Anatomy of the Upper Limb and Breast

Question 1

Parts of the pectoral girdle

Where they join

Answer 1

The clavicle and the scapula

Sternoclavicular joint and the acromioclavicular joint

Question 2

Scapula

Location

Most palpable areas

What is required for full abduciton of the arm?

Answer 2

2nd to 7th rib posteriorly

Spine, acromion, coracoid process

Rotation of the scapula required to abduct the arm

Question 3

Clavicle: difference between the medial 2/3 and lateral 1/3

Answer 3

Medial 2/3: convex anteriorly, cicular

Lateral 1/3: convex posteriorly, flat

Question 4

Articulations of the clavicle

Answer 4

Sternum (sternoclavicular joint): articular disc in joint

Acromion (acromiclavicular joint): incomplete articular disc in joint

Coracoid process; held by strong coracoclavicular ligament

Question 5

Interesting facts about the clavicle

development (x2)

what can pierce it

purpose (x2)

related to ortho?

Answer 5

first bone to ossify, only long bone to develop in membrane

supraclavicular nerves

acts as a strut to hold the arm out, transmits forces from the upper limb to the axial skeleton

most commonly fractured site in the body

Question 6

Humerus anatomy

Head

Shaft

Posterior

Lower end

Answer 6

Head: 1/3 sphere, connects tohe shaft via the anatomical neck, below it are the greater and lesser tubercles between which the bicipital groove where the tendon of the long head of the biceps lies

Upper end and shaft (circular and more flat distally) meet at surgical neck = axillary nerve + circumflex humeral vessels lie

Posterior = radial nerve lies in the spiral groove, between the medial and lateral triceps heads

Lower end has rounded capitulum for articulation with radial head, and trochlear for articulation with trochlear notch of the ulna

Medial and lateral epicondyles are extracapsular: ulnar nerve lies in a groove on the posterior aspect of the medial epicondyle

Question 7

Scapula anatomy

Anteriorly

Posteriorly

Answer 7

Posterior: superior angle, scapular notch, supraspinous foss, spine, infraspinous fossa, lateral border

Anterior: acromion, coracoid process

Question 8

Radius - parts

Ulna - parts

Answer 8

Radius: radial head, radial tuberosity, styloid process, expanded end, dorsal tubercle (posterior)

Ulnar: olecranon, trochlear notch, coronoid proces (with its radial notch), head, styloid process

Question 9

Carpal bones

Answer 9

Proximal row (L to M): scaphoid, lunate, triquetrum (+ pisiform)

Distal row (M to L): hamate, cunate, trapezoid, trapezium

Arched transversly - with the palmar aspect being concave - maintained by the posterior aspect of bone being larger than anterior aspect (except lunate)

AND

flexor retinaculum from scaphoid and trapezium laterally to pisiform and hook of hamate medially

Question 10

Metacarpals - important articulations

Answer 10

First metacarpal mobility is important for opposition of the thumb

Second metacarpal = articulates with trapezium, trapezoid, capitate

Capitate = articulates with 2nd, 3rd, 4th metacarpal

Question 11

Joints of the upper limb

Articulations

Where the capsule surrounds

Answer 11

Ball and socket

Articulations: glenoid fosssa (deepened by labrum glenoidale - cartilaginous ring) with head of humerus

Capsule - lax, around the epihyseal line around glenoid and humeral head, extends down to diaphysis at the medial aspect of humerus

Biecps tendon passes through it - capsule lined by synovial membrane here - synovium communicated with the subcapsular bursa, lying beneath tendon of subscapularis

Question 12

Muscles that provide stability to the shoulder

Answer 12

Rotator cuff

Long head of biceps

Pectoralis major, latissimus dorsi, teres major

Question 13

Muscles acting on the shoulder joint

Abduction

Adduction

Flexors

Extensors

Medial rotators

Lateral rotators

Answer 13

Abduction: deltoid, supraspinatus

Adduction: pectoralis major, latissimus dorsi

Flexors: anterior deltoid, coracobrachialis, pectoralis major

Extensors: posterior deltoid, latissimus dorsi, teres major

Medial rotators: pectoralis major, latissimus dorsi, teres major, anterior deltoid, subscapulairs

