Upper Extremity 1 Flashcards
describe the 4 regions of the UE
- shoulder girdle: bony ring (scapula and clavicle), posterior (attaches to axial skeleton via scapthoracic joint which is NOT a true joint), Anterior (attaches to axial skeleton via SC joint which IS a true synovial joing)
- arm: the region btwn the shoulder and elbow; humerous bone
- forearm: the region between the elbow and wrist; radius and ulna bone
- hand: contains carpals, metacarpals, phalanges
list 4 regions of the UE
shoulder (pectoral) girdle
arm
forearm
hand
list the bony landmarks of the shoulder girdle and arm
clavicle
scapula
humerus
list the articulations and bony landmarks of the clavicle & extra info
medial: manubrium, forms sternoclavicular joint
lateral: scapula, forms acromioclavicular joint
- sternal end-medial
- acromial end- lateral
- deltoid tubercle (superior; attachment of deltoid)
- impression for costoclavicular ligament (inferior; attachment of costoclavicular ligament)
- subclavian groove (inferior; attachment for subcalvius)
- trapezoid line (inferior; attachment for trapazoid ligament)
- Conoid tubercle (inferior; attachment for conoid ligament)
“S” shaped for optimal shoulder elevation
superior view is smooth
this is the ONLY connection of axial skeleton to UE!!!!
clinical:
fractures-Most common at junction btwn middle and lateral third
severe osteoarthritis of SC or AC joints limits functional movement of shoulder
describe the articulations, landmarks and extra info about the scapula
articulation:
scapulothoracic articulation
glenohumeral joint (glenoid fossa of scapula and head of humerus)
AC joint (acromion process of scapular with lateral en of clavicle)
- acromion (AC joint, deltoid and trapezius attachment)
- coracoid process (short head biceps brachii, coracobrachialis, pec minor attachment)
- spine of scapula (deltoid and trapezius attachment
- supraspinous fossa (posterior; supraspinatous attachment)
- infraspinous fossa (posterior; infraspinatous attachment)
- subscapular fossa (anterior; subscapularis attachment)
- suprascapular notch
- head
- neck
- glenoid cavity/fossa
- supraglenoid tubercle (long head biceps brachii attachment)
- infraglenoid tubercle (long head triceps attachment)
- medial border, lateral border, superior border
- superior angle (junction of medial and superior borders), inferior angle (junction of medial and lateral borders), lateral angle (junction of lateral and superior borders and less distinct)
shoulder blade = triangular flat bone
critical role in shoulder function
describe the articulations, land marks and extra info of the humerus
articulation: glenohumeral joint (head of humerus and glenoid fossa of scapula) elbow: 1. humeroradial joint (capitulum of humerus and radial head), 2. humeroulnar joint (trochlea of humerus and trochlear notch of ulna)
- anatomical neck (medial to tubercles , indentation distal to head of humerus is attachment for articular capsule)
- surgical neck (distal to tubercles, COMMON fracture site)
- head
- greater tubercle (attachment for external rotators of rotator cuff muscles supraspinatus, infraspinatus, teres minor)
- lesser tubercle (attachment for internal rotator of rotator cuff muscle subscapularis)
- bicipital groove (btwn lesser and greater tubercles, attachment for long head of biceps brachii, pec major lateral lip, latissimus dorsi floor, and teres major medial lip)
- deltoid tuberosity (lateral part of humerus near mid shaft for deltoid muscle)
- radial spiral groove (groove for radial nerve as it travels posterior to humerus)
- trochlea
- capitulum
- olecranon fossa (posterior)
- coronoid fossa (anterior)
- radial fossa (anterior)
- medial epicondyle (attachment for flexor muscles of forearm)
- lateral epicondyle (attachment for extensor muscles of forearm)
list muscles of the anterior thoracoappendicular region and the landmark within it
pectoralis major clavicular head and sternocostal head
pectoralis minor
subclavius
serratus anterior
deltopectoral triangle
describe the deltopectoral triangle
landmark in the anterior thoracoappendicular region
deltoid, pec major (inferior), clavicle
cephalic vein passes superficial to deep and joins with axillary vein
pectoralis major O I N A
clavicular and sternocostal heads
this is the inferior border of deltopectorial triangle
this is the lateral border of the anterior wall of the axilla
o:clavicular head = anterior surface of medial half of clavicle; sternocostal head: anterior sternum costal cartilages 1-6 and extended oblique aponeurosis
