Upper Limb

contents of the carpel tunnel

Flexor pollicis longus Flexor digitorum profundus (4) Flexor digitorum superficialis (4) Median nerve

power supination of the forearm + elbow flexion

biceps brachii

flex the elbow no matter whether the forearm is PRONATED or SUPINATED

brachialis

"workhorse FLEXOR of the elbow"

brachialis flex the elbow no matter whether forearm is pronated or supinated

what makes up the boundaries of the cubital fossa?

brachioradialis pronator teres brachialis - floor bicepital aponeurosis - roof inside: median nerve brachial artery---> radial + ulnar artery radial nerve--->superficial (cutaneous) deep branch (muscular)

the ulnar nerve and artery cross the wrist in a much more superficial passage called the

canon of guyon

of the pollex is a SADDLE (SELLAR) joint...facilitating the rotary movement known as OPPOSITION

carpometacarpal (CMC) joint

What is inside the triangular space?

circumflex scapular artery (complex anastomosis)

all 3 heads of pectoralis major insert where?

common tendon to the proximal humerus greater tuberosity

What is Saturday Night Palsy and Barstool Neuropathy or Crutch Palsy?

compression of radial nerve against proximal end of humeral shaft (within triangular interval)

Minor adductor and flexor of the glenohumeral joint

coracobrachialis

Assumes responsibility for ABduction beyond the first 20 degrees

deltoid

what membrane plays a critical role in 1) transferring forces from radius to ulna 2) providing surface area for deep forearm muscle attachments

interosseous membrane

fall on the lateral side of the outstretched hand leads to fx of what bone in the floor of the anatomical snuff box leads to avascular necrosis of the bone?

scaphoid Such a fall may also lead to ANTERIOR DISLOCATION of the LUNATE into the carpal tunnel

what only two carpal bones articulate with the distal forearm of the wrist?

scaphoid + lunate

scapulothoracic protraction (abduction)

serratus anterior pectoralis minor

Supraspinatous and the bursae which protect it are vulnerable to inflammation and wear & tear leading to...

subacromial bursitis

superficial palmar arch + deep palmar arch is normally the continuation of

superficial - ulnar artery deep - radial artery

What innervates the infraspinatus and supraspinatus?

suprascapular nerve (C5, C6) *arise from the TRUNKS

"spurt" contraction initiates abduction of arm at glenohumeral joint

supraspinatus

static contraction of this muscle resists the pull of gravity on the upper limb

supraspinatus

what kind of joint is the distal radioulnar?

synovial pivot

What makes up boundaries of the quadrangular space? What's inside of it?

teres minor long head triceps surgical neck of humerus teres major posterior humeral circumflex artery axillary nerve

The most profound effect of carpal tunnel syndrome will be on the function of what muscles at the base of the thumb?

thenar muscles

innervates latissimus dorsi

thoracodorsal nerve (C6, C7, C8) - latissimus dorsi *arise from POSTERIOR CORD

flexor carpi ulnaris and the medial half of flexor digitorum profundus are innervated by the ______nerve, arising from ________cord of the brachial plexus, and containing fibers arising from the ______Ventral rami

ulnar medial C8-T1

nerve responsible for stretching or tearing resulting from anterior glenohumeral dislocation

axillary nerve

vulnerable to destructive lesions resulting from fracture of the surgical neck of the humerus

axillary nerve

Innervates deltoid, teres minor, skin over the lateral arm and the glenohumeral joint

axillary nerve (C5, C6)

innervates both the deltoid and teres minor muscles

axillary nerve (IM injections)

If the cubital tunnel is narrowed by full elbow flexion for prolonged period of time such as excessive cell phone and sleeping in flexion....

1) Paresthesias over small finger and ulnar half of 4th finger and ulnar dorsum of the hand 2) Paresis, if it occurs, may affect many functions of hand, including finger abduction, thumb adduction and pinching of thumb & forefinger

scalene triangle is formed by 3 things...

