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Oh, good. I'm just having a look because, you know, I'm sorry. Um, it was a really nice consultant. Don't get me wrong, But I wasn't expecting to take a half hour for each patient. Um, so I just got massively dilated, right? That's what I don't know if I've managed to figure it out. Yes. No, Maybe I should be. Oh, so Well, good. I'm really sorry. Can you see now? Oh, yes, yes, yes, yes, yes, yes. Okay. One of us manage to do it. Uh, I'm very sorry. Can you I can see you. Well, I can, um, hear you well as well. Uh, let me just see if anyone it's coming up. Oh, we have some viewers. What time, people? Just give it a couple more minutes. Mhm. Okay, um, thank you very much for, um for those of you who joined up today, my name is 40. I am one of the colleagues for the Anatomy series. Along with Oscar today. We're very lucky to have Ms Sharkey, who is currently in registrar in trauma orthopedics at Leeds General Infirmary. So thank you very much, Miss Miss Sharkey, for giving us this presentation on upper limb anatomy. I really hope you do enjoy it. Please. If you have any questions, please do, um, asking the chat and we'll get them answered. Um, either probably at the end of the session, to be fair, um, and yeah, feel free to, um, to chip in any any. Any thoughts or anything. Thank you, Mr Hanky. And over to you. Thanks, sweetie. So you're my name is Sam Sharkey. I'm one of the registrar's and leads General Infirmary, and I'm very grateful to be asked to come and speak to you today about upper limb anatomy, which is obviously a subject which is very important in orthopedics. Um, so the names of the session really is just to give a bit of an overview on upper limb anatomy going through bones and joints, neurovascular structures and muscular compartments along the way. It will be, I think, more interesting if we just sort of discussed how that's relevant clinical practice because I don't know about anyone else, but I find anatomy a little bit dull sometimes when I've not got any sort of reference to it and a bit hard to remember. But when I've got some sort of clinical setting, and I find it much easier. Um, upper limb anatomy is a massive topic, and every single part of the upper limb could be like a few a recession on its own. So definitely what we won't be going into, um, brachial plexus, because that's a huge topic. Um, other things that people are thinking about doing MRCS to be aware of is just about some spaces and intervals that we won't really discuss, especially around the Axilla, um, and the extensive compartments of the rest, which are really important but that we're not going to touch on today. And so we may as well just start from the top. So thinking about the clavicle as their first bone of the upper limb, Um, it's an S shape bone, which usually we tend to split into thirds when we describe it. When it fractures, 80% of the fractures will occur in the middle third, and that's because it's the thinnest part of the bone, and it doesn't have any ligamentous attachments, which makes it more vulnerable to injury. Um, clavicle fractures always tend to be quite displaced, and they're always more or less displaced in the same way, and that's just because of the muscular attachment and where they pull things. So the lateral end or the distal end of the clavicle will be displaced by both the weight of the arm and the pool of Peck Major. And the medial end is always displaced caudally. And that's from the pool of Sternocleidomastoid. Um, it has two articulations, and the one on the medial aspect or the proximal aspects will be the the the sternum. So Sternoclavicular joint, Um, and then on the other end, distally you've got the acromioclavicular joint. The coracoclavicular ligament also comes from the clavicle. So there's two parts to that ligament, the carcinoid and trapezoid ligaments, and they attach to the coracoid typical and the trapezoid Typical. Um, respectively, what you can see here, I'm not sure if you can see my cursor, but hopefully, um, I'm not going to go into too much more detail about the clavicle. But if you're ever asked about it or you're having to consider what structures could be at risk and trauma to the clavicle or, um and the approach to the clavicle, then the main structures that you have to consider would be super clavicular nerves. Subclavian vessels the apex of the lung, which sits behind um, and the brachial plexus as well, and the scapula is the next one that would be considered part of the upper limb. It's a triangular shape bone, and it has four main bony prominences, or processes that we tend to describe, So the spine of the scapula sits in the posterior aspect of the glenoid is the socket part of the ball and socket joint of the shoulder, which most of you will be aware of. The chromium is a process which comes posteriorly up towards the front, and you can feel it on yourself. So if you run your fingers slowly up your shoulder, you'll feel a little dip, and that tends to be one side of the chromium. And if you run your finger across your clavicle, you'll feel another dip, which tends, which is the acromioclavicular joint The coracoid processes. The other thing that's worth mentioned again. You can feel that on yourself just by coming down from your chromium and pressing and and you'll feel something which almost feels like a thumb stuck out forward. And that's your coracoid process. There are a lot of muscles attach to the scapula, and it's quite complex, and it's the origin or insertion of around 18 muscles. But we're not going to go through those, Um, and if it's injured, it's associated with any other injuries in about 80 to 95% of cases. And that's just because, usually to sustain a scapula fracture, then it's a high energy mechanism and often is associated with thoracic trauma as well. So the shoulder joint itself. Usually when we talk about the shoulder joint we would describe that were describing the glenohumeral joint. But if you ever asked to examine the shoulder, then you should always consider a sternoclavicular joint. And a SI joint is part of that, too. Um, the majority of the movement at the shoulder. The Glenohumeral is the glenohumeral joint movement, but around one third of it is movement of the scapula thoracic region, and that's just to allow for a better range of motion. Overall, you can perform full circumducting with the shoulder, and that is a combination of different movements, so forward flexion extension, abduction, adduction and internal and external rotation, which together will complete your circumducting. Um, stability