I: lateral lip of bicipital groove “intertubercular humerus”
N: Lateral and medial pectoral nerves: clavical c5-c5, sternocostal c7-t1
A: draw scapula anterior and inferior –adduction and medial rotation of humerus, clavicular = flexion, sternocostal = extension of humerus
pectoralis minor O I N A
deep to pectoralis major
part of anterior wall of axilla
BVs and Nerve plexuses go under this
clinical:depress scap for crutches, gym -bench press up, seated press up, stretch to improve rounded shoulder posture syndrome
O: ribs 3-5 near costal cartilage
I: medial border and superior coracoid process
N: Medial pectoral nerve c8-t1
A: inferior and anterior movement of scapula, stabilizes scapula, protraction and depression of scapula
subclavius O: I: N: A:
inferior to clavicle
O: junction of rib 1 and costocartilage
I: inferior surface of mid third of clavicle
N: nerve to subclavius c5-6
A: anchor and depress clavicle and stabilize clavicle and SC joint
serratus anterior O I N A
forms medial wall of axilla
clinical: damage to long thoracic nerve = parlaysis/ weakness of serratus anterior = winging of scapula, dysfunction of shoulder abduction
O: external surfaces of lateral ribs 1-8
I: Anterior surfaces of medial border of scapula
N:long thoracic nerve c5-7
A: upward rotation, protraction and stabilization of scapula
3 muscles causing up rotation of scapula
serratus anterior, upper trap, lower trap
3 muscles medially rotate humerus
PLT pec major, latissimus dorsi, teres major
list muscles of posterior thoracoappendicular region
superficial: trapezius, latissimus dorsi
deep: levator scapulae, rhomboid major minor
trapezius O I N A
O: axial skeleton
I: shoulder girdle
N: accessory nerve and C2 C3 C4
A: retract scapula
upper - elevate and up rotation, retract scapula
middle- retract scapula
lower- depress and up rotation, retract scapula
referred pain goes up neck and into head
latissimus dorsi OINA
“widest back”
acts DIRECTLY on GH joint
acts INdirectly on scapulothoracic joint of shoulder girdle
O:thoracolumbar fascia
I:floor of bicipital groove
N:thoracodorsal nerve
A: hand cuffs, extend, adduct, medially rotate humerus
levator scapulae OINA
O:
I:
N: dorsal scapular nerve C3 C4
A: neck- lateral flex and ipsilateral rotation; scapula - elevate and downward rotate scapula
rhomboid major minor OINA
O:
I:
N:dorsal scapular nerve
A: retract and downward rotation of scapula, and stabilize it
clinical: damage to dorsal scapular nerve = deviates from midline spine
**DEEP to trapezius
3 muscles that attach to the greater tuberocity
supraspinatus infraspinatus teres major
list scapulohumereral muscles (6 muscles with attachments on the scapula and humerus
deltoid
teres major
rotator cuff muscles (sits): supraspinatus, infraspinatus, teres major, subscapularis
list rotator cuff muscles and their action as a whole
supraspinatus, infraspinatus, teres minor, subscapularis
dynamic stability during elevation (stabilize GH joint)
deltoid OINA
clavicle to deltoid tuberosity
anterior, middle, posterior head
N: axillary nerve
A: abduct the arm; when arm is adducted it assists in resisting distraction of GH joint
posterior and anterior - stabilize humerus during abduction
anterior- flex and internal rotate humerus
middle -abduct humerus
posterior-extend and externally rotate humerus
teres major OINA
O:scapula
I: distal bicipital groove
N: lower subscapular nerve
A: Hand cuff - medially/internal rotate and adduct humerus
supraspinatus OINA
O: supraspinous fossa
I: SUperior facet of greater tuberosity
N: suprascapular nerve
A: “isolated” adbuct humerus
as a group these all dynamically stabilize gh joint during elevation
infraspinatus OINA
O: infrapsinous fossa
I: inferior to supraspinatus attachment, middle facet of the Greater tuberosity
N: suprascapular nerve
A: external rotation of humerus (working with teres minor synergistically)
as a group these all dynamically stabilize gh joint during elevation
teres minor OINA
O:superior portion of lateral border of scapula
I: inferior to infraspinatus attachment, inferior facet of greater tuberosity
N: axillary nerve
A: external rotation of humerus (works synergistically with infraspinatus)
as a group these all dynamically stabilize gh joint during elevation
subscapularis OINA
O: subscapular foss
I:Lesser tuberosity of humerus
N: upper and lower subscapular nerve
A: internal rotation of humerus
as a group these all dynamically stabilize gh joint during elevation
list and describe the anatomical landmarks of posterior thoracoappendicular region