1) anterior + 2) middle scalene 3) first rib

The "elbow" includes three joints within a common fibrous and synovial capsule

1) humeroradial - btw radial head + capitulum 2) humeroulnar - btw trochlear notch of ulna + trochlea 3) proximal radioulnar - btw radial head and radial notch of ulna

what ligament is limited by.... 1) ulnar deviation 2) radial deviation

1) radial collateral ligament 2) ulnar collateral ligamnet

muscles arising from 1) radial burse 2) ulnar bursae

1. FPL 2. FDS + FDP

Carpal tunnel syndromes include 1. ____ pain 2. Parasthesias in palmar digits _____ 2. Discomfort exaggerated by prolonged flexion or extension (e.g. sleep flexion) 4. ____ atrophy - "ape hand" 5. _____ weakness- can't pinch or hold cylindrical objects 6. Loss of fine motor activities due to decrease in proprioception

1. Wrist pain 2. Parasthesias in palmar digits 1-3 3. Discomfort exaggerated by prolonged flexion or extension (e.g. sleep flexion) 4. Thenar atrophy - "ape hand" 5. Grip weakness- can't pinch or hold cylindrical objects 6. Loss of fine motor activities due to decrease in proprioception

pectoralis major 3 divisions and origin

1. clavicular 2. sternocostal 3. abdominal

1) innervates the pectoralis major muscle 2) innervates both pectoral muscles

1. lateral pectoral (C5-C7) 2. medial pectoral (C8-T1) *arise from the LATERAL + MEDIAL CORD

1. Innervates subscapularis and teres major 2. Innervates subscapularis

1. lower subscapular nerve (C5, C6) 2. upper subscapular (C5, C6) *arise from POSTERIOR CORD

Summary of the Brachial Plexus (ventral rami of 4 spinal nerves) C5-C6 : proximal shoulder muscles C7 : elbow + wrist muscles C8-T1: distal (hand) muscles misc: "nursemaid's elbow" : cylindrical instead of tea-cup shaped in adults = dislocation of RADIAL head

5 Roots (collateral branches) Dorsal Scapular (C5) - levator scapulae + rhomboids Long Thoracic (C5-C7) - serratus anterior *RT wing scapula 3 Trunks (collateral branches) Suprascapular+ nerve to Subclavius (C5, C6) Supraspinatus - *subacromial bursitis and Infraspinatus 6 A/P Divisions = flexor/pronator + flexor Anterior = lateral + medial cords Posterior = posterior cord 3 Cords (collateral branches) 1. lateral lateral pectoralis- pectoralis major (C5, C6, C7) 2. medial - both pectoral major + minor medial pectoral (C8, T1) medial brachial cutaneous (C8, T1) medial antebrachial cutaneous (C8, T1) 3. posterior lower subscapular (C5, C6) ---subscapularis + teres major upper subscapular (C5, C6) - subscapularis thoracodorsal nerve (C6, C7, C8) - latissimus dorsi 5 Terminal Branches via posterior cord - 1. axillary nerve (C5, 6) - deltoid, teres minor, GH joint 2. radial nerve (C5, T1) - all muscles of posterior arm + forearm *is vulnerable to compression against either: The tendon of latissimus dorsi Or The proximal end of the humeral shaft SATURDAY NIGHT PALSY; BARSTOOL NERUOPATHY via lateral cord- 3. musculocutaneous (C5, C6, C7) - anterior compartment of arm via medial cord 5. ulnar nerve (C8, T1) - 1 and ½ muscles of the anterior forearm, all but five intrinsic hand muscles, and the skin of the medial 1 and ½ digits *FRACTURE OF THE MEDIAL HUMERAL EPICONDYLE via medial + lateral cord 6. median nerve (C6, C7, C8, and T1) all but 1 and ½ anterior forearm muscles...5 intrinsic hand muscles, including thenar muscles at the base of the thumb, and the skin of the median palm and lateral 3 and ½ digits *SUPRACONDYLAR FRACTURE

site of shoulder separation vs dislocation injuries

AC joint - shoulder separation GH joint - shoulder dislocation/subluxation (adhesive capsulitis / frozen shoulder)

pectoralis major function

Adduction + Internal Rotation Flexion (clavicular + sternocostal end) Assists respiration

Breast carcinoma commonly invades these ligaments, causing their contracture, which may dimple the skin when the patient is in the upright position

Connective tissue partitions called Suspensory (Cooper's) Ligaments extend from the pectoralis major fascia, through the mammary layer, to the deep surface of the skin The lymphatic drainage of the breast is directed primarily towards the AXILLARY BODIES

What is referred diaphragmatic pain?