Lateral rotators: infraspinatus, teres minor, posterior deltoid

Question 14

Ligaments of the clavicle attaching to the coracoid process

Answer 14

Conoid ligament (front)

Trapezoid ligament (behind)

Question 15

Joints of the shoulder girdle

Answer 15

Sternoclavicular joint: sternum and medial end of clavicle; the costoclavicular ligament attaches to the first costal cartilage: acting as a fulcrum when the shoulders are shrugged to depress the medial end

Acromioclavicular ligament: acormion to lateral boder of clavicle, there are two coracoclavicular ligaments: conoid (in front) and trapezoid (behind) - allows easy reduction of outer end of clavicle, but inclination of surfaces means that this can be hard to stay reduced

Rotator cuff: muscles whose tendons have a sheath surrounding most of the joint (apart from the inferior aspect)

Supraspinatous, infraspinatous, teres minor - inserts into the greater tuberosity; subscapularis inserts into the lesser tuberosity

Supraspinatous - beneath the acromion and coracoacromial ligament - separated from these by the subacromial bursa

Question 16

Abduction of the shoulder

Answer 16

Supraspinatous - 15 degrees

Deltoid - 90 degrees

Rotation of scapula by trapezius and serratus anterior - 180 degrees

Any movement of the shoulder causes reciprocal movement at the sternoclavicular joint

Question 17

Muscles to protract and retract the scapula

Answer 17

Protract: pectoralis minor, serratus anterior

Retract: rhomboids, middle fibres of trapezius

Question 18

Location of the bones after clavicle fracture

Answer 18

Lateral end of clavicle - depressed and moved medial - due to shoulder adductors

Modial end of clavicle - raised due to sternocleidomastoid

Question 19

Serratus anterior supply

Answer 19

Long throacic nerve of bell; C5,6,7

Damage causes winging of the scapula

Question 20

Joints at the elbow

Answer 20

Humeroulnar joint - trachlea of humerus with the trochlea notch of ulna (hinge joint)

Humeroradial joint: capitulum and radial head (ball and socket joint)

Proximal radioulanr joint: head of radius and radial notch of ulna (pivot joint)

Question 21

Capsule of the elbow joint

Answer 21

Lax and thin anterior and posteriorly

Laterallly: thickened to form the lateral and medial collateral ligaments

Lateral ligament is atttached to the annular ligament which holds the head of the radius in place; forms the start of the supinator muscle

Question 22

Movement of the elbow joint

Answer 22

Flexion / extension

pronation and supination at the proximal radioulnar joint

Question 23

Muscles around the elbow joint

Answer 23

Flexors: biceps, brachialis, brachioradialis, forearm flexors

Extensors: triceps, ancones

Pronation: pronator teres, pronator quadratus

Supination: supinator, biceps

Question 24

Articular surfaces of the wrist

Answer 24

Distal radus, and head of the ulnar (which has an articular disc - triangular fibrocartilage)

Proximal articulations with the scaphoid, lunate, triquetrum

Question 25

Wrist type of joint

Answer 25

Condyloid joint: can flex, extend, adduct, abduct and circumduct

Question 26

Movements of the wrist D

Answer 26

Flexion: all anterior muscles of the aforwarm - at both midcarpal and radiocarpal joint Extension:all posterior compartment mescles Adduction: flexor and extensor carpi ulnaris, - mainly at the mid carpal joint Abduction: flexor carpi radialis, extensor carpi radialis longus, adductor policis longus, extensor policis longus

Question 27

Joints of the hand

Answer 27

**Carpo-metacarpal joints** - all except thumb have limited gliding movement thumb is a saddle joint: has flexion/extension (plane of palm), adduction/abduction (right angle of palm), opposition of little finger **Metacarpo-phalangeal joints** Thumb - flexes to 60 degrees, fingers - 90 degrees Abduction, adduction and circumduction in fingers only, not possible when fully flexed Deep transverse ligaments stop fingers from spreading out during firm grip **Interphalangeal joints** Hing only- flexion, extension, collateral ligaments lax in extension, taut in flexion

Question 28

Muscles controlling the hand

Answer 28

Long flexors - FDP; FDS Long extensors - EDL + EDI / EDM Extensor expansion - covers proximal phalanx, base of middle phalanx, and two lateral slips into distal phalanx - consists of EDL, interossei, lumbricals Small muscles of hand - interossei, lumbricals Muscles of the thumb - FPL, EPL, EPB, APL Muscles of little finger - ADM, FDM, ODM

