Exam 6 Flashcards
1
Q
Rhomboid minor. O, I, I, A
A
- O: spinous processes of C6-C7 - I: medial border of scapula above scapular spine - I: dorsal scapular n - A: retract and elevate scapula
2
Q
Muscles responsible for shoulder/scapula retraction
A
- Retraction: scapula moved posteriorly and medially, moving shoulder posteriorly – squeezing pencil between shoulder blades - Trapezius (primarily), rhomboids, lat dorsi
2
Q
Actions of posterior forearm muscles?
A
- Most are extensors of wrist and/or digits - Brachioradialis is elbow flexor, can supinate too
2
Q
What is a Colles fracture? How does it occur?
A
- Most common forearm fracture where person falls forward onto a extended hand to break fall. Results in distal ulnar fracture with distal fragment displaced dorsally accompanied by avulsion of the ulnar styloid. This is called a “dinner fork” deformity.
3
Q
What is found in the suprascapular notch of the scapula?
A
- Suprascapular artery and nerve with superior transverse ligament of scapula covering the notch, artery is above, nerve is below
3
Q
Subclavius. O, I, I, A
A
- O: junction of 1st rib and manubrium - I: inferior center of clavicle - I: nerve to subclavius - A: depresses clavicle
3
Q
What muscle assists in function of lat dorsi?
A
- Teres major
3
Q
Teres major. O, I, I, A
A
- O: posterior surface of inferior angle of scapula - I: medial lip of intertubercular groove of humerus - I: lower subscapular n - A: adduction and medial rotation of arm – assists lat dorsi
3
Q
Draw the brachial plexus
A
see image
3
Q
Biceps brachii. O, I, I, A
A
- O long head (lateral): supraglenoid tubercle of scapula - O short head (medial): tip of coracoid process - I: radial tuberosity, bicipital aponeurosis blends with antebrachial fascia and attaches to ulna - I: musculocutaneous n - A: supinates, flexes forearm; assists with flexion of shoulder/resists dislocation
3
Q
What movements would you ask patient to do, to distinguish ulnar nerve damage at elbow?
A
Flex digits. Not the wrist.
4
Q
What are the rotator cuff muscles? Innervation of these muscles?
A
- Mnemonic = SITS = supraspinatus, infraspinatus, teres minor, subscapularis - Supra/infraspinatus: suprascapular n - Teres minor: axillary n - Subscapularis: upper/lower subscapular n
4
Q
What is the ulnar canal? Clinical implication
A
- Narrow passage between pisiform and hook of hamate (known as hamulus) through which ulnar nerve passes and compression can occur - Symptoms: a.) numbness and tingling medial 1.5 digits and/or b.) weakness in intrinsic hand muscles (hypothenar compartment and medial 2 lumbricals) - Known as handlebar neuropathy or ulnar canal syndrome. Note: superficial and deep branches come off after this area thus are implicated.
5
Q
What are the most common glenohumeral joint dislocation given the anatomy?
A
- Anterior/inferior
5
Q
Pectoralis minor. O, I, I, A
A
- O: ribs 3-5 - I: medial border of coracoid process of scapula - I: medial pectoral n - A: stabilizes scapula against thoracic cage, elevates rib cage when scapula fixed (accessory respiratory muscle)
5
Q
Levator scapulae. O, I, I, A
A
- O: transverse processes of C1-4 - I: superior angle of scapula - I: dorsal scapular n - A: elevates scapula
5
Q
Median nerve. Nerve root, motor to/sensory from?
A
- Nerve root: C6-T1 - Motor: motor to anterior forearm (except FCU & ½ FDP), thenar muscles, lateral 2 lumbricals - Sensory: cutaneous lateral palm, lateral 3 ½ digits including dorsal fingertips
5
Q
Extensor digiti minimi. O, I, I, A
A
- O: lateral epicondyle - I: extensor expansion of digit 5 - I: deep branch of radial n - A: extends digit 5 at all joints (MCP, PIP, DIP), assist in wrist extension and adduction
5
Q
Which cord of the brachial plexus is the largest?
A
- Posterior
6
Q
Triceps reflex is testing what nerve root?
A
- C7
7
Q
Muscles responsible for shoulder/scapula elevation
A
- Trapezius (primarily), levator scapulae, rhomboids
7
Q
Extensor carpi ulnaris. O, I, I, A
A
- O: lateral epicondyle - I: base of MC V - I: deep branch of radial n - A: extends / adducts wrist (ulnar deviation)
7
Q
How to tell the difference clinically between a clavicle fracture and a dislocation (eg. AC joint)?
A
- Dislocation: weight of upper limb on affected side is pulling arm down and shoulder shows bony promimence. - Fracture: swelling, patient is holding arm up
8
Q
Describe the superficial veins of the arm
A
- cephalic vein (lateral arm) to axillary vein via deltopectoral groove - communication between cephalic and basilic in cubital fossa = medial cubital vein - basilic vein to axillary vein through basilic hiatus
9
Pronator quadratus. O, I, I, A
- O: distal ulnar shaft - I: distal radial shaft - I: anterior interosseous n (branch off median n) - A: pronation
9
Damage to the axilla / midshaft humerus results in what? What nerve is damaged?
- This is aka Saturday night/Honeymoon/Crutch palsy Symptoms? - Damage to radial nerve Symptoms: a.) Weakness in triceps possible b.) Loss of all muscles in posterior compartment of forearm = inability to extend, tonus of flexors c.) Sensory loss to dorsum hand between MC I and II
10
Flexor pollicis longus. O, I, I, A
- O: radial shaft, interosseous membrane - I: base of distal phalanx of pollex - I: anterior interosseous n (branch off median n) - A: flex 1st wrist, CMC, MCP and IP joints
10
What is the lateral thoracic artery a branch of?
- Branch of thoracoacromial or subscapular artery
11
What is the nerve of the posterior compartment of the arm? Action produced by these muscles? Muscles?
- Nerve: radial nerve - Action: extension at elbow - Muscles: triceps brachii, anconeus
11
What is anterior interosseous syndrome? Symptoms? What is damaged?
- Aka Kiloh-Nevin syndrome - Damage to anterior interosseous nerve usually d/t trauma. Loss of FPL and lateral half of FDP resulting in inability to make OK sign with thumb and index finger. No sensory deficits result.
11
What muscle does the musculocutaneous nerve pierce through? What does this nerve become and when?
- Pierces coracobrachialis muscle - Becomes lateral antebrachial cutaneous nerve to supply sensory to lateral forearm
12
What is the nerve of the posterior compartment of the forearm? Action produced by these muscles? Approximate origin of most muscles?
- Nerve: radial nerve - Action: extensors and supinators of forearm and hand - Muscles: brachioradialis, ECRL, ECRB, ECU, ED, EDM, supinator, ABLE muscles (apL, epB, epL, Ei) - Approximate origin: common extensor tendon from lateral epicondyle/supracondylar ridge (for superficial group)
13
When landing on hand, which forearm bone is more likely to be fractured?
