GSSE upper limb

T/F median nerve gives off no branches in the arm? what is the exception?

*no branches in the arm: sympathetic filaments to brachial artery and twig to elbow joint but no muscular branches-unless the nerve to PT has unusually high origin

Name the 3 branches from the roots?

1. Dorsal scapula 2. Nerve to Subclavius 3. Long thoracic

3 branches off thyrocervical trunk

1. ascending cervical a. 2. transverse cervical a. 3. Suprascapular a.

Name the borders of the 3 divisions of the axillary artery

1. from lat. border 1st rib, Midpoint clavicle, MEDIAL pec minor 2. behind pec minor, surrounded by 3 cords 3. lateral pec minor to LATERAL teres major becomes brachial artery

Name the 3 branches of the 1st part of the subclavian artery

1. vertebral a. 2. Internal thoracic a. - pericardiacophrenic, intercostals and superior epigastric 3. Thyrocervical trunk

ossification of acetabulum by...

18 yrs

Name the borders of the 3 divisions of the subclavian artery

1st -medial to the anterior scalene 2nd- behind the anterior scalene 3rd- lateral to ant. scalene, ends at the lateral border of the 1st rib

Ulnar nerve supplies which muscles?

2 muscles in the forearm -flexor carpi ulnaris -flexor digitorum profundus ALL intrinsic hand muscles except -LOAF

How many short muscles of the thumb are there?

4 Adductor pollicis lays by itself the other 3 makeup the Thenar eminence/OAF 1. Flexor pollicis brevis 2. Abductor pollicis brevis deep to both is 3. Opponens pollicis

How many lumbricals are there? Innervation Action

4-stem from each of the FDP tendons insert radial side of extensor mechanism on dorsal lay on top of the interossei in the palm does not touch the metacarpals innervated by median-1st 2 ulnar-pinky and ring Flex the MCP and extend the PIPs Provide proprioceptive bridges between the flexor and extensor muscles

Which injury more commonly affects the axillary nerve?

5% shoulder dislocations Upper humerus fracture loss abduction

How many interosseous are there? What is their action?

7 4 dorsal 3 palmar action is to flex the MCP and extend the PIP joints same as lumbricals

Supraspinatus- action and innervation

Abduction Suprascapular nerve and artery

Segmental innervation of UL movements -Shoulder ab and adduction

Abduction-C5 Adduction C6/7/8

which 3 short muscles of the pinky make up the hypothenar eminence

Abductor digiti minimi (outer) Flexor DM Opponens DM Ulnar nerve and artery pass under the flexor and opponens as they enter the hand

Surgical approach to the median nerve

Arm: Medial border biceps Cubital fossa: Medial to the biceps tendon Forearm: Detach FDS from the radius

Describe the course of the Dorsal scapula nerve -which root numbers -where through -supplies what

C5 runs down deep to Levator scapular and the 2 rhomboids-supplying all 3. Lies on serrates posterior superior, forms neurovascular bundle with the descending scapular vessels along vertebral border of scapula

Name the 5 branches of the posterior cord?

C5, 6: Upper and lower subscapular Axillary C5,6,7,8,T1 Radial C6,7,8: Thoracodorsal

Describe the course of the nerve to subclavius -which root numbers -where through -supplies what

C5,6 Passes down in front of the trunks and subclavian vein (goes through scalenus medius) enters posterior surface of Subclavius. If it contains accessory phrenic fibres these join the phrenic nerve in the superior mediastinum

Describe the course of the Long thoracic nerve -which root numbers -where through -supplies what

C5/C6 unite in the scalenus medius, emerge from lateral border as one trunk Joined by C7 on the 1st digit serratus anterior (c7 descended on in front of scalene medius Runs down vertically behind Mid-axillary line -Behind the lateral cutaneous intercostal branches Innervates serratus anterior- rotation of the scapula for abduction of the arm C5- does 1st two C6- next two C7-lowest 4

What are the root levels for the ulnar nerve and what is it's overall job?

