Exam 2- Upper Limb Flashcards
The Hand Consists of…
Carpals, Metacarpals, Phalanges, Muscles, Fascia, Tendons, and Nerves and Vessels.
Flexor Creases
Mark Joints, Attachment points to deep fascia
PAD and DAB
Palmar ADducts and Dorsal ABducts
4 Layers of the Palm
1: Fascia (Palmar Aponeurosis, Flexor Retinacula, and Septa)
2: The short muscles of the thumb and digit 5 (for position adjustmaents and fine movement) and short muscles of the hand
3: The long flexor tendons (power for grip)
4. Adductor of the thumb and deep muscles.
Dupuytren Contraction
Disease with Palmar Fascia
Results in progressive shortening, thickening, and fibrosis of the palmar fascia and aponeurosis
This pulls the 4th and 5th fingers into partial flexion.
Treatment usually involves surgical exision of all fibrotic parts of the palmar fascia to free fingers.
Annular and Cruciform Parts
This is what ligaments are composed of
They prevent bowstringing
Run around the synovial sheath which is around the flexor digitorum superficialis and profundus
Annular is larger and runs more proximal.
Lumbricals
Originate from gaps in the profundus and insert with the lateral cord from the extensor hood.
Flexor Retinaculum
Forms the Carpal Tunnel
Tendons that pass through the carpal tunnel
Flexor Digitorum Superficialis Tendons Flexor Digitorum Profundus Tendons Flexor Pollicis Longus Tendon Flexor Carpi Radialis Tendon Median Nerve
Ulnar Bursa
The synovial sheath containing the long flexor tendons
Midpalmar Space
This space is continuous with the anterior compartment of the arm through the carpal tunnel
This is clinically significant because the spaces of the hand may become infected and consequently become distended with pus
Spaces in the Hand
Midpalmar Space (Pinky side and between middle and index) and Thenar Space (Thumb side and some index)
OAF
Opponens, Abductor, and Flexor
Thenar- Pollicis- Innervated by Recurrent Median Nerve
Hypothenar- Digiti Mini- Innervated by Deep Branch of Ulnar
Radial Nerve
Innervates posterior side of arm, forearm, and hand
Median Nerve
Innervates most of the anterior forearm and 5 muscles of the hands
Innervates most of the flexor muscles in the forearm, the thenar muscles, and the two lateral lumbrical muscles that move the index and middle fingers
Ulnar affects flexor carpi ulnaris and medial half of flexor digitorum profundus… Median is the rest
Ulnar Nerve
Innervates a little of the anterior forearm and most of the hands (especially palmar)
Only forearm muscles it innervates are Flexor Carpi Ulnaris and Flexor Digitorum Profundis
Arteries for the Lumbricals
Superficial Palmar Arch, Common Palmar Digital Arteries, Deep Palmar Arch, and Dorsal Digital Artery
Laceration of the Hypothenar Eminence
Weakness in pinky during opposition and tingling in 4th and 5th and medial palm.
Ulnar Nerve is damaged
Blood Supply to the Hand
There is a very vast blood supply to the hand
Arteries Contributing to the Superficial Palmar Arch and Deep Palmar Arch
Be able to label the arches, the common palmer digital artery, the proper palmer digital, artery and the deep branch of ulnar artery and princeps pollicis artery
Superficial Palmar Arch is a direct continuation of Ulnar Artery (some radial)
Deep Palmar Arch is a direct continuation of Radial Artery (some ulnar)
Page 781 of Moore
Radial Artery splits into Deep Palmar Arch and Princeps Pollicis.