- Radius, which is in contact with carpals and transmits most of weight. Ulnar mostly dislocates
15
Brachioradialis reflex is testing what nerve root?
- C6
15
Extensor carpi radialis longus. O, I, I, A
- O: lateral supracondylar ridge of humerus - I: base of MC II (who cares) - I: radial n - A: extends / abducts wrist (radial deviation)
16
Flexor digitorum profundus. O, I, I, A
- O: ulnar shaft, interosseous membrane - I: base of distal phalanges 2-5 - I: medial half (digits 4/5) by ulnar n; lateral half (digits 2/3) by anterior interosseous n (branch off median n) - A: flex wrist, MCP, PIP, DIP
17
Muscles responsible for shoulder/scapula superior rotation
- Superior rotation is lateral rotation of scapula - Trapezius and serratus anterior
17
Pronator syndrome. What does this look like? What nerve is damaged? Where?
- Compression of median n b/w humeral and ulnar heads of pronator teres d/t muscle hypertrophy (or trauma) - Pain in proximal forearm, weakness in flexing fingers and wrist, decreased sensation in lateral palm and fingers
18
Lateral head of the FDP is what muscle?
- Flexor indicis
20
What is Volkman’s ischemic contracture?
- Damage to brachial artery d/t supra-epicondylar fracture of trauma to cubital fossa results in ischemia to downstream muscles and tightness results
21
What travels in the radial groove?
- Radial nerve and profunda brachii artery
21
What nerve would likely be damaged if patient is able to flex, oppose and adduct thumb, but not extend it?
Radial nerve
22
Patient comes to office stating that he has carpal tunnel syndrome symptoms. He says that he has tingling sensations in his palm. What do you think?
- Sensation to palm is via the superficial branch of ulnar to medial side and the lateral side via palmar branch of median nerve - Carpal tunnel syndrome is compression of the medial nerve in the carpal tunnel. The palmar branch of medial has already come off proximal to the tunnel, so these symptoms are unlikely contributed to carpal tunnel syndrome.
23
Supinator. O, I, I, A
- O: lateral epicondyle of humerus, posterior olecranon process - I: proximo-lateral radius - I: deep branch of radial n - A: supinates forearm
23
Dorsal scapular artery is severed during a trauma. What nerve is likely affected? What muscle stops functioning if this is the case? What is the presentation?
- Dorsal scapular nerve - Rhomboids and levator scapulae - Elevation and retraction of the scapula are lost
24
Subscapularis. O, I, I, A
- O: subscapular fossa - I: lesser tubercle of humerus - I: upper and lower subscapular n - A: medial rotation, stabilization of glenohumeral joint
26
Describe levels of axillary lymph node drainage relevant to breast cancer staging. How does this affect prognosis?
- level 1: lateral to pec minor - ~65% five year survival - level 2: deep to pec minor - ~ 31% five year survival - level 3: medial to pec minor - ~ 0% five year survival
27
Pectoralis major. O, I, I, A
- O: clavicular head onto medial clavicle, sternocostal head onto anterior sternum - I: lateral intertubercular groove of humerus - I: lateral and medial pectoral n - A: adductor and medial rotator when fully activated, clavicular head flexes humerus, sternocostal extends from flexed position
29
Anatomical snuff box. Borders and contents?
- Borders a.) Tendons of APL and EPB – note these two run together, not both EPB and EPL b.) Tendon of EPL - Contents: radial artery - Sensory branch of radial nerve runs over this region
31
Extensor carpi radialis brevis. O, I, I, A
- O: lateral epicondyle - I: base of MC III (who cares) - I: deep branch of radial n - A: extends / abducts wrist (radial deviation)
32
Supraspinatus injury presents how?
- Patient unable to perform the initial 15-20 degrees of arm abduction. Deltoid muscle is the main abductor, but has no leverage when the arm is completely relaxed and at the side. These patients will attempt to swing arm out first.
33
What are axio-appendicular muscles attaching the upper limb to thorax?
- Anteriorly: pec major, pec minor, subclavius and serratus anterior - Posteriorly: trap, lat dorsi, lev scap, rhomboid major, rhomboid minor
34
What artery supplies blood to upper limb?
- Subclavian which changes its name to axillary (with 3 parts) in axilla and brachial in brachium (arm)
35
Infraspinatus. O, I, I, A
- O: infraspinous fossa of scapula - I: greater tubercle of humerus - I: suprascapular n - A: lateral rotation, stabilization of the glenohumeral joint
35
30 yo woman on hike falls on some sharp rocks, catching herself with her right hand, and resulting in deep lacerations of her medial palm and wrist. She bandages the wound and continues on. In week following, she begins to complain of numbness in palmar aspect of medial 1 ½ digits and general hand weakness. When asked to make a fist, flexion occurs at all IP joints; however, you notice clawing (extension at MCP and flexion at IP joints) of medial two digits of her right hand while at rest. She is unable to abduct her fingers against resistance or to hold a piece of paper bw thumb and lateral surface of index finger. a.) Why is flexion present at all IP joints? b.) Loss of which muscles are responsible for clawing of medial 2 digits? c.) What muscles are responsible for her inability to grip the paper between the thumb and lateral index finger? d.) What would be different if the injury were to occur at the elbow?
- numbness medial 1 ½ digits = ulnar n damage - general hand weakness = intrinsic hand loss = ulnar n damage - flexion at all IP joints = medial nerve function ok - clawing at rest medial two digits = loss of medial MCP flexors, medial IP extensors = medial lumbricals not function = ulnar n damage - loss of thumb to lateral surface index finger tension = loss of adductor pollicis = ulnar n damage - specifically here we have deep branch of ulnar n damage a.) FDS and FDP, median and ulnar intact b.) Lumbricals, clawing at 3/4 is ulnar n damage c.) Deep branch of ulnar innervating the adductor pollicis and 1st dorsal interosseous (wasting here too) d.) Ulnar n damage at elbow = complete loss of all muscles distally innervated by ulnar n = loss of FCU, medial half of FDP also affected in addition to above
36
What muscles are found in the superficial anterior compartment of the forearm?
- PT, FCR, FDS, FCU, palmaris longus
37
Teres minor. O, I, I, A
- O: lateral border of scapula - I: greater tubercle of humerus - I: axillary n - A: lateral rotation, stabilization of glenohumeral joint
37
Extensor indicis. O, I, I, A
- O: posterior ulna, interosseous membrane - I: extensor expansion of digit 2 - I: posterior interosseous n (of radial) - A: extends index finger at all joints, assists with wrist extension
37
14 yo girl slashed her right wrist with a razor blade. She was rushed to ED. After stopping bleeding, PEX revealed she could adduct, abduct and extend her thumb but was unable to oppose it. She had lost some fine control of the movements of her second and third digits and there was loss of sensation over her lateral three and a half digits. a.) Why can she adduct her thumb? b.) Why can’t she oppose her thumb? c.) Why can she abduct and extend her thumb? d.) What nerve is damaged? e.) Why are digits 2/3 affected?
