I'll just get right into it. My legs. Ok. Can you see my slides? Yeah, I can. Yeah. Ok. So, yeah, as we said, we're gonna be talking about the shoulder and the elbow today. Um, really focusing on the anatomy of everything. Um, we'll then go kind of muscles wise, we'll look at the nerve supply uh and then we'll do some questions at the end. Um So essentially, starting with the shoulder joint itself, uh consists of three bones, really the humerus, the clavicle and the scapula. So with the humerus, when we're looking at the proximal end, there's, there's quite a few things going on. Uh But things you want to focus on are gonna be the humeral head here, uh which will articulate with the glenoid fossa of the scapula. And that's gonna form the glenohumeral joint, essentially the shoulder joint, um very important as well to be appreciative of these uh of the tuberosities. You've got the greater tuberosity in the light blue and you've got the lesser tuberosity in the green. Um Now, these are serve attachment sites for um many muscles including the rotator cuff muscles. We'll discuss about a bit later on um between the two tuberosities. You've got the intertubercular groove again, another important structure um as attachment site for quite a few of the muscles which we'll discuss. You've also got the surgical neck here. Um Now, this is a quite important part because quite a lot of fractures take place um in the surgical neck and there's, there's different arteries and, and nerves that run down this um this bone here and are at risk of, of breaking um when you've got a fracture here. Um Yeah, so we've got the distal end now. So with the distal end pay particular um attention to the la lateral epicondyle and the medial. If you remember from last week, um the the lateral epicondyle is really the attachment site for all the extensor muscles of the forearm and the medial being the attachment site for all the flexor muscles. Um You've also got a really important articulation site. You've got the capitulum here, um which will articulate with the, the radius, the radial head. Um And then you've also got the um the trochlear here um which will articulate with the ulna. Now, with your scapula. Yeah, with your scapula, the scapula is a bit of a weird bone here. Um Well, you've got that glenoid fossa that we were talking about that will articulate with the, the humeral head. Um You've also got the, the acromion here. Um And then the corticoid process here and there's lots of lots of attachments going on here which we'll talk about um with uh with other bones of humerus and the clavicle. Um Two kind of important spaces I should know should know of. Um are the supraspinatus fossa and the infraspinatus fossa. And it was kind of the names. So it's quite easy to tell which muscles originate from here. So the supra uh the supraspinatus muscle originating from this fossa and the infraspinatus muscle or originating from the infraspinatus fossa. Ok. If anyone has any questions, put them in the chart. So, yeah. So now moving to the anterior part of the scapula. Um You've got that again, the acromion and the corticoid process here, uh The anterior part also has the subscapular fossa. So this would, this would be sitting at the back of the rib cage, right? Um Now, with that, that fossa, you've got the um the subscapular muscle. Um And here we've got a few of the muscles that, that will attach uh or originate from the corticoid process, um particular the um the muscles of the biceps, but we'll talk a bit more about that further on. So we've got a clavicle nerve. The clavicle is a s shaped bone. Um Really the only thing you need to know for the clavicle has got two articulations. So at the sternal end, um you have the sternal clavicular joint and uh and at the acromial end, you've got the acromioclavicular joint. Um So, yeah, quite, quite self explanatory. Um ligament wise, there's a lot of ligaments going on. One you should be particular um aware of would be um the corticola var ligament. So that essentially consists of two smaller ligaments. So you've got the trapezoid ligament and you've got the coronoid ligament here and they attach here uh and the trapezoid line in the coronoid tubercle. So we got put here. So, yeah, so, yeah, it's a very important ligament. Um They usually ask questions about this ligament. Um And if you think about it really, if you just look at it, um the whole kind of upper arm. Um, and the scapula, um, is attached to the clavicle through these ligaments. Um, so it's, it's a huge, it's a huge of, uh, weight that, that cla, hello? Ok. I think someone, no worries. Ok. Ok. Now, moving to the muscles of the shoulder, um, we've got the, yeah, sorry, we've got the extrinsic muscles of the shoulder. Um, we've got the latissimus dorsi muscles. Um, now they originated from the spinus process of T seven to T 12. And essentially they attached to that, that um that sulcus, we were talking about the intertrabecular sulcus of the humerus. Now, I think we've got a little diagram here. Yeah. So you can see really clearly see here what's going on here. So T seven to T 12. Um And you can see it's attaching to the intertubercular sulcus. So you've got your greater tran, you've got your lesser trachaner and that's where the muscle attaching to. And, you know, with all anatomy, um with movement wise, just really think of what would happen if this muscle was contracting. So if this muscle is gonna contract, it's, it's gonna bring this arm, it's gonna bring this humerus backwards, isn't it? Um And that's extension. Uh It's also going to uh it's also going to add duct uh that limb and then also cause a bit of medial rotation as well because if you look at the arrangement of the fibers itself. Um So, yeah, So that's uh innervated by the uh thoracodorsal nerve. Um You've then got the trapezius muscle. It has quite a few origins. Um in particular, the nuchal ligament and the spinal sclerosis of C seven to T 12. Um and they attach to different points. Um So the clavicle, the acromion and the, the spine of the scapula. So if we look here, so the trapezius muscle really has three sections. Uh You've got kind of the um superior fibers here. You've got the middle fibers and then you've got kind of the inferior fibers. And again, just look at what, when we think about movement wise, look at kind of what would happen if these muscles contracted. Um So if you've got your CP these muscles contracted, you can, you can see that the scapula would be elevated, wouldn't it? Um the clavicle, the scapula would move up um with the middle fibers, you can see that the, the scap if these