Upper Limb

Question 1

What is the shape of axilla?

Answer 1

It is a four sided pyramidal shaped space, situated between upper part of arm and chest wall

Question 2

What are the contents of the axilla?

Answer 2

• Axillary artery and its branches.
• Axillary vein and its tributaries.
• Infraclavicular part of the brachial plexus. • Axillary lymph nodes and lymphatics.
• Long thoracic and intercostobrachial
nerves.
• Axillary fat and areolar tissue.

Question 3

What are the boundaries of axilla?

Answer 3

• Apex: Truncated.
• Base: Skin and axillary fascia.
• Anterior wall: Pectoralis major, pectoralis
minor and clavipectoral fascia.
• Posterior wall: Subscapularis above, teres
major and latissimus dorsi below.
• Medial wall: Upper four ribs with intercostal muscles, upper part of serratus
anterior.
• Lateral wall: Upper part of shaft of
humerus, coracobrachialis, short head of biceps muscle (Fig. 2.23).

Question 4

Name the branches of axillary artery.

Answer 4

From first part: Superior thoracic artery From second part:
• Thoracoacromial artery
• Lateral thoracic artery.
From third part:
• Subscapular artery
• Anterior circumflex humeral artery
• Posterior circumflex humeral
artery(Fig. 2.25).

Question 5

What is breast?

Answer 5

It is modified gland of apocrine type, which is present in both the sexes, but is rudimentary
in males and well developed in females after puberty.
It forms as important accessory organ of female reproductive syste

Question 6

What is extent of female breast?

Answer 6

• Superiorly: 2nd rib
• Inferiorly: 6th rib.
• Medially: Lateral border of sternum.
• Laterally:Midaxillaryline
• The superolateral part of gland is
prolonged upwards and laterally, pierces the deep fascia at anterior fold of axilla and lies in the axilla at the level of third rib. This process of gland is known as ‘Axillary tail of Spence’ and the opening in deep fascia is known as ‘Foramen of Langer’.

Question 7

What is situation of breast?

Answer 7

Breast lies in the superficial fascia of pectoral region except for axillary tail which pierces the deep fascia through foramen of Langer and lies in axilla.

Question 8

What are deep relations of breast?

Answer 8

1. Retromammary space of loose areolar tissue. According to former concept of free flow of lymphatics, it was known as Lake of Marcille.
2. Pectoral fascia
3. Pectoralis major, serratus anterior and
   external oblique.

Question 9

What is the structure of breast?

Answer 9

• Glandular tissue: This consists of 15-20 lobes. Each lobe consists of several lobules and each lobule consists of a cluster of alveoli which open into the smallest branches of lactiferous ducts. These bran- ches unite to form larger branches of duct. Each lactiferous duct, drains a lobe of gland and opens at nipple. At the bottom of the nipple each duct is dilated to form a sinus. The ducts are arranged radially around the nipple. The glandular tissue is the functional portion of the breast and secretes milk.

• Fibrous tissue stroma: This consists of numerous septa connecting the lobules and supporting them. These septa link the pectoral fascia to the skin of the breast. These are known as ‘suspensory ligaments of Cooper’.
• Adipose tissue: This fills the interalveolar and interductular intervals and accounts for the smooth contour and most of the bulk of breast.
•. Skin:
– Nipple:Cylindricalorconicalprojection
directed superolaterally. It lies at the level of 4th intercostal space in nulliparous females.
– Areola: Pigmented area around nipple. Rose pink in virgins and dark brown or black after pregnancy. The nipple and the subareolar tissue contain smooth muscle but lack the fat.
– Montgomery’s tubercles: These are sebaceous glands underlying the areolar skin and are called areolar glands. They enlarge during pregnancy and lactation and form raised tubercles. Oily secretions of these glands lubricates nipple and areola and prevent them from cracking during lactation.

Question 10

How does the structure of male breast differs from the female breast?

Answer 10

The male breast is rudimentary. It consist of small ducts without alveoli. There is little supporting fibrous tissue and fat.