- A.) Adduct thumb = adductor pollicis innervated by deep branch of ulnar - B.) opponens pollicis innervated by recurrent branch of median nerve, which is damaged - C.) Abduction of thumb by abductor digiti minimi brevis and longus. Longus (main abductor) is innervated by posterior interosseous branch of radial n, which is still in tact. Brevis (intrinsic thenar) nerve is innervated by recurrent branch of median, which is damaged. Extension of thumb by extensor pollicis brevis and extensor pollicis longus, which is innervated also by posterior interosseous of radial, which is not damaged. - D.) median (recurrent branch?) - E.) branch of median also innervates the lateral 2 lumbricals of digits 2/3
37
You ask patient to hold a flat piece of paper between their 2nd and 3rd digits. What muscles are you testing?
Plantar interosseous (PADS)
38
Radius landmarks
- Head and neck - Radial tuberosity - Shaft - Styloid process - Interosseous crest
39
If the axillary artery is accidentally ligated, how does the scapula get blood?
- Thyrocervical trunk – transverse cervical – dorsal scapular – thoracodorsal – subscapular – axillary
40
Describe the dermatome pattern of the upper limb. Correlate nerve roots with specific cutaneous regions.
- Pre-axial to post-axial sequence. Pre-axial is lateral side while post-axial is medial side. - C5: shoulder - C6: tip of thumb - C7: cannot test, too variable - C8: tip of fifth - T1: medial forearm at cubital region
40
What is the difference between a dermatome vs a peripheral nerve field vs a myotome?
- Dermatome is an area of skin innervated by a specific single nerve root - Peripheral nerve field is an area of skin composed of overlapping dermatomes with the supplying nerve made up of multiple roots - Myotome is the set of muscles innervated by a specific nerve root - When assessing for nerve root injuries, use myotomes and dermatomes. When assessing for specific nerves injuries distal to root, use peripheral nerve fields.
41
Extensor digitorum. O, I, I, A
- O: lateral epicondyle - I: extensor expansion of digits 2-5 - I: deep branch of radial n - A: extends digits 2-5 at all joints (MCP, PIP, DIP), assist in wrist extension
42
What are the superficial posterior compartment forearm muscles?
- ECRB, ED, EDM, ECU, brachioradialis, anconeus
43
Lateral thoracic artery travels with what nerve? In relation to what muscle?
- Long thoracic nerve superficial to the serratus anterior
43
There is a blockage in the middle of the brachial artery. How could blood still get to the forearm and hand?
Collateral arteries of arm (duh!) Which? This might be good to draw out and tell exactly.
44
Joints of the hand. Name the joint, type, movement?
1.) Intercarpal joints: - Type: plane - Movement: sliding/translation 2.) Carpometacarpal joints (CMC): - Type: plan - Movement: sliding/translation 3.) Trapeziometacarpal joint: - Type: saddle - Movement: flexion, extension, abduction, adduction, opposition 4.) Metacarpophalangeal joints (MCP): - Type: condyloid - Movement: flexion, extension, abduction, adduction 5.) Interphalangeal joints (IP = PIP + DIP) – only IP for thumb - Type: hinge - Movement: flexion, extension
45
Brachialis. O, I, I, A
- O: ant humerus (distal half) - I: coronoid process and ulnar tuberosity of ulna - I: musculocutaneous and radial n - A: flexes forearm
46
19 yo male football player experienced lateral hyperflexion of his head and neck to right during tackle. Afterwards, he complained of numbness in his left upper limb. Palpation and radiographs confirmed that shoulder was not dislocated and no fractures were present in c-spine or pectoral girdle. 30 minutes later he began to experience severe burning pain in shoulder, lateral arm and forearm. Exam revealed he could not abduct or otherwise move the shoulder, nor could he flex at elbow. a.) What bests explains the pattern of burning/numbness? b.) What best explains the pattern of muscle dysfunction? c.) What is the level of the injury?
- A.) Dermatomal distribution. For peripheral nerve distribution, need to have damaged 3 nerves separately. - B.) No abduction at shoulder (C5), no flexion at elbow (C5) – myotomal pattern. - C.) C5 is definitely affected. Injuries such as this often also affect the C6 root or the upper trunk. If C6 injury, should see wrist flexion too. So this case isn’t Erb-Duchenne palsy. If it was, waiter tips presentation.
47
If recurrent branch of median nerve was damaged, what movements of hand would be impaired?
Opposition to 1st digit
49
What is the difference between the anatomical and surgical neck of the humerus?
- Surgical neck: thinnest part of humerus where injury is likely - Anatomical neck: bone epiphysis with primary ossification center
51
Supraspinatus. O, I, I, A
- O: supraspinous fossa of scapula - I: superior aspect of greater tubercle of humerus - I: suprascapular n - A: initiates abduction for first 15-20 degrees then deltoid takes over, stabilization of the glenohumeral joint
51
What is nursemaid’s elbow? How does this occur?
- Dislocation of radial head from annular ligament and away from humerus and ulna - Abrupt yanking of arm upwards
52
Describe blood supply to the hand. How to test for disruption in the supply?
- Blood supply to hand via radial and ulnar arteries via deep and superficial palmar arches 1.) Ulnar: a. Deep palmar branch of ulnar artery b. Superficial palmar arch i. Common palmar digital arteries (4) 1. Proper palmar digital arteries (8) – digits 2-4 ii. Proper palmar digital artery to 5th digit 2.) Radial: a. Superficial palmar branch of radial artery b. Deep palmar arch i. Palmar metacarpal arteries c. Princeps pollicis artery d. Radial indices artery (can originate from c.) - Test: Allen’s test = occlude both and release one to see
53
Humerus landmarks
- Head - Anatomical neck - Surgical neck - Greater tuberosity - Lesser tuberosity - Intertubercular groove/sulcus - Deltoid tuberosity - Radial groove - Coranoid fossa - Lateral/medial epicondyles - Capitulum - Trochlea - Olecranon fossa
54
Damage to forearm that causes inability to extend thumb and MCP joints is d/t trauma to what specific nerve?
- Deep branch of radial nerve
54
Ulnar recurrent divides into both anterior and posterior. Name this as ulnar recurrent in lab.
Ulnar recurrent divides into both anterior and posterior. Name this as ulnar recurrent in lab.
55
Groups of axillary nodes
1.) humeral (lateral axillary fossa) 2.) subscapular (posterior axillary fossa) 3.) pectoral (medial wall of axilla) 4.) central (deep to pec minor) 5.) apical (apex of axillary fossa)
56
Which lymph nodes drain the breast tissue?