contract, the, the kind of the scapula is gonna come together. So in other words, it's gonna, it's gonna retract. Um and then you got your inferior fibers that's gonna hold your scapula quite close to your uh to your rib cage. So it's gonna pull it downwards. So there we go. So we got elevation, we got retraction and we got depression of the scapula. Um and that's innervated by the accessory nerve. Ok. So the, we're moving on to the extrinsic layer nose um of the shoulder. So we've got the deep layer nose. So the deep layer essentially consists of the rhomboids, which you have to, you've got the, I think up here. Yeah. So you've got two here, the rhomboids, you've got the minor and the major um they um originate from T two to T five. And you can see here they really um attach to the medial aspect of the scapula. Again, look at what would happen if these muscles were contracting. So it's gonna, it's gonna bring the two scapula together. So it's gonna cause retraction of the scapula. Um And the innervation would be the dorsal scapular nerve, which is kind of in the name, it kind of makes sense. Um You've got the Levitra scapulae, another important muscle. Now, that kind of originates from the transverse transverse process of C one to C four and it attaches again to that medial, the medial aspect of the scapula. Um It's in the name as well. So the, the main movement of this is elevation of that scapula um and also innervated by the same nerve here. So we've got just a diagram here with movement wise, what I mean? Um So when we bring the scapula together, right? That's retraction or in other words, abduction because you're bringing it to the midline. OK. We've also got that upward rotation. Um And with the trapezius muscles, we had that depression. All right. So moving on, um we're just got the intrinsic muscles. Um So we've got the, the deltoid muscles of the shoulder. Now, so the deltoids, you've got three kind of orientation of fibers. You've got your anterior fibers, your lateral and your posterior fibers. Um Now again, quite um quite easy to understand what those muscles are doing anteriorly. Um because they're attaching into that deltoid tuberosity of the humerus. Um They're gonna cause the anterior fibers are gonna cause flexion. Um Your lateral fibers are gonna cause abduction up to 15 degrees and your posterior fibers are gonna cause extension, right? And that's innervated um by the axillary nerve. So we have that your Theresa minor. So if we go to the next muscle, we've got the teres major. Um now that will come from essentially the inferior angle of the scapula. Um and it'll attach to that same intratrabecular sulcus that we were talking about of the humerus. Um So you've got more of a clear picture here. So, again, um inferior angle, that's where it's coming from attaching into the intertrabecular groove, right? And then just think about what would happen um with the muscle if it were contracted, right. So, abduction uh and then you've also got medial rotation of the arm and then, yeah, so we've also got pictures of the, the deltoid as well. So, deltoid muscle coming from the clavicle, um the acromion as well, the spine of the scapula and all inserting into that deltoid tuberosity of the humerus. No we're just moving on to the rotator cuff muscles. I'm gonna check if there's any, is it called follicular or coronoid at the Asco or both? Um, what do you mean the, the ligament we're talking about the clavicular? I would say most is cortico clavicular. They would ask, uh, but they may ask you what two ligaments make up, um, that the cortico clavicular. Ok. All right. All right. So, moving on to the shoulder muscles. Um So you've got to repair cuff muscles. These are quite, these are quite easy to learn really because the, the name and the, the function can all really be deduced by um by a few small bits of information. So we've got the supraspinatus now that what we mentioned before, originates from the supraspinous fossa and then inserts into the greater tubercle um of the humerus. And it's responsible for the 1st, 1st 15 degrees of abduction. And another thing you can do, you can do the drop can test to, to test its function. Um And it's innervated by the suprascapular nerve. So I think we have, yeah, we have a bit of a picture here. So if you can see um you've got the uh the supraspinatus muscle in the red here. Um Here's attaching to the greater tranter. And if you can imagine if this muscle is retracting, where, where is this arm gonna go? It's uh it's gonna, it's gonna go outwards, isn't it? So, in other words, abduction and something to know for the, the supraspinatus, that's just the 1st 15 degrees of abduction kind of roughly um ok, next muscle now, so the infraspinatus um again, originating from the infraspinous fossa, uh also inserts into the greater tubercle, but it's responsible for lateral rotation. Um and it's also innervated by the suprascapular nerve. So, if we just take a look at that now, so we've got the infraspinatus again to the um greater tubercle and just think of what would happen if this was, was contracting. So, because it's a bit more um lateral, if that's going to contract, it's gonna bring, it's gonna bring the arm outwards, isn't it? So it's going to cause lateral rotation. OK. So then moving on to the um we'll go on to the teres minor um because that also helps with the lateral rotation. Um This is kind of just a smaller muscle really and helps with, helps the infraspinatus muscle. Um But something to be particular, uh something to be um aware of with this muscle and that inserts into the lesser tubercle and not the greater tubercle. Um OK. And then moving on to the uh the subscapularis, um this originates from the subscapular fossa um and then inserts into the lesser tubercle. Um Now, this is responsible for medial rotation. OK. And is innervated by the subscapular nerve. So you can see it here um in the pictures. So this is the uh the subscapularis. This is attaching to the lesser tubercle. Um And that's gonna cause the medial rotation. And if you think about it again, it's just, it's coming from the, the medial aspect of it. So it's gonna cause that arm to come over. OK. Yes. OK. We're fine, I think. All right, moving on now to the muscles of the bicep. Um So there's three muscles I should remember in the anterior compartment. Um A few of us would remember by the acronym BBC. Um So you've got the first B would be for the biceps BHA. Um Now you've got three, you've got sorry, two heads um of the biceps, you've got the long head uh which originates from that supraglenoid tubercle. So that's just above that glenoid