Question 11

What is retromammary space and what is its clinical significance?

Answer 11

It is a space which lies between the deep aspect of the breast and the fascia covering the pectoralis major. It contains loose areolar tissue and allows the breast some degree of movement on pectoral fascia.
Fixity of the breast to the pectoral fascia and the muscle may occur, by invasion, in advanced carcinoma of breast. This is of great significance in clinical staging of breast carcinoma.

Question 12

What is the clinical significance of retraction of nipple?

Answer 12

• Retraction occurring at pregnancy: It is due
to a developmental abnormality. The nipple, for some unknown reason, does not develop with breast.
• Recent retraction of nipple may be due to the fibrous contraction of the lactiferous ducts in breast carcinoma or chronic abscess.

Question 13

What is the clinical significance of the dimpling of skin over breast?

Answer 13

This is due to contraction of ligaments of Cooper. It can occur in chronic infection, after trauma or the breast carcinoma infiltrating the ligaments.

Question 14

What is arterial supply of breast?
Breast is supplied by:

Answer 14

1. Internal thoracic artery, through its
   perforating branches in 2nd-6th
   intercostal space.
2. Lateral thoracic
3. Superior thoracic Branches of
4. Acromiothoracic axillary artery 5. Lateral branches of posterior intercostal
   arteries

Question 15

What is lymphatic drainage of breast?

Answer 15

Axillary
Apical Lymph
nade
Anterior LN
Central LN
LN Lateral
LN
posterio
IN
Supraclavicular
IN
Parasternal
LN

Question 16

What is the extent of clavipectoral fascia?

Answer 16

Vertically:
Superiorly, splits to enclose subclavius muscle and is attached to the clavicle.
Inferiorly, splits to enclose pectoralis minor and continues as suspensory ligament.
Horizontally:
Medially, attached to first rib, costo- clavicular ligament and fascia covering the two intercostal spaces.
Laterally, attached to coacoid process and blends with the coracoclavicular ligament.

Question 17

Name the structures piercing clavipectoral fascia.

Answer 17

• Lateral pectoral nerve
• Cephalic vein
• Thoracoacromial vessels • Lymphatics.

Question 18

What is brachial plexus?

Answer 18

Brachial plexus (Fig. 2.31) is formed by the union of the ventral rami of lower four cervical nerves (C5,6,7,8) and the greater part of the ventral ramus of the first thoracic nerve (T1). The fourth cervical nerve usually gives a branch to the fifth cervical and the first thoracic nerve frequently receives one from the second thoracic nerve.

Question 19

How the branchial plexus forms trunks?

Answer 19

The C5 and C6 join to form upper trunk, C7 forms the middle trunk and C8 and T1 join to form the lower trunk.
Each trunk divides into ventral and dorsal division, which ultimately supply anterior and posterior aspect of upper limb

Question 20

How the cords of brachial plexus are formed?

Answer 20

Lateral cord is formed by union of ventral division of the upper and middle trunks. The medial cord is formed by the ventral divisions of lower trunk. Posterior cord is formed by union of dorsal divisions of all the three trunks.

Question 21

What are the branches of roots of brachial plexus?

Answer 21

Long thoracic nerve (Nerve to serratus anterior) C5,6,7.
• Dorsal scapular nerve (Nerve to rhomboids) C5.

Question 22

What are the branches of trunks of brachial plexus?

Answer 22

• Suprascapular nerve (C5,6).
• Nerve to subclavius (C5,6).

Question 23

What are the branches of lateral cord of brachial plexus?

Answer 23

• Lateral pectoral nerve
• Lateral root of median nerve
• Musculocutaneous nerve.

Question 24

What is the main nerve supply of pectoralis major?

Answer 24

Lateral pectoral nerve.

Question 25

What are the branches of medial cord of brachial plexus?

Answer 25

• Medial root of median nerve
• Medial pectoral nerve
• Ulnar nerve
• Medial cutaneous nerve of arm
• Medial cutaneous nerve of forearm.