C4 = shoulder pad area

nerve that innervates subclavius arises from....?

C5-C6

What fibers innervate the proximal (shoulder) muscles?

C5-C6 ventral rami

tapping this tendon elicits a myotactic reflex demonstrating the integrity of the C7 spinal cord segment

C7

What rami innervates elbow and wrist muscles?

C7 intermediate ventral rami

What fibers innervate the distal (hand) muscles?

C8-T1 ventral rami

A fall on the oustretched hand may also produce a COMPLETE TRANSVERSE FRACTURE OF DISTAL RADIUS with displacement and/or angulation of the distal fragment dorsally called

COLLES FRACTURE

Roofs the carpal tunnel Maintains the concave transverse carpal arch Receives insertion of palmaris longus Provides surface area for the origin of both thenar and hypothenar muscles

FLEXOR RETINACULUM aka the Transverse Palmar Carpal Ligament

dislocation of what carpel bone leads to carpal tunnel syndrome?

DISLOCATION of the LUNATE compresses the contents of the carpal tunnel

latissimus dorsi function

Extend Adduct Rotation medially (EAR)

T or F Tenosynovitis of Digital or Ulnar Bursa may lead to median nerve compression in the carpal tunnel

F Ulnar and Radial Bursa

Within the sheath, the ___ tendon splits (Champer's Chiasm) to allow the ____ tendon to insert on the distal phalanx

FDS FDP

As they cross the MCP joint, _______ tendons will be surrounded by both synovial and fibrous flexor sheaths

FDS and FDP

the muscles and tendons of the rotator cuff help to maintain the integrity of what joint?

GH joint

What is scalene interval / thoracic outlet syndrome?

Hypertrophy or Pathology of NVB bundle... 1) roots and/or trunks of the brachial plexus 2) subclavian artery Sx include: 1) cool, pale upper limb w/ diminished pulses 2) sensory and motor deficits in upper limb (particularly distal extremities)

ALL participate in ADDUCTION of the limb.

LATISSIMUS DORSI TERES MAJOR SUBSCAPULARIS

passes thru a muscle of the arm, CORACOBRACHIALIS, as it descends toward the elbow

MUSCULOCUTANEOUS NERVE

PROXIMAL RADIOULNAR joint along with the distal radioulnar joint and the syndesmosis (interosseous membrane) between the bones, permits...

PRONATION and SUPINATION of the forearm

brachial plexus has 11 collateral branches (Real Texas Drink Cold Beer) 5 Roots - pre-plexus lesions 3 Trunks 6 Divisions 3 Cords 5 Terminal Branches - post-plexus lesions Which ones innervate Supraclavicular vs Infraclavicular?

Roots and Trunks- Supraclavicular structures lying deep in the neck Divisions and Cords- Infraclavicular structures found in the axilla

what is is the most commonly injured part of the rotator cuff?

Supraspinatus 1) stable fx with no replacement 2) avulsion fx of greater tubercle of humerus = most common in elderly following a fall

4 "Rotator cuff" muscles

Supraspinatus - initiates ABDUCTION - doesn't rotate anything Rotators: Infraspinatus Teres Minor Subscapularis

T or F The Ulnar NVB does not pass through the carpal tunnel

T Ulnar NVB enters the hand more superficially through the "Ulnar Tunnel" aka "Guyon's Canal"

What is referred cardiac pain?

T2 = medial aspect of upper arm

Proximity of the long flexor tendons in WHAT TUNNEL makes for efficient movement but adhesions from tendon sheath infection or inflammation are problematic, forcing the finger into flexion- TRIGGER FINGER?

