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Part 1 MCQ > Upper Limb > Flashcards

Upper Limb Flashcards

1
Q

Types of ossification

A

Intramembranous (skull, face, clavicle)
Endochondral (preexisting hyaline cartilage destroyed and replaced by bone)

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2
Q

ossification

A

primary is in diaphysis en utero
secondary is when epiphysis and diaphysis fuse

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3
Q

sesamoid bones

A

patella
adductor pollicus
FPB FHB
PL
TA TP
head of gastroc

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4
Q

Scaphoid articulations

A

Radius, lunate, capitate, trapezoid, trapezium

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5
Q

TFCC Attachments

A

Medial border of distal radius to ulna styloid
Stabilises DRUJ and distal carpal row
Triangular fibrocartilaginous complex

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6
Q

Attachments of axial skeleton to arm?

A

Sternoclavicular joint
and lesser extent ACJ

Mostly muscular

Strong coracoclavicular ligament attaches clavicle and scapula

Costoclavicular ligament anchors 1st CC to clavicle

All movement through humerus and glenoid is also accompained by scapula movement

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7
Q

Direct muscular attachments between pectoral girdle and trunk

A

Muscles inserted into clavicle of scapula
Pectoralis minor, subclavius, trapezius, rhomboids, levator scapulae and serratus anterior.

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8
Q

Indirect muscular attachments between pectoral girdle (shoulder)

A

Great muscles of axillary folds aka pectoralis major and latissimus dorsi
These move pectoral girdle on trunk via upper humerus

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9
Q

Muscular attachments between upper limb and shoulder/pectoral girdle

A

Deltoid
Short scapular muscles
All insert upper end of humerus

plus biceps and long head or triceps which are inserted beyond elbow into bones of forearm

Important stabilisers of mobile shoulder joint

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10
Q

Pectoralis Major
-Origin
-Insertion
-Nerve supply
-Related anatomy
-Action

A

Clavicular head
-Medial 1/2 of anterior surface of clavicle
-Fibres run horizontal and lateral
-Insert on anterior lamina of tendon into lateral lip of intertubercular/bicipital sulcus of humerus

Sternocostal head
-Lateral 1/2 anterior surface manubrium and sternal body, upper 6 CCs and aponeurosis of EO over upper attachment of rectus abdominus
-Manubrial fibres insert on anterior lamina of tendon into lateral lip of bicipital sulcus of humerus
-Lower sternocostal and abdo fibres go up and lat to insert higher into posterior lamina of tendon producing anterior axillary fold
ie fibres originating lowest insert highest.
Blend into shoulder joint capsule.

Related anatomy- perf branches of internal thoracic pierce deep surface at sternal edge and can be damaged.

Nerve supply- ALL 5 SEG OF PLEXUS C5-T1
lateral and medial pectoral nerves.
Lateral pectoral nerve pierces clavipectoral fascia medial to pec minor. Medial pectoral nerve pierces pec minor to react pec major.
C5,6 clavicular head
C6-8, T1 sternocostal head.

Action- powerful adductor and medial rotator.
Clavicular head is flexor of shoulder. also accessory inspiration muscle.

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11
Q

Pectoralis Minor

A

Small, triangular
From 3-5th ribs under pec major
Inserts by short thick tendon onto medial border and upper surface of coracoid process of scapula (NOT tip this is occupied by biceps and coracobrachialis)

Not great functionally but does form tight band over axillary NVB and lymphatic contents

Division facilitates surgical clearence of axillary nodes

Nerve supply- C6-8 pectoral nerves

Assists serratus anterior in scapula protraction so keep anterior/glenoid angle in apposition with chest wall.

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12
Q

Subclavius

A

Costochondral junction of 1st rib and inserts into subclavian groove on inferior clavicle

Nerve- subclavius from upper trunk C5,6

Stabilises clavicle in shoulder movements.

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12
Q

Pectoral and clavipectoral fascia
-Attachments
-Relevant clinical anatomy

A

Pectoral- Thin lamina of fascia covering anterior surface of pec major. Attached to sternum medially and continuous w axillary fascia laterally.
Forms FLOOR of retromammary space
Gives origin to platysma muscle in upper part

Clavipectoral- STRONG fascial sheet deep to pec major. Upper part known as costo-coracoid membrane. Attached laterally to corocoid porcess and medially blends with external intercostal membrane of upper 2 spaces.

Splits ABOVE to enclose subclavius and attached to edge of subclavian groove on undersurface of clavicle

At lower border of subclavius layers fuse to form COSTOCORACOID LIGAMENT (from knuckle of coracoid to 1st costochondral junction). From this ligament it stretches over membrane to upper border of pec major splitting to enlocose muscle.

Below pec major fascia known as suspensory ligament of axilla extends down and attaches to axillary fascia on floor of axilla- tension maintains concavity of axilla.