- ~75% of lymph from breast drained in axillary nodes
58
Musculocutaneous nerve. Nerve root, motor to/sensory from?
- Nerve root: C5-7 - Motor: motor to anterior arm - Sensory: cutaneous lateral forearm via lateral antebrachial cutaneous n branch
60
The ulnar nerve travels with what muscle in the forearm?
- FCU with ulnar artery
61
Scapula landmarks
- Glenoid cavity/fossa - Supraglenoid and infraglenoid tubercles - Suprascapular notch - Neck - Spine - Acromion - Coracoid process - Superior and inferior angles - Lateral and medial borders - Subscapular fossa - Infraspinous fossa - Supraspinous fossa
61
Name the 3 parts and branches from each for the axillary nerve
- Clavicle to proximal pec minor: 1st part - Deep to pec minor: 2nd part - Distal to pec minor: 3rd part 1.) 1st part a.) superior thoracic artery 2.) 2nd part a.) thoracoacromial trunk: Mnemonic (Cadavers Are Dead People): Clavicular, Acromial, Deltoid, Pectoral b.) lateral thoracic artery 3.) 3rd part a.) ant circumflex humeral artery b.) post circumflex humeral artery c.) subscapular artery: circumflex scapular artery, thoracodorsal artery
61
Hand of the Benediction. What does this look like? What nerve is damaged? Where?
- Inability to flex lateral three digits during active formation of tight fist. - Damage to median nerve in cubital fossa or more proximal
61
What is handcuff palsy? Nerve implicated? Symptoms?
- Compression of superficial branch of radial nerve at wrist (using handcuffs inappropriately ;) ) - Symptoms: paresthesia over dorsum of hand bw MC I and II
62
What structures emerge from the distal supinator muscle?
- Posterior interosseous nerve and artery
63
Adductor pollicis is a thenar muscle. True / False. What is it innervated by?
- False. - Innervated by deep branch of ulnar n
65
What is the main flexor of the elbow?
- Brachialis muscle
67
Latissimus dorsi. O, I, I, A
- O: spinous processes T7-T12, thoracolumbar fascia, iliac crest - I: floor of intertubercular groove on humerus - I: thoracodorsal n - A: adduct, extends and medially rotate humerus – think pull-up
68
Which muscle(s) is/are the lateral rotator(s) of the arm? What nerve supplies these? What happens if there is damage to this/these nerve(s)?
- Infraspinatus and teres minor - Innervated by suprascapular and axillary nerves respectfully - Patient will present with medial rotation to the arm. Damage to proximal parts of brachial plexus causes this.
70
Skydiver complained of right arm weakness and numbness that began after training in a vertical wind-tunnel in which the arms were abducted, extended and externally rotated for a prolonged period of time. Exam revealed weakness in right elbow flexion and forearm supination, and diminished sensation in right lateral forearm. Electrodiagnostic testing revealed decreased amplitude in right lateral antebrachial cutaneous nerve sensory nerve action potential. a.) What nerve is damaged
- a.) musculocutaneous nerve. Muscular part to anterior arm. Not complete loss of flexion in elbow as brachialis receives radial nerve innervation. Also brachioradialis is a flexor innervated by radial. Biceps brachii is supinator too. Can still supinate some using supinator muscle. Cutaneous becomes lateral antebrachial cutaneous and therefore decreased sensation in lateral forearm.
71
Abductor pollicis longus. O, I, I, A
- O: posterior ulna, radius, interosseous membrane - I: base of MC I - I: posterior interosseous n (of radial) - A: abducts pollex
72
Name and describe the three elbow joints. What type of joint is each, what movements occur at each joint and what ligaments are found at each?
1.) Humeroradial: capitulum of humerus with head of radius - Type: functional hinge (technically ball and socket) - Movements: flexion, extension, pronation, supination - Ligaments: annular ligament surrounds head of radius and attaching to lateral epicondyle via radial collateral ligament 2.) Humeroulnar: trochlea of humerus with trochlear notch of ulna - Type: hinge joint - Movements: flexion, extension - Ligaments: anterior, posterior and oblique ulnar collateral ligaments attached from coronoid and olecranon to medial epicondyle of humerus 3.) Radioulnar: radius to ulnar - Type: pivot joint - Movements: radius rotates 180 at this joint through pronation and supination - Ligaments: annular ligament
72
Manifestations of ulnar nerve damage
- Ulnar claw: injury at elbow or more proximal a. ulnar claw (passive sign): MCP 4/5 hyperextended with IP joints flexed b. compromise of abduction/adduction of digits c. atrophy of first dorsal interosseous muscle d. sensation loss to medial palm and 1 ½ digits - Cubital tunnel syndrome: compression of ulnar nerve in cubital tunnel a.) numbness and paresthesia of medial palm and medial 1 ½ digits
73
Wrist joint. Name, bones involved, type, movement?
- Radiocarpal joint - Bones: radius and scaphoid+lunate. Note: no ulna contacting carpals, separated by articular disk - Type: condyloid synovial - Movement: flexion, extension, abduction, adduction (greater than abduction – think about space with ulna)
74
Anconeus. O, I, I, A
- O: lateral epicondyle of humerus - I: posterior ulna (lateral surface of olecranon) - I: radial n - A: extension of elbow, stabilize elbow
75
If patient could not flex their forearm at elbow and only weakly supinate it, what nerve is likely damaged?
- Musculocutaneous nerve
75
A patient has point pain at the top of the shoulder joint and is unable to abduct the arm from a resting position without pain in the first few degrees of abduction. Which muscle (s) is/are involved? Discuss.
Supraspinatous
77
Describe anastomosis around the humerus
- Anterior circumflex humeral anastomosis with posterior circumflex humeral. Both arise from 3rd part of axillary
79
Describe myotome testing of the upper limb.
- C5: abduction of shoulder, flexion of elbow (mnemonic: five fingers in face) - C6: extension of wrist - C7: flexion of wrist, extension of fingers - C7-8: extension of elbow - C8: flexion of fingers - T1: ab/ad-duction of fingers
81
56 yo male treated surgically for avascular necrosis of his left navicular. His surgery was without complications and he was discharged the same day with a cast, axillary crutches and instructions on wound care. Three weeks later, he noticed numbness and weakness of his hands and wrist muscles on both sides. Over the next few hours he noticed gradual difficulty moving his fingers and his wrist and was unable to hold onto his crutches. On exam, some weakness of tricepts on both arms and bilateral wrist drop was observed. Pt had reduced sensation to dorsal forearm, hand and first digit. a.) What nerve is damaged
- a.) Radial nerve. Proximal nerve injury = extensors to fingers and wrist affected, therefore wrist drop.
82
Ulnar nerve. Nerve root, motor to/sensory from?