Question 26

What are the branches of posterior cord of brachial plexus?

Answer 26

• Radial nerve
• Axillary nerve
• Thoracodorsal nerve (Nerve to latissimus dorsi)
• Upper subscapular nerve • Lower subscapsular nerve.

Question 27

What is main nerve supply of pecto- ralis minor?

Answer 27

Medial pectoral nerve.

Question 28

What is the distribution of supra- scapular nerve?

Answer 28

Supraspinatus Infraspinatus
Shoulder joint Acromioclavicular joint

Question 29

What is Erb’s point?

Answer 29

It is the junction of the ventral primary rami
of C and C forming the upper trunk of the 56
brachial plexus. The trunk being short, the suprascapular nerve and nerve to sub- clavius which arise directly from it and the anterior and posterior divisions of trunk all lie close to the Erb’s point and may be involved in any injury at this point.

Question 30

What is Erb’s paralysis?

Answer 30

It is the paralysis resulting from a lesion of the upper trunk at the Erb’s point. It is caused by the forcible downward traction of the shoulder with lateral displacement of the head to the other side.
In this lesion, the area of distribution of C5 and C6 is affected and most commonly the muscles supplied by C5 are involved. The deltoid, biceps, brachialis, brachio- radialis and sometimes supraspinatus, infraspinatus and supinator are paralysed. The affected limb assumes a characteristic ‘waiter’s tip’ position.
• The arm hangs simply by the side due to
paralysis of the deltoid and supraspinatus and is rotated medially, due to paralysis of infraspinatus.
• The elbow is extended due to paralysis of the biceps and brachialis and imposed action of the extensors of elbow.
• The forearm is pronated due to paralysis of the biceps and supinator.
• The wrist is slightly flexed due to weak wrist extensors.

Question 31

What is Klumpke’s paralysis?

Answer 31

This is a paralysis resulting from the lesion of the lower trunk (C8 and T1 nerve roots). It is caused by forceful upward traction of the arm. The area of distribution mainly of T1 is involved, i.e. all the intrinsic muscles of the hand are affected and flexors of wrist are affected due to C root involvement. deformity described as claw hand. In this, the metacarpophalangeal joints are hyperextended due to unopposed action of the long extensors as the lumbricals and interossei are paralysed while the interphalangeal joints are flexed due to unopposed actions of the long flexors of the fingers.
• There is sensory loss along the ulnar side of the hand, forearm and arm.
• There may also be Horner’s syndrome characterised by moisis, ptosis, anhy- drosis and anophthalmos

Question 32

What is ‘Crutch paralysis’?

Answer 32

It is due to the damage to the brachial plexus in the axilla from the pressure of crutch. In these, the radial nerve is frequently implicated and ulnar nerve suffers next in frequency.

Question 33

What is ‘Saturday night palsy’?

Answer 33

This is radial nerve palsy due to the prolonged pressure on the nerve in the spiral groove of the humerus. This occurs when a drunkard falls into sleep (on Saturday night!) with his arm hanging over the back of chair. In the morning, he is suffering from the wrist drop which is temporary.

Question 34

What is ‘Winging of scapula’?

Answer 34

This is clinical condition in which the inferior angle and the medial border of the scapula becomes unduly prominent. It occurs in the paralysis of long thoracic nerve (Nerve of Bell) which supplies serratus anterior. It can be demonstrated by asking the patient to push against the wall with outstretched hands. The scapula on affected side becomes winged due to unopposed action of the rhomboids and levator scapulae, while the paralysed serratus anterior is not contracting.

Question 35

What is origin of radial nerve?

Answer 35

It is a branch of posterior cord of brachial plexus with a root value of C5,6,7,8 T1.

Question 36

What are the branches and distri- bution of radial nerve?

Answer 36

• Muscular branches: To
– Triceps
–. Anconeus
– Brachialis, only lateral part
– Brachioradialis and
– Extensor carpi radialis longus

Question 37

What are the structures supplied by posterior interosseous nerve?

