Upper Limb Flashcards
Where is the origin of the clavicular head of the pectoralis major?
medial half of the anterior surface of the clavicle
Where is the origin of the sternocostal head of the pectoralis major?
anterior surface of the sternum
upper 6 costal cartilages
EOA
Where is the insertion of the pectoralis major?
Lateral lip of bicipital groove
Nerve supply of pectoralis major
medial and lateral pectoral nerves
insertion of pectoralis minor
Coracoid process of the scapula
Nerve supply of pectoralis minor
medial pectoral nerve
Origin of serratus anterior
by 8 digitations from outer surface of upper 8 ribs
Insertion of serratus anterior
ventral surface of the medial border of scapula
nerve supply of serratus anterior
long thoracic nerve
action of serratus anterior
fixing scapula to posterior thoracic wall so its paralysis leads to winging of scapula
What structures piercing through the clavi-pectoral fascia?
CLAF
Cephalic vein
Lateral pectoral nerve
Acromiothoracic artery
Fat, LNS
Insertion of latissimus dorsi
floor of bicipital groove
Nerve supply of trapezius
spinal accessory nerve (CN11)
Nerve supply of latissimus dorsi
Nerve to latissimus dorsi (thoraco-dosral nerve)
Action of trapezius
Shoulder abduction from 90-180 (along with serratus anterior)
Shrugging of the shoulders
Abduction of the shoulder between 0 to 15 degrees
supraspinatus
Abduction of the shoulder between 15 to 90 degrees
muscle fibres of the deltoid
Abduction of the shoulder between 90 to 180 degrees
coupling action of serratus anterior and trapezius
What three muscles are attached at the bicipital groove?
- Pectoralis major = lateral lip
- Latissimus dorsi = floor
- Teres major = medial lip
What three muscles are attached at the greater tuberosity?
- Supraspinatus
- Infraspinatus
- Teres minor
Where is the origin of the supraspinatus muscle?
supraspinous fossa
Where is the origin of the infraspinatus muscle?
infraspinous fossa
Where is the origin of subscapularis muscle?
Subscapular fossa
Where is the insertion of the subscapularis?
Lesser tuberosity of the humerous
What nerve supplies the supraspinatus + infraspinatus?
Suprascapular nerve
What muscles are supplied by the axillary nerve?
teres minor
deltoid
Origin of the teres minor
upper 2/3 of lateral border of scapula
Origin of the teres major
Lower 1/3 of lateral border of scapula
Insertion of the teres major
Medial lip of the bicipital groove
What are the rotator cuff muscles
Above = supraspinatus
In front = subscapularis
Behind = infraspinatus + teres minor
Below = not supported –>** common dislocation**
Contents of the quadrangular space
Axillary nerve
Posterior circumflex humeral artery
Contents of the upper triangular space
Circumflex scapular artery
Contents of the lower triangular space
Radial nerve
Profunda brachii artery
What are the important contents of the axilla?
Intercostobrachial nerve = lateral cutaenous branch of 2nd intercostal nerve
Long thoracic + thoraco-dorsal nerve
(commonly injured in axillary node clearance)
Draw the brachial plexus from the roots to the cords
Roots (C5 to T1)
Trunks (upper = C5/6, middle = C7, lower = C8/T1)
Divisons (each trunk into ant and post)
Cords (post = all post divisions, lateral = anterior of upper/middle, medial = anterior of lower)
What nerves branch off the lateral cord?
- Lateral pectoral (C5-7)
- Lateral root of median nerve (C5-7)
- Musculocutaenous nerve (C5-7)
What nerves branch off the medial cord?
- Medial pectoral nerve (C8/T1)
- Medial root of median nerve (C8/T1)
- Ulnar nerve (C7/C8/T1)
- Medial cutaenous nerve of arm and forearm (C8/T1)
What nerves branch off the posterior cord?
ULNAR
1. Upper subscapular (C5/6)
2. Lower subscapular nerve
3. Nerve to latissimus dorsi - thoracodorsal N. (C6/7/8)
4. Axillary nerve (C5/6)
5. Radial nerve (C5/6/7/8/T1)
What is the result of an injury to the upper trunk (C5/6)?
Erb’s palsy
What is the motor impairment from Erb’s palsy?
The shoulder is:
* adducted (from supraspinatus + deltoid)
* internally rotated (from infraspinatus + teres minor)
The elbow is:
* extended + pronated (from biceps, brachialis, brachioradialis)
What is the sensory loss of Erb’s palsy?