is quite important, um, and every joint. And there's different ways of describing that. The shoulder is a place where it's asked about more often because it's quite easy to classify so you can talk about your static restraints and dynamic restraints. Static restraints will include the Glenohumeral ligaments, the labrum, which in itself accounts for about 50% of the socket depth of the glenohumeral joint. The articulation and joint capsule themselves also confer a little bit of a stability, although they are quite lax compared to some other joints. And that's just to allow for the greater range of movement, Um, and then the negative intraarticular pressure. So that's sort of suction type pressure that you have in the joint. So I'm not sure how many of you have been theater, but things like in a total hip replacement as you dislocate the hip joint, you can hear that noise of the suction as it's pulled out, and it's similar to the shoulder as well. Um, dynamic restraints. The main one is the rotator cuff muscles, which will go through but also long head of biceps tendon, which comes down from the supraglenoid typical. So the rotator cuff muscles are a high yield topic for questions around anatomy or for examination. Um, so it's worthwhile knowing and it's quite straight forwards. And once you get your head around it, really, Um, there are four muscles, so the first one is super Spinatus, and that's probably the one that, clinically you will encounter. Most often arises from the super Spinous fossil, which is superior to the the spine of the scapula and attaches to the greater tuberosity of the humeral head. Um, it's innovated by the super scapular nerves, so that's quite easy to remember and is involved in the initiation of abduction, and its action is isolated up to around 15 degrees of abduction, at which point the deltoid will assist. That's quite common to see when people have either super Spinatus impingement underneath the knee joint or if they have a super Spinatus tear, which is probably the most common rotator cuff tear that we see. Infraspinatus is the next one, and that comes from the Infraspinatus spine is fossa, which again is quite easy to remember. It's attachment is also to the greater Tuberosity, and it's innovation is the same as supraspinatus, so super scapular nerve. And that's involved in external rotation. Subscapularis sits on the anterior aspect of the scapula and the sub scapular faucet again, quite easy to remember this time, because it's on the anterior aspect attaches into the lesser tuberosity and that's supplied by the upper and lower sub scapular nerves and is involved in internal rotation of the shoulder. Um, Terry's minor is the last one, and that's just arises from the posterior surface of the scapula. Attaches to the Greater Tuberosity and assists with external rotation alongside infraspinatus. It's supplied by the auxiliary nerve. And clinically, it can be difficult to tease out the actions of both Infraspinatus and Terry's minor. And so, for the purposes of um, examination, it would be reasonable to say that it was an injury to either infraspinatus teres minor or both. The proximal humerus is the next thing to come down to. So the bony prominences in the proximal humerus, which are of notes, would be the greater tuberosity. Um, this is the attachment, as we mentioned for super Spinatus at the Superior facet infraspinatus in the Middle Facets and Teres Minor in the inferior facet. Um, that's again of clinical relevance, because what you may find is that someone can have an isolated, greater tuberosity fracture. And if you consider your attachments of your muscles and where they'll be pulling against this fragment of bone, then you can see that if you don't properly mobilized someone with a greater tuberosity fracture, then that fragment may either migrates anteriorly with super Spinatus. Or it may go around the back of the humerus from the external rotation action of Infraspinatus and Teres Minor or a combination of both. And that may mean a patient needing surgery when before they could have been managed operatively lesser tuberosity as the attachment point for subscapularis, as we've mentioned, um, and the other things on the diagram just to note, is the difference between the anatomical neck and the surgical neck of the humerus. Um, anatomical neck could be in the area of the old Fyssas um, or the area of the faces and the child, and the surgical neck is more where the head makes the shaft. And where are we with the clinical relevance again? And that the axillary nerve wraps around that point? Um, in order to try and determine where that is on yourself, if you take your hands breath bed just down from the chromium. And that's around the level that we would expect the axilla, the nerve to be found. The blood supply to the proximal humerus is mainly through the proximal humerus, a proximal humerus circumplex artery, and that's the posterior one, and that's main blood supply. However, you also get a contribution from the ascending branch of the anterior humeral circumflex, and that is known as the accurate artillery once it penetrates the humiral head, Um, and as mentioned, the most common associated injury would be axillary nerve injury. At that point of the humerus, the shaft of the humerus, um, laterally. You could find the deltoid tuberosity, which describes a rough and surface where the deltoid attach is anteriorly. You'll find coracobrachialis deltoid ridiculous and brachioradialis that will go through those plus the really you'll find the triceps and then on the shaft. Also, there's an area called the Spiral Groove or the radio groove. This is a depression which just runs diagonally down the posterior aspect of humorous and in which the radial nerve and profunda baker artery will lie. And again that's important when you're thinking about fractures of the shaft of the humerus. Um, it's an area where the nerve if you imagine it's running, such as this fracture running through the spiral groove, and then there's, um, an injury there, then it can either be damaged at the time of injury, or if you try to reduce that fracture, it can become caught inside the fracture site. So it's important to always make sure that you have a thorough assessment, particularly the radial nerve. And these fractures. Distal humerus again has many bony prominences for areas that we describe theirs to epicondyles, the medial epicondyle and lateral epicondyle, with the media being the larger the to um, this is described as a common flexor origin, and it's closely associated with the ulnar nerve and that