Lymphatics of the Hand
They all drain into one lymph node in the cubital fossa causing tenderness on the medial side
Infection of the Hand
Swells dorsally
Potential spaces may become infected and pus accumulates (hypothenar, thenar, adductor) or spead (midpalmar to proximal forearm)
Radial Nerve Injury effect on Hand
Wrist Drop (due to extensor paralysis) anesthesia on hand is limited to dorsum
Ulnar Nerve Injury effect on Hand
Compression at Ulnar Canal (Guyon tunnel) by pisohamate ligament (Handlebar Neuropathy)
Carpal Tunnel Syndrome
Caused by compression of the median nerve in the carpal tunnel
Manifests as weakness and wasting of thenar muscles, and loss of opposition of the thumb. Anesthesia of over 3.5 digtis thumb side
Causes a depression the appearat base of thumb.
Treated by cutting the flexor retinaculum
Position of Rest
Where all of the joints have the least amount of tension
This comes from Muscle Tone
Sternoclavicular Joint (SC Joint)
Attaches appendicular to axial
Ball and socket between the Sternum and Clavicle
Articular Disc serves two functions: Shock Absorption and prevents Medial Displacement
Very difficult to dislocate.
The ligaments are the Anterior and Posterior sternoclavicular ligaments reinforcing the joint capsule, the interclavicular ligament, and the costoclavicular ligament anchoring the clavicle.
Acromioclavicular Joint (AC Joint)
Clavicle and Scapula
This is the least likely to be dislocated
Main articulation that suspends upper extremity from trunk
Functions: Allows scapula additional ROM and forces to transmit from upper extremity to clavicle
Separated Shoulder is AC Joint
Has 4 Ligaments: Acromioclavicular, Coracoacromial, and Coracoclavicular- Trapezoid and Conoid (These last two cause the shoulder separation)
Glenohumeral Joint
Main Shoulder Joint from the Humerus and Glenoid Fossa
Greatest ROM in the body at the cost of stability
Dislocated Shoulder is Glenohumeral Joint (and this is the most dislocated joint)
Inferior Ligament is the one most likely to fail
SIT are the main muscles for reinforcement
Has 3 Ligaments: Coracohumeral, Transverse Humeral, and lots of Capsular Ligaments (main source of stability) (split into superior, middle, and inferior)
Scapulothoracic Articulation begins rotation when the humerus is abducted 30 degrees
Scapulohumeral Rhythm- 2:1 ratio of humerus movementto scapula movement
Elbow Joint
3 Articulations and 2 Joints Gliding Joint (Capitulum and Radius)- Functional Hinge Proximal Radioulnar Joint- Pivot Joint Trochlea and Ulna- Typical Hinge Motion Joint Capsule surrounds all 3 articulations Main ligaments: Radial (Lateral) Collateral Ligament, Ulnar (Medial) Collateral Ligament (breaks down into Anterior, Posterior, and Oblique Bands), and Anular (Lateral) Ligament (holds radial head in ulnar notch)
Proximal and Distal Radioulnar Joints
Pronation and Supination
Proximal- Proximal radial notch is the pivot
Distal- Ulnar notch of the radius is the pivot point
Interosseus membrane runs between- Tightens when radius is pushed proximally and in supination and loose in pronation
Pronate- Palm Down
Supinate- Palm Up
Wrist (Radiocarpal) Joint (RC Joint)
Ulnar has nothing to do with it
Lunate and Scaphoid articulate with the radius
Reinforced by palmar, dorsal, radial collateral, and ulnar collateral ligaments
Permits flexion/extension, and adduction/abduction
Intercarpal (Midcarpal) Joints
Between proximal and distal rows of the carpis (excluding pisiform)
Responsible for most flexion of the hand
3 articulations: Lateral (radial) part, Central (ball and socket), and Ulnar part
Scaphoid, Lunate, and Triquetrum are the most frequently fractured
Carpometacarpal Joints (CM Joints)
They are plane articulations
The thumb CM Joint is freely movable, saddle articulation
No motion for digits 2 and 3, Limited for 4, and more mobile for 5
Metacarpophalangeal Joint (MP)
The base for all of the fingers
Can flex/extend and adduct/abduct.