- Nerve root: C8-T1 - Motor: motor to FCU, ½ FDP and all intrinsic hand muscles (except thenar muscles, lateral 2 lumbricals) - Sensory: cutaneous medial palm and medial 1 ½ digits
83
30 yo male climber jumps for a hold while lead climbing. He misses and begins to fall, grabbing onto another hold on his way down, jarring his arm upward. He feels a burning sensation in his axilla and is unable to finish the route. It quickly becomes apparent that he is unable to flex, abduct or adduct his digits and the fingers assume a claw position involving hyperextension at the MCP and flexion at the IP joints. He maintains the ability to flex and extend his wrist and extend his fingers. a.) What best explains the position of the fingers? b.) What best explains the pattern of muscle dysfunction? c.) What is the level of injury? d.) What sensory deficits do you anticipate?
- a.) Loss of lumbricals = hyperextension of MCP joints and IP joints in digits 2-5, involving both median and ulnar nerves - b.) Loss of abduction/adduction of digits = T1. Loss of digital flexion = C8 involvement. Myotomal pattern - c.) C8 and T1 affected, so lower trunk injury - d.) loss of sensation in C8 and T1 dermatome = medial arm, forearm, 5th digit - This is Klumpke’s paralysis, can also present with Horner’s syndrome
84
During venipuncture of the arm, what is the typical vein used?
- Medial cubital vein
86
What are venae comitantes?
- Deep veins that accompany arterial blood supply in arm/forearm
87
Palmaris longus. O, I, I, A
- O: medial epicondyle of humerus - I: palmar aponeurosis - I: median n - A: flexion of wrist, tense palmar aponeurosis
89
Atrophy of deltoid would make one suspicious of injury at what anatomical space?
- Quadrangular space where axillary nerve is present
90
Carpal tunnel syndrome. What is it? Nerve implicated? Symptoms?
- Median nerve compression in carpal tunnel - Symptoms: a.) Loss of sensation/tingling in digits 1-3 b.) Loss of motor to thenar eminence muscles (via recurrent branch of median n): Abductor pollic brevis, flexor pollicis brevis, opponens pollicis – ultimately can lead to thenar wasting (ape hand) with thumb being laterally rotated, adducted with inability to oppose thumb c.) Loss of motor to lateral 2 lumbricals
91
Biceps reflex is testing what nerve root?
- C5
93
Which head of the triceps brachii passes between the teres muscles?
- Long head
95
Muscles responsible for shoulder/scapula protraction
- Protraction: scapula moved anteriorly and laterally, moving shoulder anteriorly - Serratus anterior (primarily), pec major/minor
97
What is the main blood supply to the deltoid?
- Posterior circumflex humeral artery
99
Extensors of the arm are innervated by what nerve?
- Radial nerve (as radial nerve, as deep branch, as posterior interosseous) - Radial: triceps brachii, anconeus - Deep branch (5): ECRB, ECU, EDM, ED, supinator - Posterior interosseous (4) – after supinator: ABLE muscles (apL, epB, epL, Ei) - Superficial branch of radial nerve does cutaneous innervation to dorsum of hand - Remember first 2 (triceps and anconeus) and last 4 (ABLE).
99
Patient arrives in ED with stab wound to the posterior shoulder. Upon further inspection, it seems as if the stab wound penetrated the quadrangular space. What are you concerned about? Is blood supply to the humerus compromised? What muscular deficits may this patient present with?
- Axillary nerve, posterior circumflex humeral artery - Anastomosis of posterior circumflex humeral artery with anterior circumflex humeral artery - Nerve innervates teres minor and deltoid - Deficit = loss of abduction (from 15/20-90 degrees), weak flexion/extension/rotation at shoulder by deltoid. Loss of lateral rotation/stabilization of glenohumeral joint by teres minor. Atrophy of these muscles would occur.
100
What is ulnar claw? Describe motor and sensory symptoms/deficits.
- Damage to ulnar nerve typically at cubital tunnel or medial arm leading to inability to make a tight fist d/t loss of intrinsic hand muscles. - Symptoms: a.) Ulnar claw: clawing of digits 4/5 displaying extension at MCP, flexion at PIP and DIP joints – this is passive sign b.) Wasting/atrophy of first dorsal interosseous e. Sensory: sensation loss to medial palm and medial 1 ½ digits
102
What nerve follows the posterior circumflex humeral artery?
- Axillary nerve
102
What is the blood supply to the latissimus dorsi?
- Thoracodorsal artery
103
What is the blood supply to the anterior forearm and hand?
- Radial, ulnar and anterior interosseous (off common interosseous, off ulnar) arteries
105
Why is a scaphoid fracture diagnosis needed urgently?
- Radial artery sends blood supply to it that enters from distal aspect and travels proximally. In injury with falling forward onto hand, this branch can be damaged and failure to treat leads to avascular necrosis in proximal part of bone.
106
Describe anastomoses around the scapula
- Both arteries could be from thyrocervical trunk, so if that is occluded, scapula does not receive blood 1.) dorsal scapular (directly from subclavian or off transverse cervical of thyrocervical) anastomoses with thoracodorsal of subscapular – axillary 2.) suprascapular (directly from subclavian or off of thyrocervical) – circumflex scapular of subscapular – axillary
107
Patient presents to ED with subglenoid glenohumeral dislocation. You suspect injury to what?
- Subglenoid displacement of humeral head can cause damage to contents of quadrangular space, which contains posterior circumflex humeral artery and axillary artery.
109
24 yo male soccer player presented with dull right shoulder pain. Reported onset following a fall onto abducted and laterally rotated right arm during soccer game 2 weeks earlier. Told he had sustained anterior glenohumeral dislocation which was reduced by team physician on site. Patient’s shoulder was immobilized in a sling after reduction. Pt told not to abduct or externally rotate shoulder. a.) What nerve is damaged? b.) If shoulder were not immobilized, what action(s) would be compromised.
- a.) Axillary nerve - b.) Deltoid innervated by axillary, so issues with abduction
110
Triceps brachii. O, I, I, A
- O long head: infraglenoid tubercle of scapula - O lateral head: posterior humerus (superior to radial groove) - O medial head: posterior humerus (inferior to radial groove) - I: olecranon process - I: radial n - A: long head extends/adducts shoulder, all heads extend elbow
112
What is the blood supply to the posterior forearm?
- Posterior interosseous (off common, off ulnar) a
114
Thoracic outlet syndrome. What is it? What structures are implicated? Symptoms?