Question 29

Long flexors of the hand

Answer 29

Flexor digitorum superficialis - attaches to sides of middle phalanx; flexes middle phalanx Flexor digitorum profundus - gives off lumbricals; attaches to base of distal phalanx; pierces FDS under the proximal phalanx; flexes distal phalamx

Question 30

Long extensors of the hand

Answer 30

Extensor digitorum longus - inserts into the extensor expansion - on the dorsum of the phlanaxes Extensor indicis - medial side of EDL to the index finger (extensor expansion) - originates from the posterior surface of ulna and interosseus membrane Extensor digiti minimi - medial side of EDL to the little finger - originates from lateral epicondyle

Question 31

Where does the extensor expansion for the fingers sit?

Answer 31

Covers the proximal phalanx Inserts into the base of the middle phalanx Provides two slips to insert into the base of the distal phalanx Receives insertion of the interossei and lumbricals

Question 32

Interossei Where they arise? Insert? Innervation? Action?

Answer 32

From the sides and front of the metacarpals Into the extensor expansion Deep branch of the ulnar nerve Abduct / adduct the fingers + flex the MCP, extend the IPJ

Question 33

Lumbricals Originate Insert Innervation Action

Answer 33

Arise from FDP tendons Insert into the extensor expansion Lateral two - median nerve, medial two- ulnar nerve Flex the MCP, extend the IPJ

Question 34

Muscles of the thumb Long muscles Thenar muscles Hypothenar muscles

Answer 34

**Long muscles** Flexor pollicis longus - into distal phalanx Extensor pollicis longus - into distal phalanx Extensor pollicis brevis - into proximal phalanx Abductor pollicis longus - into the first metacarpal **Thenar muscles** Adductor pollicis - base of proximal phalanx Flexor pollicis brevis - base of proximal phalanx Abductor pollicis brevis - base of proximal phalanx Opponens policis - along the first metacarpal **Hypothenar muscles** Abductor digiti minimi Flexor digiti minimi Opponens digiti minimi

Question 35

Abduction and adduction of the fingers - muscles in addition to the intrinsic hand muscles

Answer 35

Entensor digitorum longus - weak abduction Long flexors (FDP, FDS) - weak adduction Can be eliminated by placing the hand flat on the table

Question 36

Collateral ligaments of the wrist

Answer 36

Radial collateral ligament: radial styloid to scaphoid, trapezium U;nar collateral ligament: ulnar styloid to triquetral, pisiform

Question 37

AP ligaments in wrist

Answer 37

Strong, part of the capsule - Radiocarpal ligaments - dorsal / palmar

Question 38

Muscles of elbow flexors and extensors

Answer 38

Brachialis - anterior surface of humerus to ulnar tuberosity Biceps brachii - in front of brachilais - two heads - long attaches to supraglenoid tubercle, short head to the coracoid process (merges with the coracobrachialis tendon), inseerts on the radial tuberosity with another branch fanning out to form the bicipital aponeurosis - whicg merges with the deep fascia of the forearm Brachoradialis - from just below the deltoid tuberosity on the humerus, to the distal radius Extensor - only triceps - long head (arising from the infraglenoid tubercle); lateral head from the lateral side of posterior humerus; medial from the medial side and more of the posterior humerus; three heads converge to form a tendon attaching to the olecranon Anconeus - smaller - running from lateral epicondyle to the lateral aspect of proximal ulna Radial nerve runs inbetween the medial and lateral humerus

Question 39

Rotation of the forearm Pronation Supination

Answer 39

Pronator teres- originates from medial epicondyle (smaller head from proximal ulna) - inserts into the lateral aspect of radius, about halfway down - median nerve travels in between the two heads Pronator quadratus- on the distal forearm - originates on the anteromedial aspect of ulna - attaches to anterior aspect of radius Supinator- arises from lateral epicondyle, annular ligament, supinator crest and inserts into ulnar - just above the insertion of pronator teres Biceps- onto radial tuberosity