the ulnar nerve travels directly posterior to the medial epicondyle. It's something which you have to be very aware of if you're doing any operations around the elbow and particularly it describes, and super consular fractures of Children, and I hope that you can see my cursor. But the super consular fracture would be around this area here, and and in order to fix it, we will put wires across the fracture site and sometimes that involves a wire, which comes up from the medial epicondyle to the lateral aspect of the distal humerus. If that's the case, whilst on the lateral side you can go percutaneously with your wires, and you don't have to worry too much with the medial side, it's recommended a national guidelines that you use what they call a mini open approach. You just make a small incision and take your clip or your scissors all the way down to bone to make sure that there's no structures in a way, and namely, that the ulnar nerve isn't going to get caught up in your wire. Um, lateral epicondyle is the common extensor origin between that and the Superconductor Ridge, which is just above the lateral epicondyle. That's where your extensors will arise the other areas of notes as the electron fossa. And that's just essentially a space on the distal humerus to allow the election process to move into when your elbows in flexion and extension the chocolate, which makes up the main part of the the elbow joint and then on the anterior surface. Again and again, you can see the trochlea. You can see the coronoid fossil, which just allow space for the coronoid process. Inflection. The radio fossil, which allows space, the radial head in flexion and the capital Um, which makes up the humerus part of the radiocapitellar joint. Um, so again, just thinking about why we need to know this and what? Why is it important in our clinical practice day today? So one point, maybe about the use of kettle, which I'm sure you're mostly aware of. And essentially, that's the order of the ossification centers in the pediatric elbow. It does not ever deviate from that. It will always come in that order. So it's really important that you know where those structures are expected to be found so that you can try and determine at what stage of ossification the patients are. Um, the reason why that's important is because, for example, you may have a child and you look at the elbow X ray and you can see they've got a capital. You can see the capital. Um, you can see the radial head and you can see the lateral epicondyle, but you can't see any of them any of the others. And that would mean that that lateral epicondyle. What you thought was a growth plate is actually a factor. And and a child at that age, what would appear to be a tiny fracture in the lateral epicondyle can actually be very significant because you can't see the majority of that epicondyle. So the whole lot is probably off. And the other reasons why it could be important is when you're actually just looking at a radiograph and you're trying to see if there's an injury. You may want to use the anterior human line, which is the top left. You can see the red line, which runs down the anterior aspect of the humerus, and it should intersect in the middle third of the capital. Um, on the other hand, and the radiograph, which is underneath, if you follow that line down from the anterior aspect of the humerus, it's just skirting across the front of the capital. Um, but not in the middle third. So there is an injury there. Even if you can't see it, you know that it must have some sort of a cult factor on the other side of the radiocapitellar line, which is labeled anyway. Um, and that is just a line up through the radio neck and head and into the capital. Um, and on the second one, you can see that if you follow that line up the radial neck, then you won't intercept the capital. Um, and that means the radial head is dislocated. And it's really important to remember to do that because there are times when someone has a factor. You go and you try to manipulate the fracture, and then you get your check, actually, and you're so focused on looking at the fracture site. And if you've managed to adjust it nicely that you forget to look at the radio ahead and and people have been and continue to be sent home with Radiohead, dislocations for that reason. So it just sort of And that's just a slide to show you the humanist in itself, um, and all the different areas from the proximal humanist, the distal humerus, which hopefully we've gone through all of them already. So moving on to the elbow joint, um, the elbow is made up of two articulating surfaces, so you have the trochlear notch of the ulna and the trochlea of the distal humerus. Um, and then you have the radial head in the capital, um, of the distal humerus. The proximal radio ulnar joint is found within the elbow joint capsule, but they're often considered is often considered separate from the elbow joint. Um, the ligaments, which hold that in place would be the radio collateral ligament, which goes from the lateral epicondyle and then blends in with annular ligament and the lateral ulnar collateral ligament, which goes from the lateral epicondyle to the super later crest of the proximal ulna. And those two ligaments together make up the LCL complex, and the ulnar collateral ligament is gone. From the medial epicondyle to the coracoid processing the olecranon. Where's the annular ligament? Runs around the proximal radial ulnar joint, particularly in the head of the radius, Um, sometimes and people that have radial head dislocation, that annular ligament can slip into that space between the radial head in the capital. Um, and that may be why you end up, um, unable to fully reduce your radial head closed and have to open it up to just get the annular ligament out the elbow. Joint itself is a hinge joint, so it allows reflection and extension extension is mainly by triceps and anconeus and inflection by brachialis biceps breaking and brachioradialis. The movement of pro pro nation and super nation is actually from the proximal radial ulnar joint, as opposed to the elbow joint itself. And then this actually just shows you the various points that we have already discussed. The posterior compartment of the upper arm and the main muscle in that compartment, and the only muscle really in that compartment is triceps. It has three heads and, as the name suggests with the long hair is coming from the upper glenoid typical. And the lateral medial head's coming from the posterior surface of the humerus, both above and below the level of the spiral groove and with the