C7/8/T1 *Direct continuation of the medial cord-C8/T1. In 95% cases picks up C7 in axilla from the lateral cord (fibres are for FCU) flexor muscles of ulnar forearm skin of ulnar 1 and a 1/2 digits *chiefly the nerve for intrinsic hand muscles

Most common sites median nerve compression

Carpal tunnel AIN syndrome-motor deficit without sensory change

Describe the course of the radial nerve Long, medial (ulnar collateral nerve), lateral, medial

Continuation of posterior cord Through Triangular space -gives off Long and Medial branches Spirals across medial head of triceps to lie in radial groove on bare bone, deep to lateral head-gives off lateral and medial br Posterior cutaneous nerve arm (C8 and all of T1)-passes back medial to long head of triceps, supplies strip extensor arm Lower lateral cutaneous nerve arm (C5)-given off just before pierces lateral intermuscular septum Pierces the lateral inter muscular septum 1/3 way from deltoid to lateral epicondyle In flexor compartment-held off bone by brachialis Between brachialis (gives small br to brachialis-remember some muscles have 2 supplies) and brachioradialis Gives off PIN at bend of the elbow-through 2 layers supinator to supply ext forearm Posterior cutaneous nerve forearm (C6, 7) purely cutaneous now runs along supinator under brachioradialis runs through snuff box to reach dorsal hand skin radial 3 1/2 digits, falling short of nail beds

Whats is an Erbs palsy?

Damage to upper brachial plexus injury-C5/6 Stretching of the neck away from shoulder Can be due to birth injury ie. shoulder dystocia Loss of deltoid-abductor, Teres minor-lateral rotator, supinators =Medially rotated, limp, flexed wrist, 'waiters tip' pose

Which nerve runs through the supinator?

Deep branch of radial nerve (posterior interosseous nerve)

Surgical approach to the radial nerve

Detach the lateral head of triceps superficial part of supinator will reveal deep branch

Segmental innervation of UL movements Elbow flexion and extension

Elbow flexion-C5/6 extension-C7/8

order of 6 superficial muscles extensor forearm from radial to ulnar side

Extensor carpi radialis longus -to 2nd metacarpal Extensor carpi radialis Brevis- to 3rd metacarpal Extensor digitorum- to distal phalanx Extensor digiti mimini- to distal phalanx Extensor carpi ulnaris - base 5th metacarpal

Finger extensors One does all 4 fingers and then one for index and little finger

Extensor digitorum (4 tendons) -from lateral epicondyle under retinaculum Extensor digiti minimi ulnar side of extensor digitorum Extensor inidicus lies deep to ED (from ulnar and interosseous membrane) Extensor inidicus and minimi join their closes ED tendon over the MP joint

Segmental innervation of UL movements Finger flexion and extension

Finger flexion and extension-C7/8

Action of Flexor digitorum profundus

Flex all 3- DIP, PIP and MCP joint

Name the 3 flexors of the wrist and their origin/insertion

Flexor carpi radialis- arises from medial epicondyle to base 2nd metacarpal Palmaris longis- very superficial, from medial epicondyle to palmar aponeurosis- but frequently absent! Flexor carpi ulnaris- arises from ulnar head to pisiform bone

Which 3 muscles are in the deep forearm of the flexor aspect

Flexor digitorum profundus-can flex tips Flexor pollicis longus Pronator qaudratus

1 muscle in the middle layer of flexor forearm

Flexor digitorum superficialis "can't flex the tips"

Draw the anatomical snuff box -borders -contents

Floor-radial artery Bony prom-radial styloid, base of thumbs metacarpal, scaphoid, trapezium

Median nerve supplies the LOAF muscles, what are they?

Gives off motor branch to 3 (of 4) thenar muscles- LOAF Lateral 2 lumbricals Opponens pollicis ABductor pollicis brevis Flexor pollicis brevis other thenar =adductor pollicis which ulnar supplies

How do you test for a higher vs lower ulnar nerve injury?

High test for ulnar action of the FDP in flexing DIPs of little finger less flexion of DIPs as injury now catches FDP tendon Low- test for abduction of the index finger by 1st dorsal interossei Will have flexion of DIPs as injury lower than FDP tendon LOwUlnar palsy results in clawing of the little and ring finger with hyper-extension at the MCPs (paralysis of the fourth lumbrical and of the interossei to the little finger)

How do you test for a higher vs lower radial nerve injury?