cavity that we were talking about the glenoid fossa just above it. That's where the, the, the long head of the biceps originates from um the short head you can see here originates from the coracoid process. And these both attach down into the radial tuberosity. And again, think about what's happening if it's, if it's attaching from here into the radius, OK. It's gonna cause a flexion of that arm, isn't it? If it contracts at the elbow and it also causes supination of the forearm. So, pay particular attention to the supination. Um That's something that you can trip on in the questions, either they'll say pronation or supination. So it's supination because it's, it's attaching to the radial tuberosity So, again, think about what's going on with the muscle. If it's being attached to here, if it contracts it, it's gonna supinate instead of pronate, right. Um And all the muscles in the anterior compartment are innervated by the musculocutaneous nerve. So, moving on, next one is the cortical brachialis muscle. Um And again, uh think in the name, it really tells you where it's where it's originating from. So it's originating from the corticoid process and it will insert not into the radius but into the, into the humerus. So the medial shaft of the humerus um again, should kind of give you a hint of what, what's going on with the, the movement wise. So this doesn't cause flexion of arm um at the elbow like the biceps because it's not touching to the, the radius. Uh it will cause flexion of arm at the shoulder and innervated again by the same nerve. And then the last muscle you've got here um is the brachialis muscle muscle and that will um originate actually from just underneath this, from the medial and the lateral aspect of the humerus. Um and it will insert into the ulnar tuberosity. So, because this is inserting below the elbow, this is gonna cause flexion at the elbow, right, um and innervated by the same nerve as well. So all of these are innervated by the musculocutaneous nerve. So now we've got the, the triceps here. So the triceps instead of the two heads of the biceps, you've got three heads of the triceps. So you've got the long head here. Now, remember we were talking about the, the bicep, the bicep long head and that originates from the supraglenoid um fossa. And that was just, just right up here. Really? So that's the glenoid fossa. And that's where the biceps tendon originated. That long head originated from with the um the long head of the triceps that actually originates from the infraglenoid tubercle, which is just below the glenoid fossa. So quite an easy uh easy thing to remember. It kind of helps if you know your kind of picture in your head. So, medial head now, um that originates from inferior, inferiorly to the ra the radial groove. So I've got a picture here if you can see. Um So you've got here, this is the lateral head and the radial groove just runs behind the humerus here. So you've got the lateral head um originating superiorly to that groove. And you've got just here, if you can see that, I don't know if you can, you can't really see it well, but you've got the medial head there originating uh from inferiorly to the groove, right? And these all the long head, the medial, the lateral, they all attached to the electron no, of the ulnar here. You can see, you can see it quite obviously here. OK. And again, because it's attaching at the elbow, it's gonna cause extension of the arm at the elbow and these muscles are innervated by the axillary nerve similarly to the uh the Teres Minor. OK. So we're gonna move on to the chest muscles now. So we've got the, just check if you have any questions. OK. So we're gonna move on to the pectoralis major muscle. So it's got two heads. Um You've got the clavicular head and you've got the sternal head. So clavicular head in the name originates from the medial aspect of the clavicle. OK. And again, that makes sense. It wouldn't be lateral, would it, it's more inner. So it's the medial aspect, the sternal costal head again in the name um attached uh originates from the sternum and the superior six costal cartilages. Uh Both of them insert into that same intertrabecular sulcus that we're talking about. So there's quite a few muscles that, that insert into that intratrabecular sulcus. So it's, it's worth remembering. Um Again, if we think about what would happen if that muscle was contracting, um it's gonna cause abduction of it, right. And it's gonna also cause medial rotation um and they innervated by the lateral, medial pectoral nerve. Now, you've also got two important muscles um of the of the chest. You've got the serratus anterior. Now, they, they love asking about this one. So the serratus anterior essentially comes from the lateral aspects of ribs, 1 to 8 and it'll insert into the medial border of the scapula and the main function of this. Again, if you just think of what's going on here, it's, it's originating from here. It's right behind here. You can see behind this muscle is the scapula and it's attaching to it. And if it contracts what it's gonna be doing, it's gonna be bringing that scapula closer to the rib cage, um and holding it against the rib cage. I know with movement, it also rotates the scapula. Um Now, this is innervated by the long thoracic nerve. One of the questions you'd like to ask about this um is winged scapula. So if you have a, if you have a damage, if you just think about it, if you, if you have damage of this nerve, you're not gonna have the serratus anterior functioning properly. Um And that's essentially, it is gonna mean that that scapula is not gonna be, be able to be held flat against a rib cage and essentially, it's gonna be winging out. Um So that's what you'll see is uh you'll, you'll see bringing out of the, of the scapula. Um You've got the pectoralis minor muscle, you know, this will originate from the third and the fourth uh rib um and will attach to the cortico process and the main function of this is to stabilize the scapula. So, if you think about this, this is gonna, it's gonna be attaching to the scapula and just look at the orientation of the fibers contraction wise it's gonna be bringing that scapula again towards the rib cage and also gonna be bringing it down, isn't it? Look at the, look at the orientation. Um So it just helps you with kind of just think about the orientation of fibers and it'll help you with the movement and you don't really have to remember it then. Um and that's innervated by the medial pectoral nerve. So moving on to the elbow. So we're gonna be just focusing on the proximal end because the distal end we really talked