- triangular spaces:
A. upper triangle (superior/teres minor; inferior/teres major; lateral/long head of triceps; contains circumflex scapular artery)
B. lower triangle (superior/teres major; medial/ long head of triceps; lateral/lateral head of triceps; contains radial nerve and deep artery of arm aka profunda brachii artery) - Quadrangular space
(superior/teres minor and subscapularis; inferior/teres major; medial/long head of triceps; lateral/surgical neck of humerus; contains axillary nerve and posterior humeral circumflex artery) - triangle of auscultation
(trapezius, latissimus dorsi, medial border of scapula; breath sounds heard most clearly here)
describe upper triangle
superior - teres minor
inferior- teres major
lateral- long head triceps
circumflex scapular artery
describe lower triangle
superior-teres major
medial-long head of triceps
lateral - lateral head of triceps
radial nerve
deep artery of arm (profunda brachii artery)
quadrangular space
superior-teres minor and subscapularis
inferior- teres major
medial - long head of triceps
lateral-surgical neck of humerus
axillary nerve
posterior humeral circumflex artery
triangle of auscultation
trapezius
latissimus dorsi
medial border of scapula
most clear breath sounds
8 major arteries shoulder girdle and arm
aorta subclavian artery axillary artery brachial artery ulna artert radial artery superficial palmer arch deep palmer arch
describe the diff between R/L subclavian artery
R: brachiocephalic trunk to subclavian artery
L: subclavian artery
describe axillary artery
starts as subclavian artery
begins at the outer border of rib 1
ends inferior border of teres major
parts 1 2 3
describe brachial artery
starts as axillary artery
begins inferior border of teres major
ends as it divides into radial and ulna arteries at the elbow
major blood vessels that supply the scapula region
suprascapular artery subscapular artery transverse cervical artery circumflex scapular artery dorsal scapular artery
arteries that supply the shoulder and proximal humerus
anterior and posterior circumflex humeral arteries that branch off the 3rd part of axillary artery
arteries that supply elbow and distal humerus
deep artery of arm (posteriorly wraps around humerus)
radial collaterals (continuous of deep artery)
ulnar collaterals (branches off brachial artery)
recurrent radial artery (form anatomoses with collaterals)
recurrent ulnar artery (form anatomoses with collaterals)
describe the axilla and what it contains
pyramidal shaped region at the humction of arm and upper thoax
clinical: palpate to ID large lymphnodes.. lymph drainage of breast into nodes in axilla
cervicoaxillary canal:
axillary lymphnodes AND neurovascular bundle is within the axillary sheath
includes: axillary artery and branches, axillary vein, brachial plexus
describe the boundaries of the axilla
- medial wall (thoracic wall ribs 1-4 and intercostals; serratus anterior)
- lateral wall (narrow wall formed by humerus bicipital groove)
- anterior wall (pec major and minor and fascia)
- posterior wall (subscapularis, teres major, latissimus dorsi, scapula)
- base (axillary fascia, concave skin, subcutaneous tissue)
- apex (connection btwn neck and axilla, space btwn clavicle, rib 1, and scapula) = cervicoaxillary canal contains bvs lymphatics nerves etc that pass to get to the arm
describe brachial plexus
nerves that supply the thoacoappendicular region and UE originate C3-T1
brachial plexus = C5-T1 the network of ventral rami off these spinal nerves:
ventral rami merge and divide to form peripheral nerves
major:
1. axillary nerve
2. musculocutaneous nerve
3. radial nerve
4. median nerve
5. ulnar nerve
regions of brachial plexus
roots - trunks- divisions - cords - branches
describe the roots
formed by ventral rami of c5-t1
pas thru anterior and posterior scalene muscles
merge to form 3 trunks
*dorsal scapular nerve (supply levator scapulae and rhomboids)
*long thoracic nerve (serratus anterior)
describe trunks
superior trunk = c5-c6 middle trunk = c7 inferior trunk = c8-t1 each trunk divides into anterior and posterior to form divisions *nerve to subclavius (subclavius)
describe divisions
anterior and posterior divisions
these merge to form cords
*suprascapular nerve (supraspinatous and infraspinatous)
describe cords
lateral cord - anterior division of superior and middle trunk
medial cord - anterior division of inferior trunk
posterior cord- posterior division of all three trunks
named according to relationship with axillary artery!!