High-test elbow extension, because nerves to tricep arise before humerus Low-test PIN-extension of wrist often minimal sensory loss

Draw the BRACHIAL PLEXUS -root levels -branches from the roots/trunks/cords etc

However 10% are prefixed C4-C8 and postfixed C6-T2

Name the lateral rotators of the humerus

Infraspinatus Teres minor

Teres minor-action and innervation

Joins humerus posteriorly lateral rotation Axillary nerve

Axilla posterior wall

Lat dorsi Teres major subscapularis Thoracodorsal N Subscapular vessels

Name the 3 branches of the lateral cord?

Lateral pectoral nerve C5/6/7 -passes through clavipectoral fascia -supplies upper fibres of pec major -communicates with medial pec to also supply pec minor Musculocutaneous C5/6/7 Lateral root of median C5/6/7 -joined by medial root at the lateral side of axillary artery to from the main nerve

Infraspinatus-action and innervation

Lateral rotation Suprascapular nerve and artery

Describe the course of the median nerve -most of flexor muscles of the forearm -3 thenar and 2 lumbricals in hand- LOAF -cutaneous to flexor surfaces, nails 3 and 1/2 radial digits and corresponding palm

Leaves axilla lateral to the brachial artery, sweeps in front, therefore lies medial to it at the elbow, between the bicipital aponeurosis Descends beneath the 2 heads of pronator teres, and beneath FDS, emerges on the radial side between FCR and palmaris longus before passing through carpal tunnel In the cubital fossa it supplies muscular branches to PT, palmaris longus, FCR, FDS and gives off the AIN-nerve of the deep flexor compartment. AIN-start 4cm distal to medial epicondyle, descends on interosseous membrane to the wrist supplying radial 1/2 FDP, FPL, Pronator Quadratus and sensory to membrane, periosteum, wrist and intercarpal joints Palmar cutaneous branch-pierces deep fascia above the flexor retinaculum supplies more than half of the palmar thumb Divides in the carpal tunnel and emerges in the hand as -lateral branch-gives important muscular recurrent branch (T1), supplies 3 thenar muscles then 3 palmar digital branches-1st lumbrical -medial branch-2 palmar Digital nerves-2nd lumbrical

Name the insertions points of the 3 tricep heads

Long head: Inferior glenoid tubercle Lateral: High Lateral humerus Medial: broad area lower medial humerus all 3 converge to tendon which joins the olecranon

What is klumpke's palsy?

Lower brachial plexus injury- C8/T1 Ulnar Claw hand- ext MCP, flex DIP

Pec major

Medial 1/3 clavicle, sternum and ant. 6 costal cartilages to LATERAL LIP edge of bicipital groove Adduction, internal rotation C5/6/7-Lateral pectoral nerves- upper half C8/T1-Medial pectoral nerve-lower half AKA supply from the whole plexus Thoracoacromial artery (branch of 2nd part axillary artery)

Medial cutaneous nerve of arm and forearm

Medial cutaneous nerve to arm is a failure-sometimes repalced entirely by intercostobrachial nerve runs down with axillary vein to pierce the deep fascia and supply skin medial to the anterior axial line but fails to reach the elbow Medial cutaneous nerve to forearm is much bigger Runs between axillary artery and vein pierces deep fascia halfway to elbow sensory to medial arm and forearm-meets with lateral cutaneous from musculocutaneous without overlap at the anterior axial line separated posteriorly by posterior cutaneous br of radial nerve

Which nerve passes between the 2 heads of pronator teres?

Median

Which 10 tendons, 1 nerve pass through the carpal tunnel and it what order

Median nerve passes below the retinaculum between Flexor digitorum superficialis tendons- 23,14 and the FCR Flexor pollicis longus below next to Flexor digitorum profundus- 4 tendons with the indices seperate all tendons share a common synovial sheath, reflected on the radial side

Thoracodorsal nerve course

Nerve to latissimus dorsi Large nerve, runs down posterior axillary wall Crosses lower border teres major enters the deep surface latissimus dorsi From high up post to subscapular art, lower down in front (not the thoracodorsal art) vulnerable in operations on the scapular LNs, lies anterior to them and the subscapular artery