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13
Q

4 structures piercing clavipectoral fascia

A

2 in and 2 out
In= lymphatics from infraclavicular nodes to apical nodes and cephalic vein
Out= Lateral pectoral nerve and thoracoacromial artery and branches (pectoral, acromial, deltoid and clavicular) and corresponding veins

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14
Q

Trapezius
-Origin
-Attachment
-Nerve supply
-Related anatomy

A

Most superficial muscle of upper back, large and flat

Medial 1/3 superior nuchal line to spine of C7 vertebrae, ligamentum nuchae between external occipital protuberance and spine. Extends along spinous process and supraspinous ligaments of ALL thoracic vertebrae
Upper fibres inserted into posterior border of lateral 1/3 clavicle , medial fibres along medial border of acromion and superior lip of crest of scapula spine.
Muscle arising from lower 6 thoracic spines inserted by tendon into medial end of spine

Nerve- Accessory spinal nerve C1-5 and branches from C3-4
Enter posterior triangle to enter deep trap surface.
Accessory nerve emerges from substance of SCM and cervical nerves from behind SCM

Action- Retract scapula and upper/lower fibres rotate scapula. Also elevated acromion. Upper fibres elevate scapula. Also lateral flexion of next and extension.

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15
Q

Latissimus Dorsi
-Origin
-Attachment
-Nerve Supply
-Related Anatomy

A

Very wide origin, narrow insertion
Spines of lower 6 thoracic vertebrae T6-T12 and posterior lumbar fascia (how it attached to TS vertebrae spines) as well as outer tip of iliac crest.

Converges towards posterior axillary fold and forms lower border
Spirals around lower teres major and intermingles. Then becomes flat shiny tendon 3cm broad inserted into floor of intertubercular sulcus

Little spiral turn around insertion meaning lowest fibres insert highest and vice/versa

Good landmark of post wall of axilla as tendon really big

May also blend with pec major and blend across axillary NVB forming muscular axillary arch.

Nerve- Thoracodorsal (C6-8) from posterior cord.

Vulnerable in axilla operations

Action- Extends shoulder and medially rotates humerus. And in combo with pec major powerful adductor. Assists in deep inspiration- elevates lower 4 ribs.

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16
Q

Rhomboid major and minor
-Origin
-Insertion
-Nerve
-Related Anatomy

A

Rhomboid major
O- T2-5 vertebral spines and supraspinous ligaments
I- medial border of scapula between root of spine and inferior angle

Rhomboid minor is parallel with above
O- C7,T1 vertebral spines
I- medial border of scapula at root of spine

Nerve- dorsal scapular nerve C5 root
Nerve passes through scalenus medius and deep to levator scapulae and lies on serratus posterior on medial side of transverse cervical artery

Action- Draw vertebral border of scapula medial and upwards (squaring shoulders)

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17
Q

Levator Scapulae
-Origin
-Insertion
-Nerve
-Related Anatomy

A

Floor of posterior triangle
O- TP of atlas and axis + posterior tubercles of C3-4
I- Medial border of scapula from superior angle to spine
N- C3,4 cervical plexus anterior rami, reinforced by dorsal scapular nerve C5
A- with upper traps elevates scapula and laterally flexes neck

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18
Q

Serratus Anterior
-Origin
-Insertion
-Nerve
-Related Anatomy

A

Broad, sheetlike, thick muscle
Medial wall of axilla
O- digitations from ribs 1-8
1st digitation from 1-2nd rib, the rest from corresponding ribs, lower 4 interdigitate with external oblique.
I- costal/inner surface of scapula, 1-2 superior, 3,4 vertebral border, 4-8 inferior angle

Covered by strong fascia

N- long thoracic nerve C5-7
Behind mid-axillary line on muscle surface deep to fascia so protected in axillary operations

A- Protracts scapula (pushing or punching) elongating upper limb. Lower 4 digitations with traps rotate scapula laterally to raise arm above shoulder. more powerful rotator than traps!

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19
Q

Sternoclavicular Joint
-Type of joint
-Capsular attachments
-Ligaments
-Relevant anatomy

A

Atypical, synovial joint
Medial clavicle, superolateral manubrium and 1st CC.

Intervening fibrocartilage disc attached to joint capsule

Atypical as bony surface covered by fibrocartilage not hyaline

Capsule invests articular surfaces like a sleeve
Articular disc attached to capsule and medial end of clavicle above and behind
as well as 1st CC below

Capsule thickened in front and behind by anterior and posterior sternoclavicular ligaments

Interclavicular ligament joins upper border of sternal ends of two clavicles and attached to suprasternal/jugular notch of manubrium.