cords divide and merge to form branches (peripheral nerves)
describe branches
- lateral cord divides into:
musculocutaneous (bicep brachii, brachialis, coracobrachialis)
lateral pectoral (pec major)
1/2 median cord (muscles in forearm and hand) - medial cord divides into:
1/2 median cord (muscles of forearm and hand)
medial pectoral (pec major and pec minor)
medial brachial cutaneous (skin of medial arm)
medial antebrachial cutaneous (skin of medial forearm)
ulnar nerve (hand and forearm)
3. posterior cord divides into: axillary (deltoid and teres major) radial (triceps, anconeus, brachioradialis, muscles of forearm) thoracodorsal (latissimus dorsi) upper subscapular (superior subscapularis) lower subscapular (inferior subscapularis and teres major)
roots
dorsal scapular - pierces thru medial scalene
rhombouids and levator scapulae occasionally
long thoracic nerve
serratus anterior
trunks
nerve to subclavius
supplies subclavius
division
suprascapular nerve - passes thru scapular notch
supplies supraspinatus and infraspinatus
lateral cord
musculocutneous
- pierces coracobrachialis
- supplies coracobrachialis, brachialis, biceps brachii
- continues on as lateral cutaneous nerve of forearm (lateral antebrachial cutaneous nerve)
lateral pectoral
-supplies pec major
median nerve
- lateral and medial cords merge to form this
- supplies wrist, hand flexor muscles of forearm and muscles of thenar region of hand
medial cord
median nerve
medial pectoral nerve
-supplies pec minor and pec major
medial brachial cutaneous
-supplies skin of medial arm
DOES NOT SUPPLY ANY MUSCLES***
medial antebrachial cutaneous
- supplies skin of medial forearm
- DOES NOT SUPPLY ANY MUSCLES**
ulnar nerve
-supplies muscles of hand and 1 1/2 flexor muscles of the forearm
posterior cord
axillary nerve:
- exits thru quad space
- supplies deltoid and teres minor
- continues on as superior lateral brachial cutaneous nerve supplying skin over deltoid region
radial n
- travels posterior around humerus in radial spiral groove
- supplies triceps brachii, anconeus, brachioradialis, wrist hand extensor muscles of forearm
thoracodorsal
-supplies latissimus dorsi
upper subscapular
-supplies superior portion of subscapularis
lower subscapular
-supplies superior portion of inferior portion of subscapularis and teres major ….?