Question 40

Muscles of the wirst - flexion

Answer 40

Flexors Common flexor tendon - gives of flexor carpi ulnaris + flexor carpi radialis from the medial epicondule - together they flex - individually one side deviation FCU - has another head arising from the ulna - between which the **ulnar** nerve travels - they form a tendon which inserts into the **pisiform** - this is transmitted onto the **base of the 5th metacarpal** through the **piso-hamate** and **piso-metacarpal** ligaments. FCR - inserts into the base of the 2nd metacarpal - passing through a deep ligamentous tunnel near the carpal bones Palmaris longus - from medial epicondyle - through the carpal tunnel inserts into the deep palmar fascia fanning out; it is frequent absent

Question 41

Muscles of the wrist - extension

Answer 41

extensor carpi radialis longus and brevis - originates from the common extensor tendon; longus - lateral epicondylar ridge; brevis - lateral epicondyle; insert into the 2nd and 3rd metacarpal base extensor carpi ulnaris - from the medial surface of ulna; insert into the 5th metacarpal base Pass under the extensor retinaculum

Question 42

Superficial veins of the upper limbs

Answer 42

Starts on the dorsal venous network of the hand - then drains into the lateral cephalic and dorsal basilic Cephalic vein on the anterolateral aspect of the arm - stays superficial; runs in the groove along the **lateral** border of biceps - near the top its between the deltoid and pectoralis major (**deltopectoral triangle);** pierces the clavipectoral fascia to then enter the axillary vein Median cubital vein - joins cephalic to basilic Basilic vein runs along the posterior aspect - then becomes anteiror at the elbow - runs in the **medial** groove of the biceps. Brachial vein joins basilic vein (the venae comitantes of the brachial artery)and eventually forms the axillary vein - above it are the median nerve and axillary artery - disappears behind pec minor

Question 43

Deep veins of the upper limb

Answer 43

Also known as venae comitantes, they follow the arteries Ulnar and radial veins - drain to form the brachial vein at the elbow Brachial joins with the basilic vein = forms the axillary vein - **at the inferior border of teres major** Axillary vein terminal part is joined by the cephalic vein = **subclavian vein** when it crosses the first rib lateral border

Question 44

At the elbow what separates the veins from the arteries?

Answer 44

The bicipital aponeurosis

Question 45

Why is cephalic vein good for diaplysis?

Answer 45

Fairly constant location and in close proximity to the radial artery for a radiocephalic fistula

Question 46

Axillary artery Start to finish Branches and parts Relations

Answer 46

Subclavian into axillary -- at the lateral border of first rib Axillary into brachial at the inferior border of teres major Branches made by pec major 1st part - 1 branch Superior thoracic artery 2nd part - 2 branches acromiothoracic artery lateral thoracic artery 3rd part - 3 branches subscapular artery anterior circumflex humeral artery posterior circumflex humeral artery Relations: cords of brachial plexus - lateral, posterior, medial surround it

Question 47

Brachial artery Start to finish Where does it lie and what crosses it?

Answer 47

Lower border of teres major until the neck of the radius Lies below the deep fascia (easily accessible) and crossed by **median** nerve from lateral to medial at the level of mid humerus Gives off a profunda brachii branch immediately below the border of teres major - travelling to the posterior aspect of the humerus in between the long and lateral heads of the triceps

Question 48

Radial artery

Answer 48

Superficial - starts at the level of the radial neck Overlapped by brachioradialis in its upper half Can be palpated in between braachioradialis and flexor carpi radialis Travels deep to APL and EPB to enter the anatomical snuff box Distal to the wrist - gives branches for superficial palmar arch Pierces through first dorsal interosseus and adductor policis = deep palmar arch

Question 49

Ulnar artery

Answer 49

Travels deeper than radial lies on FDP - overlapped by FCU Crossed supreficially by median nerve with pronator teres (deep head) in between Can be palpated when superficial between FDP and FCU in the distal forearm Crosses in front of the flexor retinaculum to become the superficial palmar arch (with the radial artery) Accompanied by the ulnar nerve in the distal two thirds of the forearm and across the flexor retinaculum