Costoclavicular ligament- Clavicle to 1st CC and adjacent 1st rib.
2 laminae- anterior up and lateral, posterior up and medial (same as intercostals). VERY STRONG, main stabiliser to SCJ

Nerves- medial supraclavicular nerves C3,4 from cervical plexus

1st CC to manubrium is primary cartilaginous joint and dislocation unusual- clavicle will break in preference

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20
Q

Acromioclavicular joint
-Type
-Capsule
-Ligaments
-Relevant anatomy

A

Atypical, synovial joint between lateral clavicle and medial border of acromion

Articulating surface covered with fibrocartilage (makes it atypical like SCJ)

Sleeve-like capsula covers articular surfaces, NOT strong. but on top acromioclavicular ligament is thickening of fibres.

Coracoclavicular ligament is EXTREMELY STRONG, main stabiliser of joint

Conoid ligament goes upwards from knuckle of coracoid to wide attachment of conoid tubercle on undersurface of clavicle

Trapezoid ligament attached to ride of same name on upper surface of coracoid process, extends laterally (horizontal) to trapezoid ridge on undersurface of clavicle.
Both ligaments connected posteriorly forming an angle that is open anteriorly

Nerve- suprascapular nerve C5,6 from brachial plexus

Movements- passive via scapular muscles. Protraction, retraction, rotation, elevation and depression.

Injuries from FOOSH normally fracture clavicle as strong ligaments on either side
If fall on shoulder can dislocate ACJ so acromion goes under clavicle and tar the coracoclavicular ligament

21
Q

Shoulder muscles short summary

A

6 muscles converge from scapula to humerus to surround shoulder
Deltoid, supraspinatus, infraspinatus, teres minor, teres major and subscapularis.

Supraspinatus, infraspinatus and teres minor extend from post surface of scapula blader to insert into three impressions on greater tubercle of humerus

Subscap from thoracic surface of scapula to lesser tubercle

Teres major from inferior angle of scapula to shaft of humerus

All muscle humeral attachments lie hidden under deltoid

22
Q

Subscapularis
-Origin
-Insertion
-Nerve
-Relevant anatomy

A

O- Medial 2/3 costal surface of scapula and from intermuscular septa
I- Tendon is seperated from bare area at lateral scapula by bursa with communicates with cavity of shoulder joint. Then fuses with shoulder joint capsule and inserts on lesser tubercle of humerus. Covered by fascia.
N- Upper and lower subscap nerves C5,6 from posterior cord
A- stability, fixation of upper end of humerus during movement of arm and hand. Mediator rotator of humerus

23
Q

Supraspinatus
-Origin
-Insertion
-Nerve
-Relevant anatomy

A

O- Medial 2/3 supraspinous fossa of scapula
I- Tendon blends with shoulder joint capsule and inserts into smooth facet on upper part of greater tubercle of humerus
N- Suprascapular nerve C5,6
A- Braces head of humerus against glenoid giving stability during action esp Deltoid. Assists in abduction.

24
Q

Infraspinatus
-Origin
-Insertion
-Nerve
-Relevant anatomy

A

O-Medial 2/3 infraspinous fossa and deep surface of infraspinous fascia.
Bursa lies between bare area of scapula and muscles which can communicate with shoulder joint.
I- Tendon blends in with capsule of shoulder and inserted into smooth area on central facet of greater tubercle.
N- Suprascapular nerve C5,6
A- Braces head of humerus against glenoid cavity giving stability to shoulder. Powerful lateral rotator of humerus.

25
Q

Teres minor
-Origin
-Insertion
-Nerve
-Relevant anatomy

A

O- Elongated oval area on dorsal surface of axillary border of scapula. Passes superiorlateral edge to edge with lower border of infraspinatus behing long head of triceps.
I- Blends with capsule and attached to lower facet on greater tuberosity of humerus.
N- Posterior ranch of axillary nerve C5,6
A- Assists other small muscles in stabilising shoulder. Lateral rotator and weak adductor.
With teres major holds down head of humerus against upward pull of deltoid during abduction.

26
Q

Teres Major
-Origin
-Insertion
-Nerve
-Relevant anatomy

A

O- Oval area, dorsal surface of inferior angle of scapula.
I- Medial lip of intertubercular/bicipital of humerus. Latissimus dorsi tendon winds around lower border then lies in front of upper part at insertion.
N- Lower subscapular nerve C5,6 enters anterior to muscle
A- Stabiliser together. Alone is adductor and medial rotator. Extends flexed arm.