about in the previous lecture. So, most important thing to, to remember here um with the proximal end, you've got that radial head that we were talking about, but that will articulate with the capitate um of the humerus. Um And then you've also got this radial tuberosity. So, remember we were talking about the, the bicep muscles, so the bicep muscles will actually insert into that um tuberosity. So it's, it's a very important um point to remember, you've also got the ulna. So with the ulna again, that articulation point that we were talking about the trochlear notch, I was gonna articulate with the trochlear um of the humerus. And you've also got the electron here a very important aspect. And just if you, if you just recollect, that's actually where the triceps insert to the triceps will insert all three heads will insert into the electron. Now, with the joint itself with the articulation. So, remember the articulations you are, you'll remember those with the, the capitate, the trola. Um Also remember that these are these articulation between the two bones, the radius and the ulnar. And that's the, the proximal radial ulnar joint. Ok. So if you also remember ligament wise, two important ligaments to remember would be the ulnar collateral ligament and the radial collateral ligament. Um Now with, with bursa, I'm I'm sure you guys know what it is, but essentially, they're just fluid filled sacs that just act to kind of lubricant, the joint um and lubricant move um allow ease of movement really. Um And there's many in the elbow, but one to be particular um to be particularly aware of is the subcutaneous electron on bursa. So they, they really like to ask about this one. just because it's, it's quite uh superficial to the skin. Um It can cause bursitis essentially um with irritation um of that bursa over and over again. And we'll have some questions that would kind of focus that focus on that. So now moving on to the brachial plexus, so essentially a brachial plexus, a collection um of all these nerves, um they connect with each other and they come from these five roots C five to T one. Now, really exam wise, all you really need to know is each of these nerves know the main function, the main motor innervation um but also know what roots they're coming from. So the, the way we remember that um or the way I remember, I should say, um it's quite a common um acronym. So it would be, it would be the, the five musketeers. Um So we go five for musketeers and that would be, and if you, if you, if you kind of uh comment on C five from your thumb, five, C six, C seven, C eight T 15 musketeers. So the musculocutaneous nerve would be from C five all the way to T one. That's the root um assassinate but um is the axillary nerve. So the roots C five to C six assassinate five mice uh again, C five to T one which is be the median five rats, C five to T one which is the radius, uh the radial nerve um and two unicorns. OK. So that's your uh C eight T one which is be your ulnar um your ulnal nerve root. So quite um self explanatory. So you understand that? Yeah, sub cardia, they are here. OK? OK. Daniel. So yeah, we talked about radial, the radial, the ulnar um and the median nerve really more discussed in the previous lecture. So we're just gonna fo focus on the musculocutaneous and the axillary nerve in this, in this uh lecture. So, as we said, um uh three musketeers. So C five C six C seven. So that's the nerve root for the musculocutaneous nerve motor innervation is the BBC. OK. So, the the anterior compartment of the arm. So the biceps brachialis, a quote brachialis, muscle, um and sensory innervation um is a lateral cutaneous nerve of the forearm. So again, just look at the words itself. It's, it's easy to tell really what part of the skin is innervating. Um the lateral cutaneous nerve of the forearm. So it's the skin of the anterior lateral aspect of the forearm. All right. So no axillary nerve. Um So, assassinate axillary nerve, C five C six um motor innervation years, the deltoid and the Teres minor. So they also really like to ask about the axillary nerve. So because it's not that um that surgical neck, we were talking about the humerus, it's quite um at risk of being uh being fractured and then causing issues with the axillary nerve. Um So again, if you know the function of these muscles, you can kind of figure out what would happen if this muscle was, if this uh nerve was uh damaged. Sensory innervation is the upper, upper lateral cutaneous nerve of the arm. Um And if you, if you remember from the previous lecture, we were talking about the lower lateral cutaneous uh which would be by the median. Um but this is the upper lateral cutaneous and that's over the lower deltoid. So we're going to talk a bit about blood supply. We'll go through this quite quickly, but essentially with blood supply, again, quite quite self explanatory. So you've got the subclavian vein. Um uh sorry, the subclavian artery. Um and you've got obviously your left common carotid, you've got your brachiocephalic and then you've got your right subclavian and your right common carotid. But just thinking about the arm, just think about what structures is passing. So, after you have the left, we'll just think about the left subclavian in this, in this uh example. So the left subclavian is gonna go down to the axillary, that's your axilla. So the axillary artery then going down into your kind of bicep region, your brachial artery then splitting into the radial and the arnal uh uh ulnar artery and then going into the digital arteries um at the hand. All right. So we'll talk a bit more in detail about each one. So with your axillary artery, all you really need to remember is that, that remember that subclavian artery we had once it passes, once it gets to beneath all of this is the first rib. So once it gets to that first rib, it's then renamed the axillary artery. And the with uh all all the things to do with the axillary artery um are relative to the pectoralis minor muscle. So, you have three parts. Essentially, you've got the first part which is um which would be uh sorry, uh proximal to the uh the pectoralis minor muscle. You've got the second part which would be posterior and the third part which would be distal. So we got a bit, a good um a good uh picture here. So here you can see you've got the pectoralis minor muscle here. So remember 3rd, 4th rib attaching to the corticoid process. This is the axillary nerve here. Where's the first rib? The first rib is right there? So, really behind, behind all this is the left subclavian artery. Once it gets to this point right here, it's known