Question 50

Brachial Plexus

Answer 50

Roman Togas Dont Cover Balls Roots: C5, C6, C7, C8, T1 Trunks: Superior (C5 + C6), Middle (C7), Inferior (C8 + T1) Divisions: each trunk divides into anterior and posterior Cords: Posterior (from all the posterior divisions); lateral (anterior division of superior and middle trunks); medial (anterior division of lower trunk) Branches: Lateral cord - musculocutaneous; posterior cord - radial and axillary (only C5,6); medial cord - ulnar; lateral + medial cord - median Additional nerves: Medial cord - 3M's = medial antebrachial cutaneous, medial brachial cutaeous, medial pectoral Posterior cord - LMU - lower middle upper subscapular nerve (middle also known as thoracodorsal nerve) Lateral cord = lateral pectoral Superior trunk = 3S's = suprascapular (supplies supraspinatus/infraspinatus), subclavius, dorsal scapular (from C5 only - supplies rhomboids) C5,6,7 = long throacic nerve of Bell

Question 51

Key facts about axillary nerve

Answer 51

C5,C6 Motor - deltoid, teres minor (cant abduct if damaged) Sensory - skin over deltoid Wound around the surgical neck of the humerus

Question 52

Key facts about radial nerve

Answer 52

Arises behind axillary artery, then acoompanies profuda brachii to the posterior compartment - lies in the spiral groove - between the long and medial head of the triceps Enters anterior compartment by piercing the intermuscular septum At lateral epicondyle gives off posterior interosseos branch - this supplies supinator, adductor pollicis longus and all extensor muscles except ECR-L Continues superficially under brachioradialis, emerges posteriorly and provides sensation to radial 3,5 digits posteriorly Motor innervation of triceps, anconeus, brachioradialis, ECR-L

Question 53

Key facts about musculocutaneous nerve

Answer 53

Arises from C5,6,7 Pierces coracobrachialis - runs between biceps and brachialis Motor innervation - biceps, brachialis, coracobrachialis Sensory innervation - lateral aspect of forearm

Question 54

Key facts about the median nerve

Answer 54

From C6,7,8,T1 Anterior to the axillary artery, crosses brachial artery to become medial at the midhumerus Enters forearm between the heads of pronator teres - gives off anterior interosseous branch here Lies on the deep aspect of FDS gives off palmar cutaneous branch - supplies palmar skin over thenar eminence - does not travel in the carpal tunnel Median nerve supplies muscles of the forearm, lateral FDP, lateral lumbricals, OAF of thenar eminence Sensory to lateral 3.5 on the palmar surface

Question 55

Key facts about the ulnar nerve

Answer 55

Formed from C7,8,T1 Medial to axillary and brachial artery until midhumerus then pierces the intermuscular septum to lie on the anterior surface of the triceps Passess behind the medial epicondyle Descends between FCU and FDP - lying to the radial side of the tendon of FCU superficially Gives of dorsal cutaneous branch - sensation for the dorsal aspect of ulnar 1.5 fingers Motor to the interosseous muscles, medial lumbricals, FCU, FDP medially, adductor policis, hypothenar muscles

Question 56

Erb's palsy

Answer 56

Upper roots damaged - C5,C6 Nerves to deltoid, supraspinatus, infraspinatus (abduction) Nerves to biceps, brachialis (supination) Can be from forced downward traction during birth, falling on side of head and shoulder - pushing the two apart Leaves arm adducted, pronated and palm facing backwards

Question 57

Klumpke's paralysis

Answer 57

Lower nerve roots damaged Forced upward traction during breech delivery / fall and holding onto something Intrinsic hand muscle paralysed - claw hand to due to unopposed long flexors and extensors (long flexors flex the IP joints, long extensors extend the MCP - intrinsic muscles entend the IP) Loss of sensation on the inner and upper arm and forearm Wasting of small muscles - channels form; horner's syndome can occur due to proximity to sympathetic chain Can also occur in pancoast tumour / cervical rib

Question 58

Axillary nerve

Answer 58

Damaged during fracture of surgical neck of the humerus / anterior dislocation of the shoulder joint Cannot abduct and sensory deficit over the regimental area

Question 59

Radial nerve damage

Answer 59

Fracture of the shaft of the humerus or Saturday night palsy - lying arm over a chair and compression of the nerve between the chair and the humerus Causes wrist drop if main radial nerve is damaged If only posterior interossesous nerve is damaged then no wristdrop as EPL supplied by main radial nerve Sensory loss in the first web space of the dorsum of the hand