The FIBROUS FLEXOR SHEATHS attach to bone to form an OSSEOFIBROUS TUNNEL

Within Guyon's Canal, the ulnar nerve divides into superficial and deep branches

The SUPERFICIAL BRANCH of the ULNAR N. has an almost exclusively cutaneous distribution (except for the palmaris brevis) The DEEP BRANCH has a purely muscular distribution to intrinsic hand muscles

the forearm is divided into 2 osteofacial compartments

anterior : wrist flexors extrinsic digital flexors protonators posterior wrist extensors intrinsic digital extensors supinator

What ligament is cylindrical as it surrounds the radial head but is tea-cup shaped in adults and resists subluxation and dislocation of the radial head?

anular ligament Greater diameter superiorly Smaller diameter inferior

Resists dislocation of the radial head Serves as a joint surface for pronation and supination

anular ligamnet

The nerve is vulnerable to lesion with a fracture of the surgical neck of the humerus

axillary nerve

the smaller ulnar styloid enables greater wrist adduction or abduction?

adduction

Scapular rotation is required for ________and _________ of the arm at the "shoulder" beyond the initial 20 degrees, with a 2:1 ratio of glenuhumeral to scapulothoracic movement

abduction and flexion

right "winged" (medial) scapula is a result of

destructive lesion of long thoracic nerve resulting from trauma to the lateral thorax or mastectomy that weakens or paralyzes serratus anterior

What accepts 80% of the weight transfer form the hand across the wrist?

distal RADIUS >>>> distal ulna

What bone only articulates directly with the bones of the carpus (pronation and supination)?

distal radius

What innervates the rhomboids and levator scapulae?

dorsal scapular nerve (C5) *arise from ROOTS

Tricep major function

elbow extension

the cubital tunnel lies between the medial epicondyle and olecranon, roofed by the humeral and ulnar heads of what muscle?

flexor carpi ulnaris

inserts on the distal phalanges of digits 2-5 and flexes the DIP joints

flexor digitorum profundus

An extrinsic flexor of digits 2-5, ____ inserts on the middle phalanges and is primarily responsible for flexing the PIP joints

flexor digitorum superficialis

intermediate forearm layer contains only one muscle

flexor digitorum superficialis

flexes the thumb

flexor pollicus longus

deep layer contains 3 muscles:

flexor pollicus longus flexor digitorum profundus pronator quadratus

musculocutaneous nerve arises from _______cord containing fibers from _______ventral rami. Normally innervates then pierces the ________muscle. Supplies the muscles of the ______compartment of the arm and ends as the _________nerve

lateral C5, C6, C7 coracobrachialis anterior lateral antebracheal cutaneous

What ligament stabilizes the joint against varus stress, resulting from application of force to the elbow from the medial side?

lateral (radial) collateral ligament

shoulder adduction/extension (against resistance)

levator scapulae rhomboids latissimus dorsi pectoralis minor

the aponeurotic origins of FCU are referred to as the

ligament of osborne

Within the bicipital sulcus, what muscle is subject to frictional stress despite its synovial sheath and may develop TENDONITIS? Vigorous contraction may cause rupture or dislocation out of the sulcus...

long head of the biceps brachii

What innervates the serratus anterior?

long thoracic nerve (C5, C6, C7) *arise from the ROOTS

innervates subscapularis + teres major innervates subscapularis only

lower subscapular (C5, C6) - subscapularis + teres major upper subscapular (C5, C6) - subscapularis

3 collateral branches of posterior cord

lower subscapular (C5, C6) - subscapularis + teres major upper subscapular (C5, C6) - subscapularis thoracodorsal nerve (C6, C7, C8) - latissimus dorsi

What is the strongest elbow ligament, stabilizes the joint against valgus stress, reulting from application of force to the elbow from the lateral side?

medial (ulnar) collateral ligament

what is the most common site of venipuncture?

medial cubital vein

Site of attachment of the common flexor tendon giving at least partial origin to the five muscles of the superficial and intermediate layers of the anterior forearm

medial humeral epicondyle = overuse injury affecting the flexor-pronator muscle origin at the anterior medial epicondyle of the humerus MEDIAL EPICONDYLITIS "GOLFER'S ELBOW" (often associated with cubital tunnel syndrome)