as the axillary artery. And you see that right there, OK. Now, there's many branches of the axillary artery. You don't really need to know um all of them, one I would pay um particular attention to is the circumflex, um circumflex artery. So you've got your anterior and your posterior and you can see here how it wraps around um the humeral neck and head. So it's very important here. Again, remember when we were talking about fractures of the um of the, of the surgical area, um This blood supply can be uh can be uh interrupted. So if you're gonna have to, if you're gonna remember one of these uh these branches is a circumflex branches. Ok. So the anterior and the posterior. So no, as as we're moving down now, so the auxiliary artery has now become the brachial artery and that happens once it gets distal to the there major. Um Now, only thing to remember with the brachial artery really at this stage is that there's a deep artery um called the profunda brachial or just the deep artery of the, of the brachial artery and that artery. So, that's here. Right. That's profunda brachial right here. And that artery essentially will travel at the back of the humerus and it will travel along the radial nerve in the radial groove. So, I've got some pictures here to show you what's going on. So, we've got what this muscle right here. That's a, there's, um, that's a, there's major muscle right here. OK? And you've got the, um you've got the axillary nerve here and that's once it's past that muscle, now it's become the brachial artery. You see that, OK. So it's become the brachial artery and then that small um branch is a deep brachial artery. So that's the important one to, to remember and that's the one that they most likely ask questions about. So you in this picture right here, you've got that brachial that um that deep um brachial artery and that's going and traveling along um the radial groove. And just alongside that, you've got the red, uh you've got the radial nerve. So, again, important to know when you have midshaft fractures, you'll have um involvement of the radial nerve and ultimately, things like wrist drop. Um But also to know because they're so close together, the blood supply can be affected by it. Ok. Now, then once the brachial artery gets to the cubital fossa, then bifurcates now into the radial um and the uh and the ulnar um artery. So if you think about it again, um the radial artery is more the posterior. So all the posterior muscles are the radial nerve, aren't they? So the radial artery makes sense. So that's the the posterior lateral aspect of the forearm that will innervate uh that will um that will, that will supply and the blood supply of the radial artery. Um Now, with the ulnar artery, it's more the anterior medial aspect of the forearm. Um Yeah. And the last thing with the digital, with the uh the smaller hand branches, essentially, this, this was quite confusing to me actually. Um because it gives in the hand, there's a lot of anastomosis, there's a lot of like random branches. But really, if you just uh just make sure that you know that essentially a radial artery that will supply once it once it comes in. So the radial artery will actually come posteriorly at the dorsum of the hand will come over the anatomical snuffbox. OK. We'll give a branch to the thumb, we'll give a, a branch to the index finger. You don't have to know these branches really. Um And then we'll give the important branch you should know is the superficial palmar arch. OK? Don't know. Um And then it will continue as the deep palmar arch. So to know um if, if that's, that's the radial aspect and with the ulnar artery, um that will give rise to the deep palmar branch and then it will continue across the hand as the superficial palmar arch. Does everyone make, does that make sense? Um It confused me but maybe you guys understood it when I initially learned it. OK. Yeah, no one has any questions. Um But yeah, so essentially you got two, you've got two arches, you've got the superficial palmar arch and you've got the deep palmar arch branch, uh arch, sorry. Um And these muscles will have anastomosis between these, between these two. But just to remember them too. And then remember which gives off which OK. So here we've got a bit of a picture here. So here you can see you can see the deep palmar arch and this is the radial, this will be the radial artery. So the the deep palmar arch will come from the radial artery and that's coming down. Remember it's coming at the dorsum. This will be the, at the back of this will be the anatomical snuffbox and then it'll come around and then you've got the deep palmar branch. All right. And this here will be that branch we were talking about. That goes to the index finger if that makes sense. Now, here, this is the ulnar side, right? It's just the other side of this. That's what we're looking at here. You've got the ulnar artery here. This gives rise to the superficial palmar arch. And then this branch here, another one here, this branch here is the deep palmar branch of the ulnar artery that will connect with the deep palmar arch of the radial. If that makes sense, it's a bit confusing, but just look at diagrams. Um That's always, it always helps. Um OK, so we're gonna move to questions now. Um Oh, that, OK. So you've probably got the, I think you probably. So I think there's a question in the chart. Uh Yes. So the branch, the So, yeah. Yeah. So OK, let me go back. Do you have the pictures? So the palmar, there's a palmar arch and there's a palmar branch the way I like to think of it. There's the, the superficial arch and there's a deep arch, but there's the branches, the superficial branch and the deep branch are the branches that connect the other artery to the other branch. And that is, that probably doesn't help either. So if we just go, let's go through it again. Just one more time. So remember radial artery, dorsum of the hunt across the anatomical snuffbox gives rise to the deep palmar arch, right? Ulnar artery coming down into the, the uh the palmer aspect of the of the hand gives rise to the superficial palmar arch. But you've also got this superficial polymer bra uh deep polymer branch that will connect it, right. Look at what's happening here that will connect the branch will connect it to the deep polymer arch. So the branches connect the two Arches together. That makes sense. OK. Just, um, keep looking at pictures and stuff. OK? I hope that helps. All right. So we're gonna move to questions. You've probably seen the first answer, but that's all right. Um Anyway, so just, just one thing. And so basically