- Constriction of area between first rib, clavicle and scalene muscles through which neurovascular bundle to upper limb passes - Mostly involves C8 and T1 – medial and ulnar nerves, less common to have compression of subclavian - Symptoms: pain, numbness, weakness, edema, muscle fatigue and cold skin of upper limb
115
Trapezius. O, I, I, A
- O: occipital bone, spinous process C1-T12 - I: lateral 1/3rd clavicle, acromion, superior border scapular spine - I: accessory nerve (CN XI) - A: elevate, retract, rotate and depresses scapula
117
Describe peripheral nerve testing of the upper limb: axillary nerve, musculocutaneous n, radial nerve, medial nerve, ulnar nerve
- Axillary: lateral aspect deltoid - Musculocutaneous: lateral forearm (specifically via lateral antebrachial cutaneous n) - Radial: dorsum of webbing between thumb and index finger - Median: tip of index finger - Ulnar: medial tip of fifth digit
118
What is the blood supply to the arm?
- Brachial artery
119
Muscles responsible for shoulder/scapula depression
- Gravity (primarily), pec major/minor, lat dorsi, trapezius, serratus anterior
121
What nerve and arteries are found in the carpal tunnel?
- Median nerve after it gave off palmar branch to medial palm with 9 tendons. No arteries.
123
Supra-epicondylar fracture results in what damage and symptoms? Clinical presentation. Describe nerves affected and how they explain the deficits experienced.
- Cubital fossa contents (mostly brachial artery and median nerve) damage. - Clinical presentation = tightness of forearm muscles, Hand of the Benediction (inability to flex lateral three digits when asked to ACTIVELY do – this is very important!) - Arterial deficit a.) Brachial artery = ischemia of forearm/tightness of muscles = Volkman’s ischemic contracture - Motor deficit a.) Median nerve injury = loss of anterior forearm muscles (except ulnar innervated) and thenar muscles = inability to flex lateral three digits, ?loss/diminished of flexion wrist?, loss of thenar muscle function (abduction, flexion, opposition) - Sensory deficit a.) Numbness of lateral palm, tips of lateral three digits?
124
Where is palpating for scaphoid fracture, what landmark would you use?
- Proximal to anatomical snuff box.
125
20 yo male presents in ER with deep laceration to arm proximal to cubital fossa. Got into heated argument with roommate and punched through sliding glass door causing injury. Surgery is performed to ensure blood supply to forearm is not compromised and wound is closed. In following weeks it becomes apparent that some nerve damage occurred. Exam reveals decreased sensation over lateral palm and digits 1-3. When asked to make fist, patient can successfully flex 4/5 but lateral three digits remain extended. Patient’s thumb remains in adducted position and he cannot touch tip of his thumb to the tip of the 5th digit. When asked to flex the wrist, the hand adducts. a.) Why is his thumb adducted? b.) Why do digits 1-3 remain extended? c.) What nerve is damaged? d.) Why does his hand adduct when asked to flex wrist?
- Loss of abduction, adductor pollicis unopposed. Abductor pollicis brevis not working (median nerve innervation – recurrent branch). Would abductor pollicis longus work still? Adductor pollicis intact (ulnar n) - Inability to flex lateral 3 = FDS, lateral half, lateral FDP and FPL loss = median nerve damage - Median nerve damage - Adduction (ulnar deviation). Flexors of wrists are FCU and FCR mainly. FCR is median innervated. FCU works without help to flex wrist (by FCR) and adduction occurs. - \*\* This is similar to Hand of the Benediction
126
3 joints of shoulder
1.) Sternoclavicular joint 2.) Acromioclavicular joint 3.) Glenohumeral joint
127
Serratus anterior. O, I, I, A
- O: lateral ribs 1-8 - I: medial anterior border of scapula - I: long thoracic n --C5-7-- (on superficial surface) - A: protracts, rotates (prime), stabilizes scapula on thorax
128
What is the vincula?
- Short ligamentous bands b/w anterior surfaces of phalanges and flexor tendons
129
What are the deep posterior compartment forearm muscles?
- ABLE muscles, supinator
131
Anastomoses of hand arteries
- ulnar – superficial palmar arch – superficial palmar branch of radial – radial - radial – deep palmar arch – deep palmar branch of ulnar – ulnar
133
What are the intrinsic muscles of the hand?
\*Mnemonic: All For One And One For All OR AOF A OFA - Abductor pollic brevis, flexor pollicis brevis, opponens pollicis - Abductor digiti minimi, opponens digiti minimi, flexor digiti minimi brevis - Adductor pollicis (transverse/oblique head) \*not thenar muscle - Lumbricals (4) - Dorsal interossei (DABS) (4) - Palmar interossei (PADS) (3)
134
Axillary nerve. Nerve root, motor to/sensory from?
- Nerve root: C5-6 - Motor: deltoid, teres minor - Sensory: cutaneous lateral arm
136
What muscles are found in the deep anterior compartment of the forearm?
- FDP, FPL, PQ
137
Pronator teres. O, I, I, A
- O humeral head (superficial): medial epicondyle of humerus - O ulna head (deep): proximal ulna - I: midshaft of radius - I: median n - A: pronation
138
When is the biceps brachii a good elbow flexor?
- When FA is supinated
139
What is the concern with having cervical ribs?
- Compression of subclavian a, brachial plexus leading to TOS
141
Ulna landmarks
- Olecranon - Coronoid process - Ulnar tuberosity - Shaft - Head - Styloid process - Interosseous crest
142
Deltoid. O, I, I, A
- This muscle has origin lateral, anterior and posterior to glenoid fossa - O: lateral 1/3rd clavicle, acromion, scapular spine - I: deltoid tuberosity of humerus - I: axillary nerve - A: posterior fibers extends/laterally rotates, lateral fibers abducts, anterior fibers flex/medially rotates
143
Name the bones and joints of the hand
Bones: 1.) Carpals (proximal row lateral to medial then distal row lateral to medial): Mnemonic = Some Lovers Try Positions That They Can’t Handle - scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate, hamate 2.) Metacarpals: 1-5 3.) Proximal phalanges: 1-5 4.) Middle phalanges: 2-4 5.) Distal phalanges: 1-5 - Joints: carpometacarpal (CMC, 2-4), trapeziometacarpal (1), intercarpal joints, MCP, interphalangeal joints (PIP, DIP)
145
Innervation to lumbricals of hand. Origin and insertion? Function?
- 2 x medial by deep branch of ulnar n - 2 x lateral by median n - Origin: tendon of flexor digitorum profundus - Insertion: extensor expansion - Function: flex MCP joints, extend PIP and DIP joints
147
Muscles responsible for shoulder/scapula inferior rotation
- Inferior rotation is medial rotation of scapula - Lat dorsi (primarily), gravity, levator scapulae, rhomboids, pec major/minor
148
Cubital fossa. Borders, contents?
- Elbow pit – hahahahah! Borders: - Line connecting medial and lateral epicondyles - Brachioradialis - Pronator teres Contents: - brachial division into ulnar/radial arteries and veins - medial and radial nerves - access to medial cubital veins - biceps brachii tendon - bicipital aponeurosis
149
Which is the largest branch of the axillary artery?