Surgical approach to musculocutaneous nerve

Opening the deltopectoral groove and identifying the nerve as it pierces coracobrachialis from the lateral cord of plexus below the lower border teres minor

Name thumb pairs vs single

Pairs: Abduction extension flexion Single: Adductor Opponens

Do dorsal or palmar interossei do abduction

Palmer interossei are three muscles involved in the adduction of fingers. Dorsal interossei are four muscles that allow the abduction of fingers. PADS and DABS

Describe the course of the axillary nerve C5/6

Passes backwards through quadrangular space lying above posterior circumflex humeral vessels in contact with neck of humerus just below capsuel of shoulder joint which it supplies Divides into posterior branch-teres minor and posterior border deltoid Upper lateral cutaneous nerve of the arm-supplies skin over the lower half of deltoid and supplies small part of the muscle Anterior branch lies on posterior surface humerus between teres minor and the lateral head of triceps and supplies deltoid -small area skin centre of muscle

Name the relations of the ulnar artery

Passes deep to pronator teres Runs with ulnar nerve

Cephalic vein runs between which 2 muscles and over which muscle

Pec major and deltoid over pec minor

Which muscle would you test to assess for a 'whole' brachial plexus lesion ie. avulsion of the roots

Pec major is the only muscle to receive supply from the whole plexus-can be useful to gauge degree of injury. most common from motorbike accident-neck forced to opposite shoulder Whole limb is immobile and anaesthetic Test-rhomboids and serratus ant-if working means lesion is distal to dorsal scapula and long thoracic

Which 2 muscles go directly from the trunk to the humerus *aka dont join scapula)

Pect major and lat dorsi

Name the 2 pronators and 2 supinators

Pronation Pronator teres- 2 heads 1. medial epicondyle 2. ulnar inserts halfway down lateral radius Pronator qaudratus ulnar to radius Supinator: biceps Supinator - lateral epicondyle and medial ulnar to medial radius

Segmental innervation of UL movements Pronation Supination

Pronation-C6 Supination-C7/8

Detail the structure surrounding/near to each RTDCN

R-between scalene muscles T-in posterior triangle D-behind the clavicle C-2nd part axillary artery Branches from the roots and trunks make the supraclavicular part of the plexus, cords and their branches infraclavicular part No branches from divisions

Which 2 ligaments hold the radial head in place?

Radial colateral ligament- triangular shape lateral side annular ligament- shallow cup

Which nerve pierces the lateral intermuscular septum?

Radial nerve and profunda brachii artery (anterior descending branch).

Serratus anterior

Ribs 1-9 insert MEDIAL border of scapula protracts scapula (brings it forward), can rotate up and down Lateral thoracic artery (off axillary) Long thoracic nerve

Deltoid

Scapula spine, acromion, lateral 1/3 clavicle to deltoid tuberosity 3 different actions, flexion, extension, abduction Axillary nerve Posterior circumflex a. thoracoacromial a.

Describe the course of the suprascapular nerve -root number, branch of which part of the nerve -runs where -supplies what

Solitary branch of the upper trunk from C5/6 -Floor of posterior triangle, disappears below trapezius -Runs beneath the traverse scapula ligament (artery on top) Supplies supraspinatus Descends LATERAL the the scapular spine Supplies Infrapinatus and posterior part of capsule of shoulder

Name the relations of the radial artery

Stays superficial, running between pronator teres and brachioradialis *runs with the Median nerve

What do the upper and lower subscapular nerve innervate?

Subscapularis with lower also doing teres ?minor pg 124

Name the 1 branch from the trunks?

Suprascapular nerve

Segmental innervation of UL movements hand intrinsic muscles

T1

Latissimus dorsi

T7 to sacrum, over iliac crest, lower 4 ribs, tip scapula to intertubercular sulcus Adducts humerus, depresses scapula Thoracodorsal nerve and artery (3rd part axillary a)

What structures cross on top of the retinaculum?