guys, so this time we're gonna have polls. So you're gonna like, you're gonna call, uh, like, like five multiple choice questions. So I don't show you the question and you just pick a question, you know, answer you think, correct? OK. And then, OK, just let me know what everyone's answered. No problems. OK. All right. So Abdo Karim attended the emergency department uh after dislocating his shoulder while playing rugby, his shoulder was reduced in the emergency department and then put in a sling following this. The emergency department doctor tested for sensation in the regimental badge area, which was normal, which nerve is commonly injured during a dislocation of the shoulder joint. And the one in which the emergency department doctor was testing. So you got the radial, you got the muscle cutaneous, the median, the ulnar and the auxiliary. So put it in the pool of the cream. Let me know what's you've answered. Mm So, so far the 10 responses and a couple more seconds. So 54321 and so yeah, so majority uh or not majority heart percent. 50 a nerve. What did everyone say? Uh a nerve? Yeah. Good, good. Uh So yeah. Axillary nerve. Yeah. So, um yeah, so what we were talking about, remember the upper lateral cutaneous nerve of that arm, that branch will innervate the skin over the lower deltoid. And it's also known commonly as a regimental badge just because I guess that's where they put the badge in the army. I don't know. But, yeah, reg regimental badge. That's what it's known on. So good uh nice one. And yeah, with dislocation of the shoulder, um majority of dislocations of the shoulder are anterior dislocations. So, remember we were talking about where the axillary nerve goes. All right. Um So that, that dislocation of that shoulder, the anterior dislocation puts it at risk. So whenever you think of shou whenever you hear shoulder, um dislocation and a question at least, um think of axillary nerves. Ok. Next one. So Rian, a 55 year old accountant presents to the GP with a painful right elbow. He points to the medial epicondyle of the humerus. He does not recall any predisposing injury but describes exacerbation of the pain when using the arm which can extend into the forearm. This has caused him to stop playing golf. He is otherwise well and takes no medication from the history alone as particular diagnosis is, is it is suspected, examination supports this. Um it's a position that doesn't make any sense. What, what examination findings is most consistent with a suspected diagnosis. So, we've got quite a few here. So take your time. Think about what's going on. Movement wise of the cream. Let me know. Yeah, and no problems. Ok, so far, so we've got 80%. Uh, sure. Oh, sorry, hold on. Um, oh, a couple, a couple, couple more. It's only five response. So no worries, no worries. Take your time. How about now? So, no, we've got no responses but, uh, the majority, well, 44% saying, oh, it keeps changing because I think so far majority d the uh or the question number four. Number four. Yeah. OK. Yes, correct. So that's number four. So let's think about this. So, medial epicondyle, this is also known as golfer's elbow, right? Because I guess I've never played golf. But when you golf, it's the, the medial epicondyle. And if you think about the movement that you're doing. So if we know from uh previous the last lecture in this lecture today, um the flexor muscles they attach to the medial epicondyle, right? So this action here, all these, all these muscles, um the flexor muscles. Um Now any, any movement then, um that's gonna exacerbate the, uh the flexor muscles is gonna cause a worsening of these symptoms. So the way to answer this to, to be able to answer this question, uh you realize that um it golfers elbow, they're talking because you're talking about the medial epicondyle. You then think about what muscles and there do you know it's the, um mostly the flexor muscles, you then think of the, uh, and you, and you, at that point, you know that any, um, flexor muscle, um, movement is gonna make the, the, um, the condition worse. So, think about what movements flex, um, the flexor muscles of the forearm do. Well, it definitely is gonna cause flexion. Ok. It's not gonna be extension, it's gonna be flexion and then also, um, pronation because you've got things like the palmaris longus and the anterior aspect of your forearm that are responsible for uh pronation. OK. That makes sense. Yeah. Yeah. Yeah. OK. Anyone else have any more questions on the top? It's a bit of a diagram here. So medial epicondyle, all the anterior muscles of the forearm, all the flexor is gonna be attaching to that. So any movement, any flexion, any pronation is gonna cause that to be worse. So that's the examination finding you would sus uh suspect it'd be opposite with it if it was for the lateral epicondyle, which is also known as um tennis elbow because you know, OK, we've got a question. So in the chart. So it's saying is rest and creation um was an option if no, I'm I'm guessing uh it means a rest in was an option. Would that also be correct? What did he say uh f rest? And was an option? Would that also be correct at rest and disc? Yes, you mean? Yeah. Yeah, I think so. You can see in the chart. Uh If you open the, it's, if arrest and it was an option, would that also correct? Is she talking about what she's talking about? Ok. Yeah. But do you wanna, I don't know, clarify, maybe, I don't know. You can just see what the Yes, sir. So, I mean, yes, is flexed and super so supination. Yes, because there's some muscles that do supinate but it'd be, you would suspect much more pronation. I would say so in this, in this technically, yes. But um I would say it would just be pronation because you've got, you think about the overall, you've got Palmaris Longus there, there's a big muscle that's responsible for pronation. Supination. I would think more posterior. Yeah. No, no, you're fine. Yeah, that's fine. Yeah, no worries, you're fine. OK. Um Next one, a 41 year old presents man presents with left shoulder pain following a rugby injury. An X ray is taken what is shown on the X ray. So it's no ABCD but just have a look and um have a look what's going on and then maybe tell me maybe what has led to it, what kind of injury and you can just put in the chart if you want. So someone saying that location dislocation of uh dislocate. Someone else saying this lesion of the clavicle. OK. All right. II was saying, torn uh Carac clavicular ligament. OK? OK. Someone else saying a chro dislocation and someone else also some people say a chromar dislocation. Ok. Ok. Yeah. Good, good. So, I mean, uh, you can