Question 60

Median nerve damage

Answer 60

Usually at the wrist or a supracondular fracture At the elbow: - loss of pronation - weakness of flexion with ulnar deviation (as now depends of FCU and medial FDP only) - loss of sensation of radial 3.5 digits At the wrist - paralysis of thenar muscles - except adductor policis - paralysis of lumbricals - lateral two - loss of sensastion of radial 3.5 digits Damage at both placesL - loss of accurate opposition - loss of tactile response / cutaneous sensation = risk of serios injury

Question 61

Ulnar nerve damage

Answer 61

Fracture at the medial epicondyle / dislocation of the elbow Laceration at the wrist At the wrist: - clawing of the hand - less clawing in 2 and 3 due to supply from median nerve - sensory loss over medial 1.5 fingers At the elbow - clawing of the hand - less clawing than the wrist at 4 and 5 due to damage to medial FDP To diagnose - test sensation in medial 1.5 digits + loss of abduction and adduction in digits with hand flat on table

Question 62

Difference between claw hand and hand of benediction

Answer 62

Question 63

Pulp space of fingers What is it? Result?

Answer 63

Fat packed between fibrous septa around the distal phalanx between the skin and the periosteum The digital artery has branches that go through the pulp space (except for the branch that goes to the base of the distal phalanx) Important because pulp space infection = increased pressure = arterial thrombosis and necrosis of the distal phalanx but sparing of the base

Question 64

Bursa and sheaths of the hand

Answer 64

Flexor tendons travel in fibro-osseous tunnels - flexor sheaths surrounded by synovial membrane (synovial sheaths) For 2,3,4 fingers - stops at the base of the metacarpal For little finger - continues onto the the palmar surface forming a sheath that encloses all flexor tendons (except the thumb) - forming the ulnar bursa The thumb sheath (for FPL) - extends donwards through the flexor retinaculum to 2.5cm below - forming the radial bursa Ulnar and radial bursa may communicate Important as infection within 2,3,4 sheaths is confined, whilst elsewhere can spread through the bursa and between each other

Question 65

What is the mid palmar space?

Answer 65

Behind the sheath, bursa and flexor tendons, in fornt of 3,4,5 metacarpals Does not extend to 1,2 metacarpal as the adductor policis tendon arises from the shaft of the 3rd metacarpal

Question 66

What is the thenar space?

Answer 66

Space in front of the the 2nd and 3rd metacarpals and adductor policis, away from the mid palmar space by a fibrous partition Infection in this space - either from direct penetrating injury / neglected tendon sheath infection Palmar infections = marked dorsal oedema - cant accumulate in palmar aspect as thick skin joined heavily by palmar aponeurosis - on the dorsum skin is loose and fluid can collected easily deep to it

Question 67

Palmar aponeurosis

Answer 67

Part of the deep fascia of the hand - blends with the fibrous sheath of the fingers attached to the sides of the proximal and middle phalanges Dupuytrens contractures - thickening and contraction of the palmar fascia causing flexion of PIP and MCP

Question 68

Carpal tunnel bones Flexor retinaculum - other compartments Extensor retinaculum attachments

Answer 68

Hook of the hamate + pisiform Crest of the trapezium and scaphoid tubercle Radial side - encompasses FCR Ulnar side - ulnar artery and nerve From the ridge on the radius to the ulnar styloid, triquetral, hamate

Question 69

MCP joint - capsule

Answer 69

Capsule surrounds the MCP Lax on the dorsum - to allow flexion Thickend palmar ligament at the front - moves with flexion Also attached are the collatera ligaments - run obliquely from the back of the proximal phalanx to the the head of the distal MC - taut when flexed, lax when extended = allow side to side movement when extended but not flexed Deep transverse metacarpal ligament attached to the top - joining all for MCPs

Question 70

IP Joints - collateral ligaments

Answer 70

Equally taut in flexion and extension - so prevent side to side movement

Question 71

Borders and contents of the axilla

Answer 71

Base: skin and fascia of the armpit Medial: rib cage covered by serratus anterior Lateral: bicipital groove of the humerus Anterior: pec major and minor Posterior: latissimus dorsi, teres major, subscapularis Apex bounded anteriorly by clavicle, first rib medially, acromion and superior border of scapula posteriorly