describe anterior and posterior compartments of the arm
medial and lateral intermuscular septum divides the anterior and posterior compartments
musculocutaneous nerve supplies the anterior
radial nerve supplies the posterior
list the muscles of the arm
coracobrachilais (ant) biceps brachii (ant) brachialis (ant) triceps brachii (post) anconeus (post)
coracobrachialis OINA
O: coracoid process
I: middle third of medial humerus
N: musculocutaneous (passes thru)
A: flex and adduct arm
biceps brachii OINA
O: long head - supraglenoid tubercle of scapula
short head - coracoid process of scapula
I: radial tuberosity of radius and bicipital anponeruosis
N: musculocutaneous nerve
A: flexes arm and forearm, supinates forearm
clinical: transverse humeral ligament “contains” tendon of long head in bicipital groove- potential for dislocation of tendon
biceps tendonitis - irritation of long head tendon as it passes thru bicipital groove
rupture of long head tendon
rehab strengthening - optimal supinated position
define bicipital aponeurosis
fascia that extends from distal biceps tendon and blends with fascia of the flexor muscles of the forearm
provides protection for structures in the cubital fossa
brachialis OINA
O: distal half of anterior surface of humerus
I: coronoid tuberosity of ulna
N: musculocutaneous nerve
A: primary flexor of forearm, flexes forarm in all postions (supinated, neutral, pronated)
clinical - rehab strengthening -active in all positions
triceps brachii OINA
O:
long head- infraglenoid tubercle
lateral head - post humerus superior to radial groove
medial head -post humerus inferior to radial groove
I: olecranon process of ulna
N: radial nerve
A: primary extensor of forearm
clinical- lower cervical SCI - important for therapist to ID if triceps functions .. makes significant difference in ADLs (note tricep supplied by c7-8)
Anconeus OINA
O: lateral epicondyle
I: olecranon process of ulna
N: radial nerve
A: assists in forearm extension, stabilizes elbow joint
axillary nerve
branches off posterior cord and travels posteriorly
exits thru quad space and supplies teres minor and deltoid
musculocutaneous nerve
begins inferior border of pec minor
pierces corcobrachialis
travels btwn biceps brachii and brachialis
after innervation of biceps and brachialis the nerve becomes the lateral cutaneous nerve of forearm
radial nerve
travels posterior to brachial artery and medial to humerus
descends with deep artery of arm (deep brachial artery)
travels posterior to humerus in radial groove
wraps anterior and pierces lateral intermuscular septum
travels btwn brachialis and brachioradialis to elbow
median nerve
follows brachial artery.. runs lateral to brachial artery then crosses to run medial to brachial artery
the median nerve does not have any branches in axilla or arm
ulnar nerve
travels medial to brachial artery and anterior to triceps
mid point of humerus it pierces medial intermuscular septum and descends poteriorly
passes posterior to medial epicondyle
enters forearm
does not have any branches in axilla or arm
review of blood supply to arm: brachial artery
axillary artery becomes brachial artery (inferior border of teres major)
brachial artery branches: deep artery of arm (goes posterior to humerus in radial groove with the radial nerve) -[that branches the radial collateral arteries (supply lateral elbow)] AND the brachial artery branches into ulnar collateral (supply medial elbow) – brachial artery ends in cubital fossa and divides into radial and ulna artieries
axillary–brachial–radial/unla arteries at the cubital fossa
I I-ulnar collateral branches
deep artery of arm
I
radial collateral artery
acromioclavicular joint
acromioclavicular joint (AC)-
-AC ligament (superior and inferior)
-Coracoclavicular ligament (connect coracoid processes of scapula and inferior surface of clavicle: A. trapezoid ligament [ coracoid process to trapezoid line of clavicle], B. conoid ligament [ coracoid process to conoid tubercle of clavicle]
clinical: AC joint separation
type 1- partial injury to AC lig, corcoclavicular is intact
type 2- disruption of AC lig, coracoclavicular lig is intact
type 3-disruption of AC lig and Coracoclavicular ligaments, clavicle is displaced SUPERIORLY
Joints of UE
acromioclavicular joint AC Glenohumeral joint (GH) (sternoclavicular joint??)
glenohumeral joint (GH)
glenohumeral joint (GH) humeral head and glenoid cavity of humerus glenoid labrum increase congruency of joint
-glenohumeral ligament (strengthen anterior aspect of joint)
superior GH ligament
Middle GH ligament
inferior GH ligament
-coracohumeral ligament
coracoid process to greater tuberosity o fhumerus
-coracoacromial ligament
forms part of the coracoacromial arch (See another slide)
-transverse humeral ligament
acts as bridge over the bicipital groove
contains long head of biceps tendon
-bursa of GH:
1. subacromial bursa
2. subscapularis bursa - lies btwn subscapularis tendon and neck of scapula (kinda under the coracoid process), communicates with GH joint capsule (Really an extension of the joint capsule)
3?? subdeltoid bursa??not on hand out
clinical: supraspinatus tendonitis impingement syndrome rotator cuff tears dislocation of GH joint
coracoacromial arch
coracoacromial ligament and acromion process
“subacromial space” - suprasinatus tendon passes thru this space
supraspinatus tendon is protected by subacromial bursa (lies btwn arch and tendon )