and that sort of order so lateral above. Media below, they attach onto the olecranon process, are elevated by the radial nerve and are involved and elbow extension on the diagram. You can also see anconeus there, but that will be discussed later because it's considered part of the compartment of the program. On the anterior surface, you have three muscles, so biceps brachialis and coracobrachialis, which you can remember as BBC um, the origin of biceps as two heads again is the names just so long head coming from the supraclinoid typical and the short head from the chronic process, Um, they attach onto the radial tuberosity and are innovated by the muscular, cutaneous nerve as all of the nerves and the anterior compartment of the upper arm. The action of biceps is elbow flexion, forearm, super nation and assisting with shoulder flexion. Ridiculous. It's underneath biceps, and that is coming from the media and lateral surface of the humeral shaft and attaches onto the ulnar tuberosity that's involved in the elbow flexion as well. And coracobrachialis, which comes from the coracoid process to the medial humiral shafts around the level of the deltoid Tubercle um, that is involved in shoulder flexion but can also act as a week A doctor of the shoulder, the ulna. If we move down to the forearm now as the stabilizing bone of the forearm and has again many boney landmarks, we've discussed most of them. So the election process, which is what you can feel on the back of your elbow coronoid process, which is the little tip at the front of the Trochlear notch. It's just in red here. So just at the point, um, the chocolate or notch itself the radial notch, which is where you get your proximal radial ulnar joint and that will nurture curiosity. Um, which is your attachment point? As we discussed, um, the distal ulnar is much smaller in diameter than the proximal ulna. And and the main part there that you consider is the distal projection, which is known as the ulnar styloid process and that most people can feel and their own wrist, and that articulates with the ulnar nerve of the distal radius to form the distal radius ulnar joint. It's important to just consider this proximal and distal radial ulnar joint because sometimes when you have a fracture in either of the bones, that can give rise to specific fracture patterns where you also have joint disruption. So Montedio variants describe proximal ulnar fractures where when you alter the length of the ulna because the radius and ulna are attached, that will cause the radio radio head to be dislocated. Um, galaxy fractures were similarly, you have a distal radius fracture which has caused the ulna, which is longer because it's not being shortened by fracture and to be dissociated from the distal radius at the distal radio on the joint. The radius is the second bone and forearm, and it pivots around the ulnar. And that's what gives you your pro nations pronation super nation. Um, there's four sites of articulation on the radius, so you have the radiocapitellar joint, the proximal radio in the joint. That's the radial ulnar joint and the radio carpal joint, which is essentially your wrist joint. Um, approximately the point of note is the radial head, radial neck and radial tuberosity, which is your insertion point for your biceps. And that's where, um, for in the distal biceps repair. And then distantly, you also have a radial styloid, which you can feel it yourself. But it's not usually as prominent as the ulnar styloid process. So if you consider the normal anatomy of the rest and why, where that might be important and the position of the distal radius is really important and decision making around surgery for distal radius fractures, there's lots of different points to it, but particularly the radial height, inclination and Palmer teas are really important. Um, so radial inclination would describe the sort of angle that you can see in the first picture and down from the radio styloid to the radio on the joint, and normal would be around 23 degrees. But we would accept plus or minus five degrees for that. Radial height is the height from the, uh, from the radial styloid down to the distal ulnar, and that is usually around 13 millimeters. But we can accept less than five millimeters, so essentially sort of 8 to 13 would be acceptable. Um, Palmer Till is probably one of the more important ones as well. Where if you consider a lateral view of the distal radius, then you your thought might be that neutral is good, but actually the distal radius. It's at an angle of around 11 degrees towards the palm of the hand. Um, so a distal radius, which is neutral, is actually not not normal. But we can accept less than five degrees of dorsal ambulation, and most patients will obviously you have to take the patient's individual characteristics into consideration, so the anti your forearm can be split into different compartments so it can be split into superficial, intermediate and deep compartments. So the superficial compartment I know this side is a bit wordy, but I think you've got access to the slides after. So I thought it might be helpful to put that on. You've got from all the, uh, the ulnar side to the radial side. You've got flexor carpal Maris f see you and that attaches to the medial epicondyle or originates sorry from the medial epicondyle and the olecranon and attaches into the peace of form hook of the same. And the base of the fifth metacarpal is innervated by the ulnar nerve and is involved in flexion and reduction of the rest. And that's just because adduction, if you remember your anatomical position will be with your arm fully supine. So adduction refers to, um, move in the hands. Elderly, um, Palmyra's longest is the next one along, but it's only present around 85% of people. It's more common for it to be absent absent in women than it is men. And some people say that it's a marker of evolution, and I quite like that because I don't have one. So I I like to go with that reason. Um, the origin is the medial epicondyle again and attaches into the flexor. Retinaculum is innervated by the median nerve, and it contributes to get strength by allowing flexion of the hands at the wrist level. And if you were to try and yourself to try and lift something, you'll notice that when you go to grip something, you tend to flex your wrist and your much stronger with your wrist flex than with extended. And so that's why the flexion of the wrist is contributing to grip strength. But that said, people who have an absolute Palmyra's longest haven't been found to have a significantly different grip