- Subscapular artery
151
Two muscle groups attaching upper limb to thorax
1. Axio-appendicular: extrinsic – originate elsewhere and insert onto arm 2. Scapulohumeral: intrinsic – originate on arm and insert onto scapular
152
What travels through the glenohumeral joint?
- Tendon of biceps brachii long head
153
Innervation to dorsal and palmar interossei muscles
- Deep branch of ulnar n
154
Clavicle landmarks. How can you tell which side is superior?
Clavicle landmarks. How can you tell which side is superior? - Acromial end - Sternal end - Shaft - Conoid tubercle \* Superior aspect is smooth
155
Corachobrachialis. O, I, I, A
- O: tip of coracoid process of scapula - I: medial humerus (middle third) - I: musculocutaneous n - A: flexion of shoulder, adduction of arm, prevents dislocation of humerus
157
What is the nerve of the anterior forearm compartment? Action produced by these muscles? Muscles? Approximate origin of most muscles?
- Nerve: ulnar and median nerves - Action: flexion, abduction, adduction and pronation of forearm/wrist - Muscles: pronator teres, palmaris longus, FCR, FCU, FDS, FDP, FPL, pronator quadratus - Approximate origin: common flexor tendon from medial epicondyle (for superficial group)
158
Klumpke’s paralysis. Mechanism of injury that can cause this? Clinical presentation. Describe nerves affected and how they explain the deficits experienced.
- What: Lower brachial plexus injury with lesion to roots C8-T1. Mechanism: arm pulled/jarred upward, ie. during birthing process, falling from tree and trying to hang on. Therefore aka strap hanger’s syndrome. - Presentation: “claw hand” (full claw) – hyperextension of MCP joints, radial deviation of wrist, wasting of intrinsic hand muscles/FCU and ulnar half of FDP, arm supination and wrist extension. Also may present with Horner’s syndrome: miosis (pupil constriction), ptosis (eyelid drooping) and anhydrosis (lack of sweat) on ipsilateral injury side. - Nerves affected: ulnar nerve, part of median nerve (C6-T1) - Motor deficit: a.) Loss of ulnar nerve (innervating FCU, medial ½ FDP and intrinsic hand muscle (except thenar and lateral 2 lumbricals) = radial deviation, wrist extension, extension of MCP b.) a.) with weakness to median nerve (anterior FA except ulnar innervation, thenar muscles and lateral 2 lumbricals) = flexion at PIP, DIP - Sensory deficit: a.) No ulnar, MBP and MABC = C8-T1 dermatome loss = loss of sensation to medial arm, forearm and hand - Horner’s syndrome: Loss of sympathetics as T1 carries sympathetic rami communicantes to SNS chain. - Presentation: miosis (pupil constriction), ptosis (eyelid drooping) and anhydrosis (lack of sweat) on ipsilateral injury side. - Why? a.) Ptosis: d/t superior tarsal muscle loss b.) Miosis: d/t unopposed PSNS c.) Anhydrosis: d/t loss of sweat gland innervation
159
Compartments of the hand. Function, innervation, muscles?
\* Know that this is clinical definition, some text books list 5 compartments. 1.) Thenar compartment - Function: flexion, opposition and abduction of thumb - Innervation: recurrent branch of median nerve, except deep head of FPB - Muscles: Abductor pollicis brevis, flexor pollicis brevis (deep head by deep branch of ulnar n.), opponens pollicis 2.) Hypothenar compartment - Function: flexion, opposition and abduction of the 5th digit - Innervation: deep branch of ulnar n. - Muscles: Abductor digiti minimi, flexor digiti minimi (brevis), opponens digiti minimi
160
Rhomboid major. O, I, I, A
- O: spinous processes of T1-4 - I: medial border of scapula below scapular spine - I: dorsal scapular n - A: retract and elevate scapula
161
What is the largest branch of the brachial artery?
- Profunda brachii
163
Common locations for radial nerve damage
1.) Axilla / proximal / midshaft humeral arm: aka Saturday night/Honeymoon/Crutch palsy, wrist drop 2.) Damage in forearm 3.) Damage at wrist: handcuff palsy Triangular triangle. Borders and contents. Borders: - Lateral: lateral head of triceps - Medial: long head of triceps - Superior: teres major Contents: radial nerve and deep brachial artery
164
What is the cubital tunnel?
- Formed by the humeral and ulnar heads of the flexor carpi ulnaris posterior to the medial epicondyle – ulnar nerve in this vicinity and can be compressed leading to cubital tunnel syndrome, which is numbness/paresthesia of medial 1 ½ digits and medial palm
165
Radial nerve. Nerve root, motor to/sensory from?
- Nerve root: C5-8 - Motor: motor to posterior arm and forearm, ½ brachialis - Sensory: cutaneous dorsolateral hand and posterior forearm
166
Describe motions of thumb
\*\* Since thumb is rotated 90 degrees away from other digits, movements are rotated too see picture - Opposition involves all of these motions in addition to rotation of MC
167
Extensor pollicis longus. O, I, I, A
- O: posterior ulna, interosseous membrane - I: base of distal phalanx of pollex - I: posterior interosseous n (of radial) - A: extends pollex at all joints
168
Quadrangular space. Border, contents?
- Borders: a.) Lateral: surgical neck of humerus b.) Medial: long head of triceps brachii c.) Superior: teres minor d.) Inferior: teres major - Contents: axillary nerve, posterior circumflex humeral artery
169
Erb-Duchenne (Erb’s) Palsy. What is this? Mechanism of injury that can cause this? Clinical presentation. Describe nerves affected and how they explain the deficits experienced.
- What: Upper brachial plexus injury with lesion to roots C5-6. - Mechanism: lateral traction on newborn’s head during birthing, head and shoulder being forcibly moved apart - Presentation: “waiter’s tip” – arm hanging at side: shoulder adducted, internally (medially) rotation, elbow extended, forearm pronated, wrist flexed, atrophy of deltoid and anterior arm compartment muscles - Nerves affected: suprascapular, axillary, musculocutaneous – most commonly – what about radial partially?? - Motor deficit: a.) Loss of suprascapular (innervating: supraspinatus, infraspinatus) and axillary (innervating teres minor and deltoid) nerves = loss of abduction and lateral rotation b.) Loss of musculocutaneous (innervating biceps brachii, brachialis and coracobrachialis) = loss of elbow flexors and forearm supinators c.) ? Dunn doesn’t talk about this, but my thought is also partial loss of radial nerve (innervating posterior forearm muscles) = loss of extension at wrist - Sensory deficit: a.) Sensory loss at shoulder and lateral arm and forearm with loss of C5/6 dermatomes. Dunn doesn’t talk about this, but tip of thumb sensation loss?