Tendon of palmaris longus-fused to midline On either side there are cutaneous branches -on the ulnar side small palmar branch of the ulnar nerve enters the palm -on the radial side the palmar branch of median nerve and the superficial palmar branch of radial artery cross the retinaculum Ulnar nerve and artery -superficial (cutaneous) and deep (muscular) branch at the distal border of the retinaculum Radial side of retinaculum pierced proximally by the tendon of FCR over the scaphoid

Which 4 muscles are in the superficial forearm of the flexor aspect

Think pass, fail, pass, fail-from lateral arm to medial Pronator-brachioradialis Flexor carpi radialis Palmaris longus muscle Flexor carpi ulnaris

T/F: Median and ulnar run nerves right down to the elbow without supplying anything

True, because they do the forearm compartment

Which nerve roots make up the Ulnar nerve?

Ulnar nerve is a direct continuation of the medial cord-C8/T1 95% picks up C7 from Lateral cord in the axilla and innervates FCU

Palmar digital arteries come from which artery?

Ulnar- does superficial palmar arch which gives off the proper digital arteries Radial does deep palmar arch

Name the route of the long head tendon of the biceps

Up the bicipital groove, INTO the joint capsule to reach the supraglenoid tubercle of the scapular

Describe the contents and borders of the Cubital fossa

Upside down triangle Line going humeral epicondyles Medial: Pronator teres Lateral: brachioradialis Roof: deep fascia forearm reinforced medial side by bicipital aponeurosis lying on the Bicipital aponeurosis is the median basilic vein with medial cutaneous nerve forearm on its medial side, seperate from the structures below Floor: brachialis muscle contents: from medial to lateral median nerve, brachial artery, tendon of biceps further laterally-radial nerve and PIN-sitting under brachioradialis

Which 2 muscles control "key pinch"

adductor pollicis and dorsal interossei

Name the 5 branches of the medial cord?

all C8/T1 except ulnar which also has 7 Medial pectoral nerve Medial root of median Medial cutaneous nerve arm Medial cutaneous nerve forearm Ulnar

Brachialis Why does brachialis work well in either pronation or supination?

anterior humerus to ulnar tuberosity because it joins the ulnar which doesnt move

Does the median nerve run ant. or post. to the brachial artery?

anterior in 85%

Most common sites of ulnar nerve compression

between the two heads of FCU/aponeurosis within arcade of Struthers (hiatus in medial intermuscular septum) between Osborne's ligament and Medial Collateral Ligament

PIN-posterior interosseous nerve

c5,6,7,8 Extensor carpi radialis brevis and supinator in the cubital fossa spirals down around radius between 2 layers supinator to extensor compartment forearm- 7 muscles

which 3 tarsal bones ossify at birth

calcaneus talus cuboid

All dorsal hand/forearm veins converge on which vein? The flexor forearm drains where?

cephalic Basilic

Short head of the biceps joins what other muscle?

coracobrachialis therefore joins the coracoid process

Coracobrachialis muscle is supplied by..

coracoid process to middle third of medial humerus flexes and adducts arm Muscular branhces of brachial artery Musculocutaneous nerve

Which two nerves run through the middle scalene?

dorsal scapula and long thoracic

Order of 6 deep muscles extensor forearm

elbow to hand, ulnar to radius Anconeus Supinator Extensor indices- to distal phalanx -top of snuff box Extensor pollicis longus- ulnar to DIP Extensor pollicis brevis (brevis sandwich)-radius to PIP Abductor pollicis longus-from radius and ulnar, base thumb

Medial intermuscular septum of the arm- pierced by?

extends along the medial supracondylar line behind the coracobrachialis insertion and fades out above, between that muscle and the long head of triceps. It gives origin to the most medial fibre of brachialis and the medial head of triceps *pierced by the ulnar nerve and ulnar collateral artery*

Medial pectoral nerve (C8, T1) innervates...

gives a branch to pec minor then pierces it to supply the lower fibres of pec major

Ulnar artery

gives off common interosseous artery runs between flexor digitorum superficialis and profundus superficial -runs behind palmar interosseous deep-runs between hypothenar muscles Superficial palmar arch -anastomoses deep palmar arch

Teres major

inferior angle scapula to MEDIAL lip of intertubercular surface on humerus Lower subscapular nerve Circumflex scapular artery Adducts and medially rotates

basilic vein joins into what vein?

joins the 2 brachial veins and becomes the axillary vein Runs alongside median nerve and axillary artery