strength. And equally, those who have a Palmyra's longest tendon used as a graft don't have any deficit after that. So how much it contributes is a little bit debatable. Um, flexor carpi radialis. So fcr is the next one along that is, from the medial epicondyle to the base of the 2nd and 3rd metacarpal, is innervated by the median nerve and is involved in flexion and abduction of the wrist. So, in that case, moving radially, that's another really important intending to be aware of, and you can see it in yourself or in patients by bringing your thumb and your fourth finger together and flexing the wrist, and you can feel a tendon, which becomes quite prominent when you do that movement, and that's fcr. The reason why it's so important, or of how why it's so relevant is because that tends to be our approach for a plating of the distal radius. So you'll feel for the patient's fcr, and then you'll make an incision directly on top of it to find the tendon. Um, and then that way you know where all of your relevant and asked me would be donator. Terry's is the next one along, and it's more proximal so that comes from medial epicondyle and coronoid process and attaches to the mid shaft of the radius again, innervated by the median nerve and involved in combination of the forearm. As the name suggests, the intermediate compartment and sometimes can just be classed as another part of the superficial compartment. Um, the median nerve and the ulnar artery actually passed between the two heads of the flexor Digitorum superficialis the FDs, which is the only muscle found in that compartment. Um, and the tendons of FDs also travels through. The carpal tunnel originates from medial Epicondyle and the Radius. As I mentioned, it has two heads, and it attaches to the middle phalanges of all four fingers. It's innovated by the median nerve, and it flex is at the MCP J P I PG and at the wrist, the deep compartment. Next we will find flexor digital and profunda. So FDP, um that is originating from the ulna and interosseous membrane and that attaches to the distal phalanx of the four fingers. Um, I usually remember. That is, that's the deep one. So it's distal, and that's how I tend to remember the difference between the two. That innovation is a little bit more complex. So the radial half so. Therefore, the tendons, which go to your index and middle finger, are innovated by the median nerve and more specifically by the anterior interosseous nerve, which is a branch of the median nerve. And another way of remembering that is just obviously, anterior Interosseous is just describing where the nerve is, so it sits on the anterior surface of the interosseous membrane. Therefore, it's deep, and therefore it will innovate, flex their digital and profundus. The ulnar half is innervated by the ulnar nerve, so your ring finger and little finger that's involved in flexion at the MCP J So metacarpal phalangeal joint and the D. I. P. G. And at the wrist. F P l is the next one that you'll find and that and that's originating from the radius and interosseous membrane and attaches into the base of the distal phalanx of the thumb again that's generated by median nerve and specifically the i N and it involved in flexion of the Inter Phalangeal joint and the metacarpal phalangeal Joint the Thumb. And then P Q is the last one, which arises from the volar surface of the distal ulnar and attaches onto the volar surface of the distal radius. So that's just a little square muscle sitting in here and green, um, innovated again by the I N and is involved. Inflammation of the forearm is another important point that you'll come to when you're doing your distal radius plating, so you'll get down through your through your muscles and tendons to find P. Q. And then you have to strip peak you off the distal radius to get yourself access on to the bone. The posterior forearm is made up of the extensors except the Brachioradialis, which is part of the posterior forearm compartment but doesn't act as an extensive. And all of these are generated by the radial nerve, and this can be split up again and too superficial and deep compartments. So superficial compartment has brachioradialis, which comes from the lateral supracondylar region to the distal radius, and that's involved in elbow flexion rather than extension. Um, extensive carpi, radialis longest and brevis are considered together here, so the longest comes from the lateral Supracondylar bridge and brevis from the lateral epicondyle. However, I think if you said the lateral epicondyle for both, you probably would be fine. Um attaches onto the 2nd and 3rd metacarpal and is involved in extension and abduction at the rest. So again, just remembering that this is carpal radiologist. So it's going to move to the radio side, which is abduction. E. D. C. Is your next muscle and that is originating again from lateral epicondyle, but this time into the extensive hoods of the fingers and is involved in extension at the MCP J and at the I pee joints of your fingers. Extensive digital enemy is another extensive, which is specifically for the little finger. So it comes from, um, the lateral epicondyle and potentially from part of extensive digitorum communists as well. UM attaches onto the extensive good, just the little finger and is involved in the extension of the little finger and wrist E. C. You come from lateral epicondyle to the base of the fifth metacarpal and is involved and extension and adduction of the wrist. And then anconeus, which we've seen earlier, is coming from the lateral epicondyle to the lateral surface of the electron and posterior surface of the proximal ulna. And that's involved in assisting with elbow extension, particularly the extremes of extension. Um, it acts as an elbow joint stabilizer and does assist with pronation. Overall, though it doesn't contribute a huge amount, and actually, sometimes it can be part of anconeus can be taken off and mobilized so that you can then cover metal work over the olecranon, and that just helps to give a bit more padding between your metal work and the skin to stop skin breakdown. It's not routinely done, but it's an option if you need it, um, posterior forearm. So the deep compartment have super later, which comes from the lateral epicondyle and the posterior ulna, uh, with its got to head. So that's why it's got two different origins and attaches onto the posterior radius and, as the name suggests, is involved in Super Nation abductor policies. Longest is from the interosseous membrane to the base of the first metacarpal and is involved in abduction of the thumb as names. Yes, extensive