Upper Limb Flashcards
What is clavipectoral fascia and name the structure piercing it.
Clavipectoral fascia is a fibrous sheet situated deep to
the clavicular portion of the pectoralis major muscle.
Structure piercing it are:
1) Lateral pectoral nerve
2) Thoracoacromial artery
3) Cephalic vein
4) Lymphatic from breast and pectoral region to axillary lymph nodes.
Breast
Present in superficial fascia of pectoral region.
Accessory sex organ in females but rudimentary in males.
A small opening present in upper lateral quadrant called axillary tail of spence which passes through an opening in deep fascia called foramen of langer.
Extends from 2nd to 6th rib vertically and lateral border of sternum to midaxillary line.
Breast lies on deep fascia which is pectoral fascia below which lies pectoralis major, serratus anterior and external oblique muscle of abdomen.
Breast is separated from pectoral fascia by loose aerolar tissue called as retromammary space.
Breast is divided into skin parenchyma and stroma.
Skin has a conical projection called nipple and surrounding it a pigmented area called areola which is rich in modified sebaceous glands.
Parenchyma which forms mammary gland which consisted of 15 to 20 lobes with each lobe has cluster of alveoli and draining into lactiferous duct.
Stroma which forms supporting framework of gland which is partly fibrous and partly fleshy. Fibrous part of stroma forms suspensory ligament of Cooper and fatty stroma forms main bulk of gland.
Blood supply is internal thoracic artery, lateral thoracic, superior thoracic and acromiothoracic branches of axillary artery.
Venous drainage is into internal thoracic vein, axillary and posterior intercostal vein.
Nerve supply is through cutaneous branches of 4 to 6 intercostal nerves and secretion of milk is controlled by hormone prolactin.
Lymph drains into axillary (anterior), anterior thoracic and supraclavicular lymph nodes.
Lymphatic vessels in which superficial drain skin over breast and deep lymphatic drain parenchyma, nipple and areola.
Clinical anatomy of breast
Mastectomy
Radical Mastectomy
Lumpectomy
Self examination
Retracted nipple
Most common breast cancer in postmenopausal women
Increase or decrease in size
Serratus anterior
Origin is from midaxillary line of upper 8 ribs
Insertion is along the medial border and inferior angle along costal surface.
Nerve supply is long thoracic nerve which arises from C5,C6,C7
Action
Pushing and punching movement
Forced inspiration
Clinical features
Paralysis of serratus anterior causes winging of scapula in which medial border and inferior angle is prominent.
Clinical testing is by applying forward pressure against any resistance.
Axillary artery and it’s branches
Axillary artery extends from outer border of first rib to lower border of teres major muscle
It’s course divided into 3 parts by pectoralis minor muscle.
First part gives superior thoracic artery which supplies to pectoralis major and minor and thoracic wall.
From second arises Thoracoacromial artery which gives 4 branched ABCD.
Also arises Lateral thoracic artery which gives lateral mammary branches to breast.
From 3rd part arises Subscapular artery which is largest branch of axillary artery and supplies latissimus dorsi and serratus anterior. It gives circumflex scapular artery which forms anastomoses around scapula.
Anterior circumflex humeral artery also arises which gives ascending branch and runs in intertubercular sulcus and supplies head of humerus and shoulder joint.
Posterior circumflex humeral artery arises and after passing through quadrangular intermuscular space . It anastomoses with anterior circumflex humeral artery around the surgical neck of humerus and supplies should joint, deltoid and muscles forming quadrangular space.
The branches of axillary artery anastomoses with each other so when axillary artery is blocked , then a collateral circulation is established.
Axillary artery pulsation can be felt against lateral wall of axilla. It can be compressed against humerus in order to stop check bleeding from distal part of limb during injury, operation ,etc.
Axillary lymph nodes
They are divided into five groups
1)anterior (pectoral) group receive lymph from breast and anterior wall of trunk.
2) posterior (scapular) group receive lymph from posterior wall of trunk above umbilicus and axillary tail of breast
3) lateral group lymph nodes receive lymph from upper limb
4) lymph nodes of central group receive vessels from floor of axilla.
5) apical or infraclavicular group receive lymph from breast, thumb and it’s web.
Infection or malignant growth of cells in upper limb or breast or anterior and posterior body walls gives involvement of axillary lymph nodes.
Axillary abscess should be incised through the floor of axilla between anterior and posterior axillary folds.
Brachial plexus
The lateral cord, medial cord and their branches form
the letter ‘M’ . The plexus consists of roots, trunks, divisions, cords
and branches.
Roots C5 and C6 join to form the upper trunk. Root C7
forms the middle trunk. Roots C8 and T1 join to form
the lower trunk.
Each trunk (three in number) divides into ventral and
dorsal divisions.
The lateral cord is formed by the union of ventral
divisions of the upper and middle trunks.
The medial cord is formed by the ventral division
of the lower trunk
The posterior cord is formed by union of the dorsal
divisions of all the three trunks.
Branches
Of roots -
1) long thoracic nerve(serratus anterior)C5to7
2) dorsal scapular nerve (rhomboids)C5
3) branches to longus coli and scaleni C5 to C8
Of trunks - both from C5,C6
1) suprascapular - supraspinatus and infraspinatus
2) Nerve to subclavius - subclavius muscle
Of cords -
1) Branches of lateral cord
Lateral pectoral nerve C5 to C7 - to both pectoral muscles.