Question 72

Contents of the axilla

Answer 72

Brachial plexus Axillary artery Axillary vein lymph nodes fat

Question 73

Antecubital fossa relations and contents

Answer 73

Medially - pronator teres Laterally - brachioradialis Inferiorly - brachialis + supinator Superiorly - skin + superficial fascia + deep fascia of bicipital aponeurosis Contents: brachial artery and median nerve (medially)

Question 74

Carpal tunnel relations and contents

Answer 74

Scaphoid tubercle + crest of the trapezium Hook of the hamate and pisiform FDS + FDP + FPL + median nerve + FCR (runs in its own osseo-fascial compartment) Superficial palmar branch of median nerve - innervates the palmar aspect of thenar eminence - not affected in carpal tunnel syndrome

Question 75

Anatomical snuffbox contents and relations

Answer 75

Medial border - extensor pollicis longus Lateral border - extensor pollicis brevis + abductor pollicis longus Contents - base of thumb metacarpal, trapezium, scaphoid, radial styloid, dorsal branch of the radial artery (close proximity to cephalic vein = good for fistula)

Question 76

Structures around the wrist

Answer 76

See image

Question 77

Axillary lymph nodes

Answer 77

**5 groups** Apical (all drain into here) - immediately behind clavicle at the apex of axilla above pec minor, along axillary vein "Medial" - deep to pec major along border of pec minor Lateral - along axillary vein Central - in the axillary fat Posterior - along subscapular vessels From these the subclavian lymph trunk forms

Question 78

Leves of axillary lymph nodes

Answer 78

Level 1 - below and lateral to the inferolateral border of pec minor Level 2 - behind pec minor Level 3 - above the upper border of pec minor

Question 79

Dermatomes in the arm

Answer 79

C5 lateral C6 index C7 middle C8 medial T1 upper inner aspect of arm

Question 80

Cutaneuous nerve suply of the hand

Answer 80

Anterior: Medial 3.5 fingers Ulnar 1.5 fingers Posterior Radial 1.5 fingers Ulnar 2.5 fingers Fingertips of 2.5 fingers + thumb = median

Question 81

Cutaenous nerve of the arm

Answer 81

Anterior Supraclavicular Upper and lower lateral nerve of the arm Intercostobrachial nerve Medial and lateral cutaneous nerve of the forearm Posterior Supraclavicular Posterior cutaenous nerve of the arm Medial cutaneous nerve of the arm Posterior cutaneous nerve of the forearm Medial and lateral cutaneous nerve of the forearm

Question 82

Composition of the female breast Glands in the areola

Answer 82

Fat, fibrous tissue, glandular tissue 15-20 lobules of glandular tissue - separated by fibrous septa (goes from subcutaneous tissue to the fascia of the chest wall - known as ligaments of Astley Cooper) Each drains into a lactiferous duct - converges at the nipple - lactiferous sinus Areola - lubricated by glands of montgomery - large modified sebaceous glands

Question 83

Blood supply of the breast

Answer 83

Axillary artery via lateral thoracic and acromiothoracic branches Internal mammary (thoracic) artery via its perforating arteries Intercostal arteries - via lateral perforators Venous system corresponds to the arteries

Question 84

Lymphatic drainage of the breast

Answer 84

**Laterally** via the **axillary vessels** to the **axillary lymph nodes** **Medially** via the **internal mammary vessels** to the i**nternal mammary chain**

Question 85

Male breast

Answer 85

Rudimentary Small primitive ducts may be present, supported by fat and fibrous tissue At risk of carcinoma

Question 86

Where can breast malignanyc spread via lymphatics?

Answer 86

Lymphatic of the contralateral breast Contralateral axillary lymph nodes Cervical nodes Inguinal nodes

Question 87

What is a glactocoele?

Answer 87

Blocked lactiferous duct during lactation

Question 88

Montogomery's tubercles?

Answer 88

Dilatation of montogomery's glands during pregnancy

Question 89

Dimpling of the skin over a breast: cause and pathophysiology

Answer 89

Due to contraction of ligaments of Astley-Cooper - due to malignant infiltration by carcinoma Can also cause nipple inversion