policies brevis from We're moving sort of from the ulnar side to the radio side, and that's interesting membrane and posterior surface of the radius. But this time in the proximal phalanx of the thumb. And that's involved an extension of the MCP J and the CMC joint of the thumbs of carpal metacarpal joints. Extensive policies longest. So EPL is quite an interesting tendon and that, um, it travels from the interosseous membrane to the posterior surface of the ulna to the distal phalanx of the thumb, but takes a bit of a turn around to the typical in the distal radius, and that allows it to have just a sort of pulley effect, which makes it a bit stronger and and it leads to extension of the CME, C J P M. C P. J. And the Inter phalangeal joint of the thumb. Um, E P. L is one of the commonly injured attendance and distal radius fractures or fixations, and that could either be from the fracture itself. It could be from your drill when you drill through from the front of the radius, so volar side and then you get through your second cortex. You may catch E p l on the back the drill. Or if you leave screws, which are too long, then that can just rub and rub away at E P. L. Every time the patient moves their thumb and they may end up with a rupture later down the line. Extensive and this is appropriate is just an additional extensive tendon for just the index finger, so that attaches into the extensive hood of the index finger. Um, the hand bones are not really going to go into much because it's very straightforward. You've got three phalanx and each of your fore fingers to for Alex on the thumb metacarpals. You've got one per finger, and then your capital bones will go through. So the carpal bones, um, there's loads of different acronyms for this and there is some which are PC and so much aren't I prefer this one because I can see it in front of anyone and I don't have to worry. And so I've always remember that I stopped letting those people touch the cadavers hand, so that's going from the left of the skin to the right, and then back to the left again before you start so scaphoid. Let me, uh, get you a piece of form trapezium, so thumbs trapezium, trapezoid, capitate and hamate. The carpal tunnel is definitely worth mentioning because again, it has a lot of clinical relevance. And it's a high yield topic, and exams and the floor of the carpal tunnel is made up of bones were made up of the carpal arch laterally. It's bordered by the scaphoid and trapezium tubercles, and then immediately it's bordered by the hook of the hamate and peas form. The roof of the carpal tunnel is created by the flexor retinaculum, and it's entrance. If you look at yourself at the distal um, wrist crease, then that's the entrance of the carpal tunnel. Contents of the carpal tunnel as 89 tendons and one nerve. So four FDP tendons for FDs, tendons and then f p l. And, as I say, your median nerve. The Palmer Cutaneous branch of the median nerve. However, it comes out before the carpal tunnel, and therefore in carpal tunnel syndrome, you'll have sparing of sensation on the palm, but not on the Palmer's surface of your fingers. Thena Eminence is your next sort of muscle bulk in the hand, and it's made up of the muscles, all innovated by the media nerve opponents policies, which is involved in the opposition from the typical of the trapezium to the radio margin of the first metacarpal abductor policies. Longest a doctor policies brevis. Sorry, Um, is from the scaphotrapezial again over to the radio margin of the proximal phalanx, and that's abduction of the thumb. And then finally, flexor pollicis brevis, which again is from the trapezium, the typical of the trapezium to the base of the proximal phalanx and his reflection, Hyposthenia eminence is innervated by the ulnar nerve, and that's your muscle belly that you can feel just on the palm next to your little finger. Um, opponents Digit Um, enemy is the first muscle, and and that's from the hook of the hamate to the medial margin of the fifth metacarpal and again is involved in opposition. Then you've got abductor Digital Enemy Um, which arises from pizza form and part of FC You Tendon and goes into the base of the proximal phalanx of the little finger and flex the digital enemy Brevis, which is again from the hook of the hammock to the base of the proximal phalanx of the little finger, and is involved infection. Your other intrinsic hand muscles to be aware of is your lumbar ankles, which there's four of them. 21 pair finger and they originate from the FDP tendons. They pass dorsally and laterally around each finger, and then they go into the extensive hood. Uh, they're innovation is the same as FDP, which is unsurprising because that's where they originate from. So the radio, too, with the median nerve and not only to from the ulnar nerve, and they lead to a reflection of the MCP G and extension at the I PG. So that's this position, which is also known as you're reading proposition or safe position. The intimacy I There's two groups of them, so you have Palmer and or so. And I remember that as pad and dab So, Palmer and to us a lead to adduction of the fingers. And if you think about where your muscle would have to be in order to facility adduction, you can see that they would only really need to be three palmer interosseous because the middle finger doesn't require one because all of the other fingers are coming in to meet it. Um, dorsally, you have abduction of the fingers and therefore you have four, um, enterocele I they originate from each of the metacarpals and again go around to the extensor hood and proximal phalanx of the same finger. Um, and again, the deflection of the MCP GI. An extension of the I P. J. Tomorrow's brevis is just a small, thin muscle. It just wrinkles the skin so you can get more of a curve in your hand infection. And that improves grip strength as we discussed before. And that's when everything by the ulnar nerve, um, and a doctor policy. So the big triangular muscle in the middle of the hand through which there's two heads and through that the radial artery will pass to form the deep Palmer Arch and the first head originates and the third metacarpal and the other from the capitate in the 2nd and 3rd metacarpal. And that leads to adduction of the thumb and again is generated by the ulnar nerve. Um, the vascular structures have not going to do too much, but the diagram sort of sums it up. So if you think all the way from the left ventricle of the heart, your heart set slightly to the left, so it's your blood vessels have to travel further on the right side. So you have an