Loss of sensation on radial side of arm + forearm
What are deformities noted in Erb’s palsy?
Policeman tip paralysis
Waiter’s tip deformity
What is the result of an injury to the lower trunk (C8/T1)?
Klumpke’s paralysis
What is the motor impairment from Klumpke’s paralysis?
- Paralysis of intrinsic muscles in hand
- Hyperextension of MCP and flexion of IP joints
- Paralysis of wrist flexors
What is the sensory impairment from Klumpke’s paralysis?
Loss of sensation over ulnar border of forearm and arm
What deformity is seen from Klumpke’s paralysis?
Klumpke’s paralysis
Complete claw hand
What are the branches of the axillary nerve?
- Articular branch = to shoulder joint
- Muscular branch = to deltoid + teres minor
- Cutaenous branch = to skin over upper 1/2 of lateral side of arm
Cause of axillary nerve injury
fracture of surgical neck of humerus
Sensory loss from axillary nerve?
Loss over skin of upper part of lateral arm
Motor effect of axillary nerve
paralysis of deltoid + teres minor = loss of abduction of arm (15-90)
Deformity from axillary nerve injury
flat shoulder due to atrophy of deltoid
Origin of axillary artery
Outer border of first rib
termination of axillary artery
lower border of teres major
Course of axillary artery
crossed by pectoralis minor + divided into 3:
1. above muscle
2. behind muscle
3. below muscle
Branches of axillary artery at 1st part
Superior throacic artery
Branches of axillary artery at 2nd part
- Acromiothoracic artery
- Lateral throacic artery
Branches of axillary artery at 3rd part
- Anterior circumflex humeral artery
- Posterior circumflex humeral artery
- Subscapular artery
What muscles form the anterior group of arm?
- Coracobrachialis
- Brachialis
- Biceps
Where is the origin of the coracobrachialis?
Tip of coracoid process in common origin with short head of biceps
Where is origin of short head of biceps?
tip of coracoid process
Where is origin of long head of biceps?
from supraglenoid tubercle
Where is the insertion of the brachialis?
ulnar tuberosity
Where is the insertion of the biceps?
By tendon in radial tuberosity
What muscles of the arm are supplied by the musculocutaenous nerve?
Coracobrachialis
Biceps
Medial part of the brachialis
What muscles of the arm are supplied by the radial nerve?
Lateral part of the brachialis
Triceps
What is the action of the biceps?
Flexion of the elbow + shoulder joint
Powerful supination of forearm
Where is the origin of the long head of the triceps?
From infraglenoid tubercle of scapula
Where is the origin of the lateral head of the triceps?
From back of humerus above spiral groove
Where is the origin of the medial head of the triceps?
From back of humerus below the spiral groove
What is the main action of the triceps?
Extensor of the elbow joint
What are the boundaries of the cubital fossa?
Lateral = brachioradialis
Medial = pronator teres
Floor = brachialis
What are the contents of the cubital fossa (from medial to lateral)?
- Median Nerve
- Brachial Artery
- Biceps Tendon
- Radial Nerve
MBBR
Name the five superficial flexors of the forearm
- Pronator teres
- Flexor carpi radialis
- Palmaris longus
- Flexor carpi ulnaris
- Flexor digitorum superficialis
What superficial flexors of the forearm are supplied by the median nerve?
Pronator teres
Flexor carpi radialis
Palmaris longus
Flexor digitorum superficialis
What superificial flexors of the forearm are supplied by the ulnar nerve?
Flexor carpi ulnaris
What is the insertion of the flexor digitorum superficialis?
Muscle is divided into 4 tendons + inserted into the middle phalanges of the medial 4 fingers
Name the three deep flexors of the forearm.
- Flexor pollicis longus
- Pronator quadratus
- Flexor digitorum profundus
What nerve supplies the deep flexors of the forearm
anterior interosseous nerve
What nerve supplies the ulnar side of the flexor digitorum profundus?
Ulnar nerve
What is the insertion of the flexor digitorum profundus?
Base of distal phalanges of medial 4 fingers
Name the 7 superficial extensors of the forearm
- Brachioradialis
- ECRL
- ECRB
- Extensor digitorum
- Extensor digiti minimi
- Extensor carpi ulnaris
- Anconeous
Name the 5 deep extensors of the forearm
- Supinator
- Abductor policis longus
- Extensor policis brevis
- Extensor polices longus
- Extensor indices
What is the nerve supply to the extensors of the forearm?
Posterior interosseous nerve (branch of radial), except for the BEAT muscles, which are supplied by the radial nerve.