see, right. It's, uh, look at, look, look at the clavicle really. Look just if you, if you start, um, at the sternum here, clavicle goes all the way up here, doesn't it, it just looks off if you seen, um, have you seen a normal, uh, shoulder and, uh, x-ray. So, yeah, so this is a chromar joint injury. So you've got that ac joint, um you've got that, that's been disturbed, that's been injured and, and you'll have what's essentially is called the step deformity, um which the, the, the clavicle has just gone up. So, remember we were talking about the um the, the, the ligament um how that's connecting really the, the upper arm to that clavicle? Uh I don't wanna, yeah. So here we go. So the acromioclavicular ligament, um You've got there and that's been damaged, that's gonna just like kind of p up really um that, that clavicle and that's what's l this. Bye. OK. So next question, a 27 year old man attends the emergency department complaining of pain in his right arm. He explains that I came on suddenly while lifting at the gym. Uh and now his arm feels weaker than normal. An ultrasound of the upper arm indicates the presence of a tear in the distal biceps tendon. What movement is most likely to be affected? Ok. And thank you. For your movements. Thank you. Your muscles. Thank you. Attachments. Yes. OK. So, uh majority saying D or like uh after number four cation uh and elbow flexion it, it, yep. So c and flexion um pretty straightforward uh biceps. Uh the BBC muscles uh mostly responsible for elbow flexion, of course, uh and cation as well. All right. So don't forget the supination. Um Yeah. All right. Next one I think. Yeah. So after a fall at home, a 79 year old woman with a history of osteoporosis experienced a humeral shaft fracture in the distal third of her humerus due to landing on her outstretched left arm. What manifestation would align with the probable nerve palsy she likely experienced. So, just kind of, I we talked to. So you should all get this right? Oh, no way. I'll be quick. So a couple more seconds guys. Ok. So 54321 and so, yeah. Majority saying 75%. Uh answer number one. Let's drop. Iy, that's, that's the answer. So, distal humeral fracture, I remember we were talking about that radial groove. That's where the uh the radial nerve uh travels along um function of the radial nerve that innervates most of the extensor muscles, right? So, if you've got damage of that nerve, you're gonna have no more extension and you're just gonna have unopposed flexion. So that's why you've got um you've got too much flexion. So that's why you've got that wrist drop, pretty uh, self explanatory. Um Can someone tell me what muscle will then? So we're doing wrist drop, what muscle in the arm would also, uh, be affected just a little, uh, extra. So think about what muscles supplied, what, what uh, muscle of the heart, the nerve supplies just put in the chart if you, if you of the cream anyone put on. Um, so yeah, so is the exterior car, uh carpi ulnaris or radialis? Uh Yeah, but uh no, so the with, with uh maybe I asked her in the wrong way. Um So radio said someone said triceps as well. Yeah. Yeah, triceps. So just, yeah, I think a big your triceps. Yeah, that's, that's what I meant. I should have been clar clarified a bit more triceps. Yeah. So you're also gonna have a, a issue with elbow extension, aren't you? Because your triceps are finished? Ok. Next one, I think this is maybe the last one or maybe two more. Ok. So an injury to the spinal accessory nerve will affect which of the following movements? Ok, a couple more seconds and your last minute answers. Ok. 254321. Ok. Uh So the majority answer said, uh answer number two traction of the scapula. Ok. Fine. This is a bit of, this is a bit of a dodgy question because there's actually quite a few answers in here. So technically the, the um, so sorry, spinal accessory nerve we're thinking about one muscle, we're thinking about Trapezius muscle. So with the Tras trapezius muscle, it does help with protraction on the scapula. It does also help with the up upward rotation and it also does help with the auction of the scapula. But the most maj the majority of movement um with the scapula and the trapezius muscle is upward rotation of the scapula. So that the shrugging of the uh of the traps will cause the upward rotation mostly. But to be um because it's a, it's a bit of a dodgy question because number two and number four are also correct, but much less so than upward rotation. That's the main movement. OK. Yeah. OK. It was, it was the 2nd 2nd best answer. So and on the chart anyways, what do you say to that? So the, the most common answer was number two. But then the, the, the, the one after that was the right answer to it. A bit of a sneaky one, I'll ad but fair enough. But yeah, as well as OK. A um next one. So a 35 year old patient presents with pain and swelling in the elbow joint after experiencing a direct blow to the posterior aspect of the elbow. On examination, there is tenderness and swelling over the electron on process, which of the following conditions is the most likely diagnosis. So just guys, uh also, while I'm answering, we sent in the chart um the link for the feedback. So just in case anyone needs to go, uh the feedback is there. So we just do uh we love to hear what you, what you thought about the session. But yeah, for the guys, yeah, just uh you can fill out a now or later but uh it's there for uh for you. Yeah, please do guys. Please do help us out. Yeah. And I think we just in terms of that uh question seven. So the majority uh said it's answer numbers. Uh answer C bursitis. Good, good. Yes. So yeah, that's the, that's the correct answer. So remember we were talking about the um the bursa and the elbow. Um Essentially you've got that inflammation of that bursa and uh most likely it's due to trauma. So think of your, a few of your other answers. So your um you're gonna have golfers elbow, your tennis elbow. That's more with repeated stress, more with more re repeated movement. So just the, the clinical picture and the clinical history as I should say. And the question is more pointing you towards the bursitis point of view. Um Yeah. OK. So I think I might. Oh, no, no more. Ok. So a seven year old boy presents to the GP with arm problems after falling from a tree during which he caught a branch to save himself on examination. He has a claw hand with a hyperextended wrist. What nerve roots have been damaged. In this patient. So no ABCD just put it in the chart on bonus points if you could tell me what type of injury this is. Mm So someone's saying intrins minus. Mhm So what what