Answer 37

Muscular branches:
• Extensor carpi radialis brevis
• Supinator • Extensor digitorum
• Extensor digiti minimi • Extensor carpi ulnaris • Extensor pollicis longus • Extensorindicis
• Abductorpollicislongus • Extensor pollicis brevis

Question 38

What is the commonest site of radial nerve injury? What are the common causes of lesion?

Answer 38

In the region of radial (spiral) groove of humerus.
The common causes of injury are: • Fracture of shaft of humerus
• Intramuscular injections in arm

Question 39

What are the effects of the lesion of radial nerve in the spiral groove?

Answer 39

• Triceps is not paralysed since the branches
supplying arise from the radial nerve
more proximally.
• There is wrist drop, i.e. hand is flexed at
wrist and it lies flaccid due to the paralysis of the extensors of the wrist. The fingers are also flexed and when an attempt is made to extend them, the last two phalanges only will be extended, through the action of lumbricals and interrossei.
• Supination is completely lost when the forearm is extended on the arm, but is possible to a certain extent if the forearm is flexed to allow effective action of the biceps.

Question 40

What will be the effect of cutting the radial nerve just below the elbow?

Answer 40

Sensory loss: It is marked on the lateral part of the dorsum of the hand.
Motor loss:
• Wrist drop
• Loss of power of supination
• Extension of elbow is retained because of
the intact triceps
• Flexion of elbow in normal position will
also be retained because of intact biceps brachii and brachioradialis.

Question 41

What are the boundaries and contents of Quadrangular space?

Answer 41

Boundaries (Fig. 2.33):
• Superior:
– Subscapularis
– Capsule of shoulder joint – Teres minor
• Inferior: Teres major
• Medial: Long head of triceps
• Lateral: Surgical neck of humerus
Contents:
• Axillary nerve
• Posterior circumflex humeral vessels.

Question 42

What are the boundaries and contents of upper and lower triangular space?

Answer 42

Upper triangular space:
Boundaries:
• Superior: Teres minor Subscapularis
• Lateral: Long head of triceps
• Inferior: Teres major.
Contents: Circumflex scapular artery
Lower triangular space:
Boundaries:
• Superior: Teres major
• Medial: Long head of triceps
• Lateral: Medial border of humerus Contents:
• Profunda brachii vessels
• Radial nerve

Question 43

Whatiscubitalfossa?

Answer 43

It is a triangular hollow in front of elbow.

Question 44

What are the boundaries of cubital fossa?

Answer 44

• Laterally: Medial border of brachioradialis. • Medially: Lateral border of pronator teres. • Base: By an imaginary line joining two
epicondyles of the humerus.
• Apex: By meeting point of lateral and
medial boundaries. • Floor: By
– Brachialis and
– Supinator. • Roof:
– Skin
– Superficial fascia
Deepfasciaand
– Bicipitalaponeurosis(Fig.2.14).

Question 45

What are the contents of cubital fossa?

Answer 45

• Median nerve.
• Termination of brachial artery.
• Tendon of biceps with bicipital apo-
neurosis.
• Radial nerve.

Question 46

Name the structures lying in superficial fascia of cubital fossa.

Answer 46

• Median cubital vein
• Lateral cutaneous nerve of forearm
• Medial cutaneous nerve of forearm.

Question 47

What is the clinical importance of median cubital vein?

Answer 47

It is the vein of choice for intravenous injections because it is fixed by perforator, so it does not slip away from needle.

Question 48

What is carrying angle?

Answer 48

It is the angle between long axis of arm with long axis of forearm, when forearm is extended and supinated. It disappears in full flexion of elbow and in pronation.
It is about 170°.

Question 49

Whatarethefactorsresponsiblefor carrying angle?

Answer 49

• Medial flange of trochlea is larger than
lateral flange and projects downward to a lower level. As a result lower edge of trochlea passes downwards and medially.
• Superior articular surface of coronoid process of ulna is oblique.