170
Branches of the brachial artery. Describe anastomosis around elbow
a.) Profunda brachii (deep brachial a) – middle collateral a, radial collateral a b.) Superior ulnar collateral a (runs with ulnar artery in gross dissection) c.) Inferior ulnar collateral a - bifurcates (typically in cubital fossa) d.) radial a – radial recurrent a – anastomosis with radial collateral a e.) ulnar a with branches: - anterior ulnar recurrent a – anastomosis with inferior collateral a - posterior ulnar recurrent a – anastomosis with superior ulnar a - common interosseous a with branches i. posterior interosseous a – recurrent interosseous a, which has anastomosis with middle collateral a ii. anterior interosseous a – perforating branches
171
Triangular space. Borders, contents?
- Borders: a.) Lateral: long head of triceps brachii b.) Superior: teres minor c.) Inferior: teres major - Contents: circumflex scapular artery (from subscapular off 3rd part axillary)
172
What muscle is an elbow flexor in the extensor compartment of the forearm?
- Brachioradialis
173
Organization of the brachial plexus
- Mnemonic: Randy Travis Drinks Cold Beers - Roots: ventral rami from C5-T1 - Trunks: upper, middle and lower - Divisions: anterior and posterior - Cords: lateral, medial and posterior - Branches: axillary, musculocutaneous, medial, ulnar and radial
174
Flexor carpi radialis. O, I, I, A
- O: medial epicondyle of humerus - I: base of MC II - I: median n - A: flex and abduct wrist (radial deviation)
175
Extensor pollicis brevis. O, I, I, A
- O: posterior radius, interosseous membrane - I: base of proximal phalanx of pollex - I: posterior interosseous n (of radial) - A: extends pollex at MCP joints
176
Damage to the musculocutaneous nerve will prevent flexion at elbow. True / False.
- False. Brachialis (main flexor) is innervated by radial n and musculocutaneous. Also brachioradialis (innervated by radial n) is an elbow flexor.
177
What muscles does the median nerve innervate in the hand?
- Mnemonic = LOAF muscles 1.) lateral two Lumbricals 2.) Opponens pollicis 3.) Abductor pollicis brevis 4.) Flexor pollicis brevis
178
What are the structures found in the supraspinous fossa?
- Suprascapular ligament bridges the scapular notch - Army on land, Navy under water - Suprascapular artery on top - Suprascapular nerve on top
179
Brachioradialis. O, I, I, A
- O: lateral supracondylar ridge of humerus - I: styloid process of radius - I: radial n - A: flexion of elbow, can supinate too
180
Flexor digitorum superficialis. O, I, I, A
- O: medial epicondyle, proximal radius - I: base of intermediate phalanges of digits 2-5 - I: median n - A: flex wrist, MCP, PIP – no flexing DIP
181
How would you assess the function of the long thoracic nerve? Damage to this nerve results in?
- Ask patient to push up against wall with both arms stretched out. - Deficit: Winged Scapula (scapula no longer stabilized against thorax), cannot abduct arm above 90 degrees
182
What are innervated by the dorsal scapular nerve?
- Levator scapulae, rhomboids
183
Branches of subclavian artery.
- Right subclavian branches from brachiocephalic artery - Left subclavian branches directly from aorta - Each divides into three parts (VIT = 1st, C = 2nd, D = 3rd) - Branches – VITamen C & D (without accounting form branches of thyrocervical) a.) Vertebral b.) Internal thoracic c.) Thyrocervical trunk (STI: suprascapular^ can be a separate branch from subclavian, transverse cervical, inferior thyroid,) d.) Costocervical trunk e.) Dorsal scapular\* can be a branch of transverse cervical - Subclavian is now called axillary when it passes under clavicle
184
What is the only joint connection between the upper limb and thorax?
- Sternoclavicular joint
185
Median nerve is found between what muscles in the anterior forearm compartment?
- Median nerve enters into this compartment between the two heads of the pronator teres, courses through forearm between the FDS and the FDP muscles.
186
Name and describe locations and types of joints of upper limb. Include ligaments found in those locations.
1.) Sternoclavicular joint: clavicle to sternum (only connection between upper limb and thorax) a.) Saddle joint with articular disc b.) Ligaments: ant/poster sternoclavicular ligament, interclavicular ligament 2.) Acromioclavicular joint: acromion of scapula with clavicle a.) Plane joint b.) Ligaments: acromioclavicular ligament, coracoclavicular ligaments 3.) Glenohumeral joint: glenoid fossa of scapula with head of humerus a.) Ball and socket joint b.) Ligaments: coracoacromial ligament (reinforces superior border), glenohumeral ligaments (sup, middle, inf), coracohumeral ligament, transverse humeral ligament (holds long tendon of biceps brachii in place in bicipital groove)
187
Flexor carpi ulnaris. O, I, I, A
- O: medial epicondyle of humerus, olecranon process of ulna - I: hook of hamate, pisiform, base of MC V - I: ulnar n - A: flex and adduct wrist (ulnar deviation)
188
What are the nerves that supply cutaneous innervation to the digits of the hand?
- Medial 1.5 by proper digital nerves from superficial branch of ulnar nerve - Lateral by proper digital nerves from median nerve
189
What nerve roots comprise the brachial plexus? What are the 5 peripheral nerves that it terminates as?
- C5-T1 ventral rami 1. Axillary (C5-6) 2. Radial (C5-8) 3. Musculocutaneous (C5-7) 4. Median (C6-T1) 5. Ulnar (C8-T1)
190
What is the nerve of the anterior compartment of the arm? Action produced by these muscles? Muscles of this compartment?
- Nerve: musculocutaneous nerve (brachialis also by radial) - Action: flexion at elbow, supination of forearm/wrist - Muscles: biceps brachii, brachialis, coracobrachialis
191
Patient cannot extend their fingers or their wrist, but can extend elbow. What nerve is lesioned? Discuss where location of lesion may be.
Radial nerve
192
What are the scapulohumeral muscles attaching the upper limb to thorax?
- Deltoid, teres major/minor, supraspinatus, infraspinatus, subscapularis
194
Patient arrives in ED with obvious trauma to the upper arm. X-ray shows that patient has fractured his surgical humeral neck. What arteries are compromised? What nerve would be damaged? What are the deficits?
- This type of fracture typically damages contents of the quadrangular space, which includes the axillary nerve and posterior circumflex humeral artery. Anterior circumflex humeral artery (if in tact) can take over blood supply. - Axillary nerve innervating teres minor and deltoid would be damaged. - Deficit = loss of abduction (from 15/20-90 degrees), weak flexion/extension/rotation at shoulder by deltoid. Loss of lateral rotation/stabilization of glenohumeral joint by teres minor. Atrophy of these muscles would occur.
195
What nerve follows the profunda brachii?
- Radial nerve
196
Which is smaller, anterior or posterior circumflex humeral artery?
- Anterior circumflex humeral artery