extra trunk there. So you've got brachial Catholic trunk, which goes the right subclavian, right, axillary right ratio at the level of the elbow. That then becomes the right radial ulnar arteries, which I'm sure you've all seen before. An access before. Maybe, geez, they. Then you form an anastomosis, which is a superficial and deep palmer arches, and that's the basis of your islands test. And that forms each of the common digital arteries. And it's the same on the left side, except from you don't have a break of Catholic trunk go directly to the left subclavian. The nerves are probably the most clinically relevant. Um, for I mean for neurovascular nerves. That's what we tend to see, and you have to really be aware of where they are. Trying to avoid them when you're doing approach is obviously to avoid iatrogenic injury. So exhilarating Nerve originates from C five c six Nerve roots, and that's from the possible records of the brachial plexus travels posterior to the auxiliary artery, and anterior two subs cap um, It then goes to the surgical neck of humorous when it divides into its terminal branches. Um, motor function of the axillary nerve includes Terry's minor and deltoid Um, and sensory function is the skin over the lower deltoid, which is also known as Regimentally badge area, because that's where officers would have their badge on the uniform. Um, so any time that you see particularly shoulder dislocation, you should test axillary nerve function because that can be associated. So you want to feel over that area of scan and see if the sensation is intact. Water function is very difficult when someone has a shoulder dislocation there in a lot of pain, but sort of sensory functions intact, and that's usually enough document. However you may wish to put your hand over deltoid and ask them to abduct and just see whether you can feel any sort of twitch of the deltoid muscle that might suggest and motor functions also intact. Muscular, cutaneous nerve is the next big nerve in the upper limb. So this is from C five c seven. Um, that's a terminal branch of the lateral cord of the brachial plexus and emerges at the inferior border of Pectoralis Minor. And it leaves the Exelon and goes into coracobrachialis, which it supplies and then passes down the flexor compartment of the upper arm. Superficial tuberculous. But beneath biceps, um pierces the deep fascia lateral to the biceps tendon, um, and brachioradialis and then continues into the forearm when it becomes all, uh, exclusively sensory supply. The lateral cutaneous nerve of the forearm and motor function is biceps breaky brachioradialis and particle. Very callous. Um, I'm sorry. Um, and, uh, we've already been through those already. Uh, the median nerve, um, is see 61 nerve roots and is derived from the media and lateral cards. Uh, its course. So it travels lateral to the brachial artery and then crosses immediately halfway down the arm. Uh, it goes into the anterior compartment before and via the Cubital fossa in the elbow and travels in between F d, P and F. D s. Uh, at this point, it gives off a i n and the plumber cutaneous branch, and that's both before entering the carpal tunnel, and then it divides into its terminal branches motor function we've already been through. But this is just a reminder. If you're looking at the nerves specifically and you know the sensation is, uh, the Palmer Aspect of the Palm and also the Palmer aspect of the radio. 3.5 digits, which is really interesting. If you ever get a chance to see a patient with the median nerve injury that you can look at either side of the ring finger and it will be different. There's two main sites of injury or compression, and that can be at the elbow or within the carpal tunnel, although obviously it can be damaged at any point along its course. Um, the clinical signs will be what's called the hand of benediction, which is seen in the picture. Um, and that's due to, um, the loss of motor innovation, which leads to super nation ulnar deviation and week flexion of the wrist. Um, you tend to have loss of sensation over the median nerve distribution, but the palms spared and carpal tunnel. And we've discussed why, um, you'll see wasting of the frontal eminence, and they also have associated signs of a I an injury because it's a branch of the median nerve. So anti your interosseous nerve comes from the central aspect of the median nerve around 4 to 6 centimeters distal from the elbow and runs on the interosseous membrane between the radius and all that between F, d, P and F d l. Um, as we've discussed it, supplies half of F, d, p, f, p, O and P Q. And that means that patients are not able to make an okay time because they can't flex there. I pee joint of the thumb, and they can't flex their d I P index finger. So when you ask them to try to do it, you have to be really careful. They're really making a circle, and they're not doing what's seen in the second picture, which would be a sign of an AI in policy radial nerve, um, is derived from all nerve roots of the brachial plexus. So C 5 to 81 it comes from the posterior cord that PSA rises in the axilla posterior. So the axillary artery exits and fairly through the triangular space, which is one of the spaces we've not really gone into. Um, it descends down the arm, and the radio crude, as we've discussed, enters the forearm through the Cubital Fossa Terminating Institute. And she's your deep branches, the posterior and interosseous nerve, which runs in the posterior aspect of intraosseous membrane. And that's, um, motor nerve. And then the superficial branch, which is your sensory branch. We've been through motor function, so it's the extensors that it supplies and sensory wise that supplies the posterior aspect of the forum. And hand signs of palsy again will depend on the level of the lesion. And there's three main areas where that may happen. So the axilla is your typical Saturday night. Palsy have fallen asleep over something and has pressure in the axilla on the radial nerve, and those patients will have a wrist drop, will be unable to extend at the elbow either, and they'll have loss of sensation across the entire radial nerve distribution of the arm. If it's injured in the radio grooves, that's when you think about factors. You have weakened elbow extension, but it won't be lost entirely. Uh, they will have a wrist drop, and they won't be able to extend the fingers either, and have normal sensation of their upper arm but not lost on the forearm in hand. The forearm. You can have, um, superficial branch that can be affected. And that will mean lots of sensory