nerves have been damaged now? Someone, so someone saying radio, someone else saying C 56 or seven. All right, a couple more. You have all the big hill. OK. So uh someone else said ulnar nerve C eight T one. OK. Yeah. Think about, think about your um your a, think about the nerve effect and think, think about your nerve roots. Remember the five musketeers um assassinated five months, five rats, two unicorns or you should, should we give it a bit more time now? No. Yeah, I think uh it's not, it's, it's just uh continuous. Uh So answer. Yeah. OK. So um the answer is tt one. So with this question, 1st, 1st step is to find out what nerve is affected. Now, you can see that he has a claw hand. Um Now the claw hand is a uh is a that term um is known for being associated with an ulnar nerve injury. OK. That's what leads to that kind of claw hand. Um because the intrinsic muscles of the hand, OK. In particular, the medial lumbrical and the interosseous muscles are not working. And the the function of the lumbrical muscles is to do extension of the interphalangeal joints. If you've got no extension, it means you have too much flexion. Therefore, you have claw hand right. Now, you've also with the ulnar nerve, you also have innervation of the FDP, the flexor to deum profundus and flexor carpi, ulnaris. Now, it's in the name, what the, the function of those two muscles are to flex. Now, if you, those muscles are not working because we've got ulnar nerve injury, we're gonna have too much extension, right? Because you've got no flexion or, but you do have flexion in the, I mean, you don't have flexion in the ulnar side. So it's gonna be much more hyperextended. So that's so you've sorry, so you've, you've, you've uh realized it's uh uh ulnar nerve entry, then you go with your five musketeers assassinated, five mice, five rats, two unicorns. So your unicorn as your ulnar nerve and your roots are therefore C eight T one. And then for bonus points, this particular injury and kind of the, the history of it is a so is known as a, is known as a particular injury. So does anyone know that? What's it called? Ok. That's fine. So it's called, it's called Clumps injury. Ok. So this is a, so with, um, if you've ii with um I think we did in a lecture once, I think um I can't remember, I think it was one of the lectures I can't remember who did it, but it, with brachial plexus, you can have ebs palsy or you can have this type of clumpy injury. Um And essentially what this, this usually happens when a, a person's uh particular Children um when their arm is abducted um and kind of and pulled. So it ha you see it quite happen quite often in, in Children who have had a bit of a traumatic delivery um during childbirth or in like breach position. Um and what's happening really, you're just pulling on that brachial plexus and you're causing damage to the C eight T one. So you'll have, as we mentioned, you have paralysis of the, the ulnar aspect of the intrinsic hand muscles and your FDP and your flexor carpi ulnaris will be, will, will be effective. OK. And then with your erb's palsy, you have like wait or tip sign. Um So, yeah. OK. I think that is, I think just before we finish this, uh someone asked if you think you go back to question five, I think it was sure but it uh scapula. Um Yeah, it was the upward, not the next one. Sorry as well. No. Well, I know that was the one that the um the trapezius, if it was er if the accessory nerve was injured. Uh What is it? Yeah. So that one, yeah, I was asking is upward rotation of the scapula the same as elevation. Yeah. So uh actually if we go to the first, it's a really good uh can you see here? Uh Yeah. So with your, yeah, with your upward rotation and your elevation, um they're different as an upward rotation kind of comes outwards and elevation come, comes, comes upwards straight up. But the trapezius muscle will do both. OK. If you think of it, when you're, when you're shrugging your shoulders, your arms naturally come out as well. So your, your scapula at the behind, so it comes up up upwards as well. Um So what I would say with the, with the trapezius muscle, most uh the biggest um uh movement would be upward rotation. And then you have, you have a lot of other things going on as well. You've got retraction. Um You've got depression with your, with your inferior fibers and you've got elevation as well with still those, those anterior fibers. But most I would say majority of it would be upward rotation. That's the main uh movement. Yeah. OK. So I appreciate it. Everyone. I hope um the questions weren't too difficult. Last time we got some feedback that the questions uh were a bit perhaps uh too difficult. So, uh hopefully these ones are a bit more um better. Um If you find that they're too easy, too hard, um whatever, just let us know and we'll try to make the next session better, but I appreciate everyone coming. Um Please do fill out our feedback forms that really helps us. Um Thank you. Yeah. So, yeah, like I said, so, thanks and thanks everyone for attending. Um Yeah, like I, like, I, like I said, feedback is the way, the way we know how to improve and what to, you know, uh what works, what doesn't work for you. Um, and the other thing is, um, the slides and the recorder will be available like you to the same length. So the same length you joined this meeting from er, after meetings done. If you join, join back, you may take us until this evening to do. But, um you know, if you check back later this evening or maybe tomorrow at my latest, we will have the recording up along with the slides. So, but yeah, thanks for joining and uh hope to see you all next week uh for the third session and also just a, a reminder if you guys are. So, you know, if you guys are interested as well, we've got, er, some other events happening. Um So, uh we've got the, on, on Sunday, we've got like a limbs and back m secure crash course, like, but mostly M secure. Um So I will uh this teaching with that everyone has been giving you like this week and last week will help. Uh And you know, so just a question based uh rather than like teaching. Um So if you want, if you guys want to attend, uh check our socials go some, like other events lined up. Uh But yeah, otherwise I'll see you all next Thursday. Uh Same time. Uh and that will be for the hip and knee. Yeah. All right, I appreciate thank you. Thank you. Have a good evening. Ok, do you know? Ok, I the cream I appreciate you. Oh, he's not here. I said I appreciate that. I'm gonna go now. Ok. Yeah, no problem. Thank you so much. Ok, bye-bye thank you and send me, send me the feedback we will do uh. Ok.