Some opposition occurs at digit 5
Interphalangeal Joint (IP)
DIP/PIPIP is technically only the thumb Movements are flexion and extension Synovial Joint capsule reinforced by collateral ligatments Distal Interphalangeal Joint Proximal Interphalangeal Joint
Power Grip
The most energy “expensive” hand action
Medial, Ulnar, Radial, and maybe Musculocutaneous Nerves all effect this
Actions of the Hand
Power Grip- Forcing digits against the palm around an object with opposing force from the thumb
Hook Grip- Carrying a briefcase/bag with handle. Mainly the long digit flexors
Precision Grip- fine control from intrinsic hand muscles like holding a pencil
Pinching- Compression between thumb and index finger
De Quervain’s Tenosynovitis
Inflammation, swelling, and irritation in tendons from thumb to wrist
Painful to turn wrist, grasp, and make a fist
Can cause pain in the forearm
Involves Extensor Pollicis Brevis and Abductor Pollicis Longus Tendons
Lateral Epicondylitis
“Tennis Elbow”
Overuse syndrome of the common extensor tendon
Gradual Symptoms develop
Involves Extensor Carpi Radialis Brevis, Extensor Carpi Ulnaris, and Extensor Digitorum
Medial Epicondylitis
“Golfer’s Elbow”
Overuse syndrome of the common flexor tendon
Involves Pronator Teres, Flexor Carpi Radialis, Palmaris Longus, Flexor Digitorum Superficialis, and Flexor Carpi Ulnaris
Pronator Teres Syndrome
Compression of the Median Nerve that runs between the 2 heads of the Pronator Teres
Tingling or nukbness in the palm, thumb, and fingers (minus pinky)
Frozen Shoulder
Pain and stiffness in the shoulder joint resulting in a loss in ROM
Erb-Duchenne
Injury to the superior brachial plexus
Results in “waiters tip” position because C5-C6 innervates flexors of the arm and a primary supinator of the arm and C7-C8 innervate extensors
Musculocutaneous Nerve
Mixed Nerve (Motor and Sensory Nerves) As it courses distally it becomes primarily cutaneous
Median Nerve
If the Brachial Plexus is injured at all, the median nerve will always be affected
Posterior Cord
The posterior cord is about the same size as the other two put together
Flexor Carpi Ulnaris
Tendon guides Ulnar nerve and artery
Palmaris Longus
Missing in 14% of people
To test, oppose thumb and pinky and flex wrist in order to palpate
Inserted in distal half of flexor retinaculum
Flexor Digitorum Superficialis
Piano Playing Muscle
Hand of Benediction
Median Nerve is injured at the Elbow
Can’t flex digits 1-3
Ulnar Claw
Ulnar Canal Syndrome
Causes “clawing” of the 4th and 5th fingers (hyperextension at the metacarpophalangeal joint with flexion at the PIP)
Their ability to flex is unaffected
Handlebar Neuropathy
Riding a bike and puts pressure on the hooks of their hamates, which compresses their ulnar nerves
Results in sensory loss on the medial side of the hand, and weakness of the intrinsic hand muscles
Off-Shoot Nerves of the Brachial Plexus
Dorsal Scapular
Long Thoracic
Suprascapular
Nerve to Subclavius
Lateral Pectoral Nerve
Upper Subscapular Nerve
Middle Subscapular Nerve (Thoracodorsal Nerve)
Lower Subscapular Nerve
Medial Pectoral Nerve
Medial Cutaneous Nerve to Arm
Medial Cutaneous Nerve to Forearm
Axillary
Musculocutaneous
Median
Radial
Ulnar- Dorsal Scapular- Rhomboids and Levator Scapulae
- Long Thoracic- Serratus Anterior
- Suprascapular- Supraspinatus and Infraspinatus
- Nerve to Subclavius- Subclavius
- Lateral Pectoral Nerve- Pectoralis Major
- Upper Subscapular Nerve- Subscapularis
- Middle Subscapular Nerve (Thoracodorsal Nerve)- Latissimus Dorsi
- Lower Subscapular Nerve- Subscapularis and Teres Major muscles
- Medial Pectoral Nerve- Pectoralis Major and Minor
- Medial Cutaneous Nerve to Arm- Skin of the Arm
- Medial Cutaneous Nerve to Forearm- Skin of Forearm
- Axillary- Teres Minor and Deltoid
- Musculocutaneous- Biceps Brachii, Coracobrachial, and Brachialis
- Median- Innervates most of the flexor muscles in the forearm, the thenar muscles, and the two lateral lumbrical muscles that move the index and middle fingers
- Radial- Innervates the triceps brachii, and the extensor muscles in the posterior compartment of the forearm
- Ulnar- Innervates the muscles of the hand (apart from the thenar muscles and two lateral lumbricals), flexor carpi ulnaris and medial half of flexor digitorum profundus
Klumpke Palsy
A lower brachial plexus injury results from excessive abduction of the arm (e.g person catching a branch as they fall from a tree)
Nerves affected: Ulna and Median nerves.