What nerve is vulnerable to injury in 1. A supracondylar humeral fracture 2. Between the heads of pronator teres 3. Under the flexor digitorum superficialis 4. Deep to the flexor retinaculum at the wrist in the carpal tunnel

median

all but 1/2 muscles of the anterior compartment of the forearm are innervated by the ______nerve arising from the ________and _______cords of the brachial plexus and containing fibers arising from ____ventral rami

median medial and lateral C6-T1

innervates all but 1 and ½ anterior forearm muscles...5 intrinsic hand muscles, including thenar muscles at the base of the thumb, and the skin of the median palm and lateral 3 and ½ digits

median nerve

supracondylar fracture may lesion what nerve?

median nerve

Innervates the three muscles of the anterior compartment of the arm and continues distal to the elbow as the lateral cutaneous nerve of the forearm

musculocutaneous nerve

superficial layer of forearm contains 4 muscles:

pronator teres flexor carpi radialis palmaris longus flexor carpi ulnaris

all muscles of the posterior compartment of the arm are innervated by the ______nerve, a branch of the ______cord of the brachial plexus, containting fibers dervied from _______ventral rami

radial posterior C5-T1

the muscles of the posterior compartment are innervated by branches of _________nerve, a branch of the _______cord of the brachial plexus, containing fibers arising form __________ventral rami

radial , posterior, C5-T1 ventral rami

attaches inferiorly not to bone to the anular ligament

radial collateral ligament

What is nursemaid's elbow?

radial head subluxation/dislocation often in children due to cylindrical and not tea-shaped anular ligament

The nerve is vulnerable to injury: 1) In the triangular interval 2) In the radial groove 3) As its deep branch passes under the tendinous superior border of the supinator (Arcade of Frohse)

radial nerve

exists the axilla through the triangular interval with the deep brachial artery

radial nerve

nerve that is vulnerable to compression against the tendon of latissimus dorsi

radial nerve

nerve that is vulnerable to lesion with a midshaft humeral fracture within the spiral groove

radial nerve

Innervates ALL muscles of posterior arm and forearm and has an extensive cutaneous distribution to the posterior arm, forearm and most of the dorsum of the hand

radial nerve (C5, T1)

What pulse is palpable when compressing the skin overlying the anatomical snuffbox?

radial pulse

what is a condyloid or ellipsoid synovial joint?

radiocarpal joint

scapulothoracic retraction (adduction)

rhomboids middle trapezius

biceps brachii long head and short head origin and insertion

origin: long head- superglenoid of scapula short head - corocoid process of scapula insertion :radial tuberosity

contraction of this muscle causes the mobile arm to move at the glenomhumeral joint

pectoralis major

inserts on the coracoid process of the scapula lowers the raised arm assists in respiration

pectoralis minor

scapulothoracic depression

pectoralis minor latissimus dorsi lower trapezius

posterior compartment anterior

posterior - triceps brachii, anoconeus anterior - biceps brachii, brachialis, coracobrachialis

What ligament is particularly important in the throwing athlete, who places significant forces on the elbow when cocking the arm and accelerating it forward?

ulnar collateral ligament

What nerve is vulnerable to injury in 1. Under the Arcade of Strothers (thru the medial intermuscular septum) 2. At the medial humeral epicondyle 3. Between the two heads of FCU under the Ligament of Osborne in the "cubital tunnel" 4. Superficial to the flexor retinaculum at the wrist in the Canal of Guyon

ulnar nerve

descends from the lateral cord and, in the middle of the arm, pierces the medial intermuscular septum and descends in front of the medial head of the triceps; - in 70-80% of individuals, the nerve passes under the Arcade of Struthers - the arcade is a thin aponeurotic band extending from the medial head of triceps to the medial intermuscular septum

ulnar nerve

fx of medial epicondyle may lesion what nerve?

ulnar nerve

This nerve is vulnerable to lesion at the wrist resulting from trauma, hamate fracture, pisiform or ulnar head dislocation, arthritis and...

ulnar nerve air hammer and handlebar neuropathies

Innervates 1 and ½ muscles of the anterior forearm, all but five intrinsic hand muscles, and the skin of the medial 1 and ½ digits

ulnar nerve (C8, T1)

where does brachialis insert?

ulnar tuberosity

shoulder abduction/flexion

upper trap lower trap serratus anterior

scapulothoracic elevation

upper trapezius levator scapulae