supply to the hand and then the posterior interosseous nerve, which is your motor. So you have lots of extension to the fingers. But crucially, you won't have a wrist drop because that innovation has already come off. Sorry. Um, the ulnar nerve is from C one C A. T. One. It's from the media. Word comes down. The medial aspect of the upper arm passes posterior to the medial epicondyle, where it's at risk, and then Pierce is the two heads of F. C. You traveling deep to this and gives off It's three main branches. It travels it professionally to the flexor retinaculum, which is important because although it was over the rest that doesn't go through the carpal tunnel. Instead, it goes through genes canal and then gives rise too superficial and deep branches. We've been through the motor function, and your sensory function will be the sensation to the other half are part of the hand. So essentially your ulnar 1.5 digits and then the associated it is in the pan. And the ulnar nerve paradox is something which is often brought up in exam settings as well or in clinical practice. And it really just describes the fact that normally if you have a lesion which is more proximal and therefore knocks out more muscles, that you would expect the deformity to be worse. However, an ulnar nerve palsy, the more proximal lesion, the lesser the deformity clinically, when you're looking at the patient. So if you consider that approximate lesion, um will allow you to flex your best because you have, um, Fcr, Um, but it means because you're using fcr, not F. See you. Then you'll have radio deviation. With that, you'll lose the ability to add up to add up the fingers. A movement of the 4th and 5th digits and the thumb will be impaired. You have positive Lhermitte's sign, which is seen in the top picture. And essentially, that's when you can add up to hold abduct to hold your bit of paper. So instead you flex your thumb to try and grip it. So it's not a normal adduction, and you can see that and the patient's right hand in this photo, and you have lots of sensation over your entire ulnar nerve distribution. With the distillation, you tend to have an owner called Hand Again. You've lose adduction and abduction of the Fingers. You have a positive Lhermitte's sign, but because you have unopposed, you've got FDP. But it's unopposed, and then you'll have this clot hand appearance, and that's from the loss of your lumbrical the ulnar side. But FDP is still flexing because your forearm, uh, innovation comes off before your level of injury. Um, and you have loss of sensation to your media. 1.5 fingers, but not the associated palm areas. That is quite a lot of information. Um, I wasn't sure about the format, whether you guys would want anything interactive or not. A lot of the time at this time of night. People don't really want to interact, But there's a couple of resources there that I used when I was studying for my exams. Teach me anatomy is very straightforward. Most of the diagrams where this came from teaching anatomy, but it is still good. Um, Ortho Bullets is another thing, which is really helpful. Um, and does go through some anatomy Ackland video at this Ken Hub and the funky professor videos. All right, resources, particularly at plans for the MRCS and then going to theater, I think is one of the best things. Because as you go through approaches, you ask people to point stuff out for you. And once you remember case you remember an approach, then you're more likely to remember where, particularly nerves and vessels are running. I'm sorry. That was very much me talking. But if anyone has any questions or anything, I'd be happy to answer or my email address is there. So if you've got questions you don't want to ask, then you can email me instead. Thank you so much, Miss Jackie. Um, I think I got a couple of things coming up from the child. Everyone's saying thank you. I just have a quick question. If you don't mind, it's when it comes to compartment um, Syndrome. So obviously we have, um, in compartment syndrome. There are increased pressures within within these compartments. And so when you're assessing whether someone has an anterior compartment and normal posterior compartment and etcetera, how what what sorry movements would you do to to to figure out which compartments being, um affected. So I think that what compartments affected is probably not really that important. If you have a patient who has significant pain, it's not settling with reasonable analgesia, especially in the context of trauma or crush injury. Um, then you're probably already thinking compartment syndrome before you even get to the point of actually moving their arm. Um, I would probably say that when you go there, then try and touch them. They will hit the roof regardless of what you're doing. But if you try to flex and extend, then you may find that the passive stretch causes or unless it's a bit more pain. All of that is like greatest academic. And, um, if you're considering, it could be compartment syndrome and getting to the point of thinking what compartments affected probably just should be arranging to take them to the theater. Because realistically, when they go to theater, you will release all the compartments. And you don't just released the affected one. So it doesn't really make that much of a difference that your decision making also both like so both anterior posterior upper and lower would be opened up. So no upper and lower forearm than you would do both front and back. Same with upper arm. And you would do it would release all compartments. It's the same with the lower leg as well as lower limb. You release all compartments the only variation that maybe like the thigh, or sometimes you might not go all the way immediately because it can be difficult and high risk. Thank you very much. Um, any questions on the chat were getting really good feedback. So thank you so much, Miss Jackie. Um, yes. There will be a feedback from, um I will send it right now. Hopefully, you can all see it. Um um, any anatomy slash or speculated questions? If not, we can always call it a day. Um, this recording video will be recorded it has been recorded. Even so, it will be available for you on metal. And the slides have been put up as well. So you should be able to access the slides. So if you can all please complete the feedback form, that will be really appreciated. Thank you very much and sorry for someone wanted to come to my door. I'm sorry. That's fine. I'm just ignore that. So thank you so much, Doc. I think we can call it, um and yeah, once again. Thank you very much. Bye bye.