Brachioradialis
ECRL
Anconeous
Triceps
What is the insertion of the extensor digitorum?
Extensor expansion of the medial 4 fingers
What is the distance between the ulnar nerve to ulnar artery?
1cm
What is the flexor retinaculum?
Thickened band of deep fascia lies in front of the carpal bones, converting the concavity on their anterior surface into a tunnel.
What are the lateral attachments of the flexor retinaculum?
to the scaphoid + trapezium
What are the medial attachments of the flexor retinaculum?
Pisiform + hook of hamate
What structures are superficial to the flexor retinaculum?
- ulnar nerve
- ulnar artery
- palmar cutaneous branch of ulnar nerve
- palmer cutaneous branch of median nerve
- palmaris longus tendon
What structures are deep to the flexor retinaculum?
Dr PM
Digitorum (FDS, FDP)
Radialis muscle (FCR)
Policis muscle (FPL)
Median nerve
What are the names of the carpal bones?
made of two rows of 4 bones
She Looks Too Pretty, Try To Catch Her
Scaphoid, Lunate, Triquetrum, Pisiform, Trapezium, Trapezoid, Capitate, Hamate.
What nerve supplies the adductor pollicis?
Ulnar Nerve
What muscles are supplied by the median nerve?
LOAF
Lateral 2 lumbricals
Opponens pollicis
Abductor pollicis brevis
Flexor pollicis brevis
What is the origin of the median nerve?
Lateral root from lateral cord
Medial root from medial cord
Course of median nerve in axilla + arm?
LAM
Lateral to upper 1/2 of brachial artery
Anterior to brachial artery
Medial to lower 1/2 of brachial artery
What does the median nerve supply in the forearm?
PT, FCR, PCL, FDS
What does the anterior interosseous nerve supply in the forearm?
FPL, PQ + Lateral 1/2 of FDP
What is the sensory innervation by the median nerve?
Lateral 2/3 of palm
Palmar surface of lateral 3.5 fingers
Motor injury to median nerve
Paralysis of:
1. thenar muscles –> flattening in thenar eminence + loss of thumb opposition
2. lateral 2 lumbricals
3. PT + PQ –> loss of pronation
4. Flexors of forearm (except FCU + medial 1/2 of FDP) –> weak flexion of wrist with ulnar deviation due to unopposed action of FCU
Deformity presentation of median nerve
Ape-like hand
Cause of injury to anterior interosseous nerve
Supracondylar fracture humerus in children
Origin of ulnar nerve?
Medial cord of brachial plexus
Ulnar nerve supply to what muscles in forearm?
FCU, medial 1/2 of FDP
Ulnar nerve supply to what muscles of hand?
Adductor policis muscle
Hypothenar
Palmar + dorsal interossei
3rd/4th lumbricals
Injury to the ulnar nerve causes…
Paralysis of:
1. adductor policis –> abducted thumb
2. hypothenar –> atrophy + flattening of hypothenar eminence
3. Interossei + lumbricals –> loss of adduction + abduction, loss of extension of IP –> clawing
4. FCU –> lateral deviation of hand
What deformity is noted when ulnar nerve injured?
Clawing -
Ulnar paradox (higher the lesion the less clawing, lower the lesion the more clawing)
What are the boundaries of the snuff box?
Medial = EPL tendon
Laterally = tendons of APL, EPB
Floor = Scaphoid, Tendons of extensor carpi radialis longus + brevis
Roof = skin + fascia
What are the contents of anatomical snuff box?
Radial artery
Radial nerve
Cephalic vein
Tendons of ECRL + ECRB
What is the blood supply to the scaphoid bone?
from the distal end by the radial artery
AVN to proximal part of scaphoid
What are the thenar muscles (lateral)?
Abductor policis brevis
Flexor policis brevis
Opponens policis brevis
Adductor policis
What is the action of the interossei?
PAD
Palmar = ADduction
Dorsal = ABduction
Origin of radial nerve?
Posterior cord of brachial plexus
What is the course of radial nerve?
Passes in the lower triangular space, and into the spiral groove downward + lateral between lat/med head of triceps
What is the motor consequence of injury to radial nerve?
Loss of extension in:
- fingers = fingers drop
- wrist = wrist drop
- elbow = paralysis of triceps muscle
Loss of supination
Cause and consequence of posterior interosseous nerve
during lateral approach to elbow
Loss of motor function only –> finger drop
No sensory loss
What is the drainage of the basilic vein?
Into the axillary vein