Musculocutaneous nerve C5 to C7 to coracobrachialis, biceps and brachialis
Lateral root of median nerve C5 to C7
2) Branches of medial cord
Medial pectoral nerve C8,T1 supplies pectoral muscles
Medial cutaneous nerve of forearm
Medial cutaneous nerve of arm
Ulnar nerve C7-T1
Medial root of median nerve - C8, T1
3) Branches of posterior cord
Upper Subscapular - Subscapularis 5,6
Lower Subscapular - Subscapularis 5,6
Axillary - deltoid and teres minor 5,6
Thoracodorsal - latissimus dorsi 6,7,8
Radial - triceps and muscles on back of forearm and arises from 5,6,7,8,1
Vertebral artery and thyrocervical trunk supply blood to brachial plexus.
Erb’s Palsy & Erb’s Point
The deformity is known as ‘policeman’s tip hand’
or waiter’s tip hand or ‘porter’s tip hand’
Site of injury: One region of the upper trunk of the
brachial plexus is called Erb’s point (Fig. 4.15). Six
nerves meet here. Injury to the upper trunk causes
Erb’s paralysis.
i. Birth injury/difficult childbirth
ii. Fall on the shoulder
iii. During anaesthesia
Muscles paralysed: Mainly biceps brachii, deltoid,
brachialis and brachioradialis. Partly supraspinatus,
infraspinatus and supinator.
Deformity and position of the limb:
• Arm: Hangs by the side; it is adducted and
medially rotated.
• Forearm: Extended and pronated
Movements lost are :
• Abduction and lateral rotation of the arm at
shoulder joint.
• Flexion and supination of the forearm.
• Biceps and supinator jerks are lost.
• Sensations are lost over a small area over the
lower part of the deltoid.
Klumpke’s Paralysis
Site of injury: Lower trunk of the brachial plexus
Cause of injury: Undue abduction of the arm, as in
clutching something with the hands after a fall from a
height, or in birth injury
Nerve roots involved: Mainly T1 and partly C8
Muscles paralysed
• Intrinsic muscles of the hand (T1).
• Ulnar flexors of the wrist and fingers (C8).
position of the hand: Claw hand due to
the unopposed action of the long flexors and extensors
of the fingers.
Disability
Complete claw hand
Vasomotor changes: The skin area with sensory loss
is warmer due to arteriolar dilation
Trophic changes: Long-standing case of paralysis
leads to dry and scaly skin.
Horner’s syndrome- ptosis, miosis, anhydrosis,
enophthalmos, and loss of ciliospinal reflex
Quadrangular space of scapular region
Boundries -
Superior
i. Subscapularis in front.
ii. Capsule of the shoulder joint.
iii. Inferior border of teres minor behind.
Inferior - Superior border of teres major
Medial: Lateral border of long head of the triceps brachii
Lateral - Surgical neck of the humerus
Contents
i. Axillary nerve
ii. Posterior circumflex humeral vessels
Upper and lower triangular space and contents.
Upper Triangular Space
Boundaries
Superior: Inferior border of teres minor.
Lateral: Medial border of long head of the triceps brachii.
Inferior: Superior border of teres major.
Contents - Circumflex scapular artery and vein
Lower Triangular Space
It is diagonally opposite the upper triangular space.
Boundaries
Medial: Lateral border of long head of the triceps brachii.
Lateral: Medial border of humerus.
Superior: Lower border of teres major
Contents
i. Radial nerve
ii. Profunda brachii vessels
Deltoid muscle
Origin - anterior border of lateral one-third of clavicle
Acromion process
Lower lip of crest of spine of scapula
Insertion
The deltoid tuberosity of the humerus
Nerve supply- Axillary nerve C5,C6
Action-
1) Powerful abductor of arm at shoulder joint
2) Anterior fibres are flexors and medial rotators of
the arm.
3) Posterior fibres are extensors and lateral rotators
of the arm.
Clinical important
Intramuscular injection given in middle of deltoid muscle
Contents under cover of deltoid muscle
Upper end of humerus
Coracoid process
Anterior and posterior circumflex humeral vessels
Axillary nerve
Shoulder joint
Musculotendinious cuff of shoulder
Coracoacromial ligament
Musculotendinous Cuff of the Shoulder or Rotator Cuff
It is a fibrous
sheath formed by the four flattened tendons which blend
with the capsule of the shoulder joint
The muscles which form the cuff arise from the scapula
and are inserted into the lesser and greater tubercles of
the humerus.
They are the subscapularis, the
supraspinatus, the infraspinatus and the teres minor
The cuff gives strength to the capsule of the shoulder
joint all around except inferiorly, dislocations of the humerus occur commonly in a
anteroinferior direction.
Carpal tunnel syndrome
Occurs due to compression of median nerve in carpal tunnel.
Froments sign which include book holding test and paper holding test.
Monkey like thumb deformity with loss of opposition of thumb and index and muddle finger lag behind while making fist due to paralysis of 1st and 2nd lumbricals muscle.
Loss of sensation of lateral 3½ digit including nail bed and distal phalanges on dorsum of hand.
The skin with sensory loss is warmer due to arteriolar dilation. And becomes drier due to absence of sweating.
Long standing cases of paralysis leads to dry and scaly skin. Nails crack easily with atrophy of pulp of finger.
Occurs in both males and females and attacks occur frequently at night.
Superficial palmar arch
The arch represents an important anastomosis between
the ulnar and radial arteries.
Arch is convex towards finger and base is situated at level of distal border of fully extended thumb.
The superficial palmar arch is formed as the direct
continuation of the ulnar artery. On
the lateral side, the arch is completed by superficial
palmar branch of radial artery.
The superficial palmar arch lies deep to the palmaris brevis
and the palmar aponeurosis.
Superficial palmar arch gives off three common digital
and one proper digital branches which supply the
medial 3½ digits.