Brachioradialis

lateral humerus to distal radius

Medial wall

long thoracic nerve (on way to serratus anterior)

which is the growing end of the femur?

lower end 3 secondary centres up top which arent till way after birth lower femur present before birth

Surgical approach to the ulnar nerve

medial border of biceps nerve is adjacent the brachial artery elbow behind the medial epicondyle follow upwards from the pisiform, sitting between the bone and artery, displace FCU medially

Detail the course of the ulnar nerve

medial/behind brachial artery pierces medial intermuscular septum lies alongside triceps, on shaft of humerus between medial epicondyle and olecranon between 2 heads FCU thus enters flexor forearm -Palmar cutaneous branch-supplies skin Hypothenar -Dorsal cutaneous branch-1 or 2 1/2 fingers, not nails Crossing sublime tubercle sits on FDP covered by FCU crosses under FCU tendon Joined by ulnar artery Above flexor retinaculum, travels in Guyons canal Splits into: Deep-supplies all 3 Hypothenar muscles, adductor pollicis, ulnar lumbricals and all interossei Superficial branch-runs beneath palmaris brevis, sensory 1 1/2 fingers incl nail beds

How do you test for a higher vs lower Median nerve injury?

more commonly injured at wrist High Test-flexor pollicis longs and finger flexors-Ok sign Low Test-abductor pollicis brevis (do not choose flex poll brevis due to uncertain supply)

Describe the course of the musculocutaneous nerve

muscular to the flexors in the arm and cutaneous in the forearm leaves the lateral cord Supplies coracobrachialis then pierces it, passes down between biceps and brachialis-supplying both BBC Lateral border biceps tendon Pierces deep fascia at crease elbow Now called lateral cutaneous nerve of the forearm-supplies elbow to wrist skin with anterior and posterior branch's along the radial border of forearm

Brachial artery gives off which artery near the latissimus tendon? which nerve runs with it?

profunda brachii -passes backward deep to the triceps and radial nerve

Median supplies 4 muscles as well as common long flexors

pronator teres Pronator quadratus Flexor carpi radialis Palmaris longis

The single belly of the biceps muscle then goes into 2 tendons which join where?

radial tuberosity fans out to form the bicipital aponeurosis continuous with deep fascia that surrounds the forearm, therefore "indirectly" attached to the ulnar

Radial collateral ligament joins which 2 carpal bones? Ulnar collateral ligament joins which 2 carpal bones?

scaphoid and trapezium ulnar styloid to triquetrum and pisiform

Which 2 carpal bones articulate with the radius?

scaphoid, lunate

Order of the subclavian vein, artery in relation to scalene anterior

subclavian artery anterior scalene subclavian vein- in front

Subscapularis-action and innervation

subscapular fossa to lesser tubercle medial rotation Subscapular nerves and artery

Name the medial rotators of the humerus

subscapularis teres major

Is supination or pronation more powerful?

supination

Name the abductor and adductor of the humerus

supraspinatus teres major

Name the 4 rotator cuff muscles

supraspinatus, infraspinatus, teres minor, subscapularis

The strength of the wrist comes from where?

the dorsal and palmar Radiocarpal ligaments

Radial nerve-muscles it innervates

triceps, anconeous, brachialis, supinator, extensor carpi radialis brevis brachioradialis extensor carpi radialis longus 3 from common extensor origin: extensor digitorum, extensor DM, extensor carpi ulnaris 3 thumb muscles: Abductor pollicis longus Ext pollicis longus Ext pollicis brevis Ext indices

T/F carpal bones are all cartilagenous at birth

true largest one-capitate ossifies first

T/F carpal bones each have their own ossification centre

true, one ossifies each year aka till 7yrs age

What pierces the medial intermuscular septum?

ulnar nerve colateral ulnar a.

Course of subclavian vein

underneath pec minor over 1st rib, under clavicle and subclavius muscl Joined by internal jugular vein at medial border 1st rib making brachiocephalic R +L join right of midline to make SVC

How do you test for musculocutaneous injury?

very rarely injured test: flexion of elbow by bicep

Segmental innervation of UL movements wrist flexion and extension

wrist flexion and extension-C6/7