Muscles paralyzed: All the small muscles of the hand
Sensory functions: Loss of sensation along medial side of arm.
The metacarpophalangeal joints are hyperextended, and the interphalangeal joints are flexed. This gives the hand a clawed appearance.
Know the Pathway of the Arteries
SEE PICTURE
Radial Groove
Radial Nerve and Deep Branch of Brachial Artery course through it together.
Snuff Box
Radial Artery and Radial Nerve in snuff box floor
Ulnar (medial) border: Tendon of the extensor pollicis longus.
Radial (lateral) border: Tendons of the abductor pollicis longus and extensor pollicis brevis.
Proximal border: Styloid process of the radius.
Floor: scaphoid and trapezium.
Quadrangular Space
Axillary and Posterior Circumflex Humeral Artery course through it
Know the Palmar Arches and the arteries that contribute to it. Also be able to label a picture of it (Arches, Common Palmer Digital Artery, Proper Palmer Digital Artery, Artery and the Deep Branch of Ulnar Artery, and Princeps Pollicis Artery)
STUDY PICTURE
Pages 435 and 453 of Atlas
Page 781 of Moore
Nerve and Artery Together
Ulnar Nerve runs with the Superior Ulnar Collateral Artery
Nursemaid’s Elbow
Also known as Babysitter’s Elbow
Nursemaid’s elbow is a common injury of early childhood. It is sometimes referred to as “pulled elbow” because it occurs when a child’s elbow is pulled and partially dislocates. The medical term for the injury is “radial head subluxation.”
Nursemaid’s elbow occurs when there is a partial separation of the radiocapitellar joint. Because a young child’s ligaments are not fully formed, even a mild force on the joint may cause it to shift, or partially dislocate.
The annular ligament surrounds the radius and may be particularly loose in some young children, which may lead to nursemaid’s elbow recurring over and over again.
General Drainage of Lymph of Upper Limb
Right side drains to the Lymphatic Duct
Everything else drains into the Thoracic Duct
Scaphoid
The most frequently fractured carpal bone
Extensor Retinaculum
Function?
General Digit Formula for Fingers
Order of length in most people
Digits 3,4,2,5,1 is in men.
In women, 2 may be the same length as 4. THere are also times tat it’s longer.
General Digit Formula for Fingers
Order of length in most people
Digits 3,4,2,5,1 is in men.
In women, 2 may be the same length as 4. THere are also times tat it’s longer.
Flexor Retinaculum and Extensor Retinaculum
Prevents Bowstringing of the Flexor Muscles and Extensor Muscles
Branches of Radial Nerve
Once the deep branch of the radial nerve leaves/pierces the supination, it becomes the posterior interosseus
Most superficial Muscles/Tendons in the Wrist
Flexor Carpi Ulnaris, FLexor Carpi Radialis, and Palmaris Longus