27
Q

Infraspinatus fascia
-Key anatomy

A

Infraspinatus and teres minor lie deep to it
Strong, firmly attached to bone at margins of muscles
Attached to lower border scapular spine beneath deltoid.
Does NOT cover teres major.
Landmark in surgical procedures in this region. If fractured blade can haemorrhage and will be confined beneath scapula, swelling will be limited to margins of bone

28
Q

Deltoid
-Origin
-Insertion
-Nerve
-Relevant anatomy

A

O- Anterior border and upper surface of lateral 1/3 clavicle, whole lateral border of acromion and inferior lip of crest of scapular spine. 4 fibrous septa from acromion pass down into muscle.
I- Deltoid tuberosity on lateral aspect of humerus (V with central ridge) 3 septa from this ridge pass upwards between 4 septa from acromion.
The anterior and posterior fibres from clavicle and scapular spine are NOT multipennate.
N- Axillary nerve C5,6
A- Adducts arm by multipennate acromial fibres. Anterior assist pect major in flexion and medial rotation. Posterior assist lats in extension and lateral rotation.

29
Q

Scapular anastamosis

A

Dorsal scapular artery (branch of transverse cervical or 3rd part of subclavian)
Travels with dorsal scapula nerve down vertebral border of scapula to inferior angle.

Transverse cervical and suprascapular artery branches of thyrocervical trunk (1st part of subclavian)

Suprascap artery crosses over suprascapular ligament THROUGH the supraspinous fossa TURNS around lateral border of scapula spine and supplies infraspinous fossa.

Subscap artery, from 3rd part of axillary supplied subscap muscle. Has circumflex scapular branch which enters infraspinous fossa on dorsal surface of one, grooving axillary border.

Vessels anastamose (dorsal scap S1 Suprascap S3 Subscap A3) on both surfaces of scapula so 1st subclavian and 3rd axillary connected providing collateral circulation to subclavian artery if obstructed. e.g cervical rib or fibrous band.

30
Q

Shoulder joint
-Type
-Capsule

A

Multi-axial ball and socket type joint
4-1 proportion of humeral head and shallow glenoid fossa of scapula

Glenoid labrum-
Ring of fibrocartilage
Attached to margins of glenoid cavity

Capsule-
Attached to scapula beyond supraglenoid tubercle and margins of labrum, humerus around articular margin of head (anatomical neck) and inferiorly to surgical neck.

Gap anteriorly allows communication between synovial membrane and subscapularis bursa
May be posterior gap for infraspinatus bursa

Capsule is thick strong and lax

Long head of biceps is intracapsular and blends with labrum at supraglenoid tubercle of scapula

Synovial membrane- around glenoid labrum and lines of capsule. Attached to articular margin at head of humerus covering bare area of SNOH
Herniates through hole anterior to communicate with subscapularis bursa and sometimes infraspinatus bursa.
Communicates with synovial sleeve of long tendon of biceps during abduction and adduction.

31
Q

Ligaments of shoulder joint

A

Transverse humeral ligament
-Upper end of intertubercular sulcus capsule bridges gap between superior and lesser tuberosity

Glenohumeral ligaments
-Three thickened bands between glenoid labrum and humerus.
-Reinforce anterior capsule
-Only visible WITHIN joint cavity and communicate with subscapular bursa though aperture between superior and middle glenohumeral ligaments.

Coracohumeral ligament
-Quite strong.
-Base of coracoid process to front of greater tuberosity and blends with capsule.

Coracoacromial ligament
-Medial border of acromion at anterior acromioclavicular articulation.
-Strong, flat, triangular band
-Fans out to lateral border of coracoid process.
-Above head of humerus and supports it.
-Seperated from rotator cuff by subacromial bursa

Subacromial bursa
- large bursa under coracoacromial ligament
-Attached to ligament in upper layer and lower to supraspinatus tendon
-Extends beyond lateral border under deltoid and when abducted disappears under acromion
-Tenderness over GT beneath deltoid which disappears when arm is abducted is feature of subacromial bursitis
-Tearing of supraspinatus tendon brings bursa into communication with joint cavity but otherwise does not communicate.

32
Q

What stabilises shoulder joint?

A

-Capsule fused by tendons
- Glenohumeral and coracohumeral ligaments
-Coracoacromial arch
-Deepening of glenoid cavity by labrum

Upward displacement stopped by
-Coracoid and acromion processes and coracoacromial ligament

Least supported inferiorly
Axillary nerve can get damaged in dislocation

33
Q

Axillary boundaries and communications

A

Anterior wall- Pec major, pec minor, subclavius and clavipectoral fascia
Posterior- Subscapularis and teres major and tendon of lat dorsi
Medial- upper serratus anterior and lower 4th rib
Lateral- Anterior and posterior walls converge to lips of intertubercular groove of humerus, where long head of biceps tendon lies, overlapped by coracobrachialis and tendon of short head of biceps
Apex- Clavicle, upper border of scapula and outer first rib
Floor- axillary fascia from anterior and posterior axillary folds, fascia over serratus anterior and suspensory ligament from lower border of pec minor

Communications- via Apex posterior triangle of neck

34
Q

Elbow Joint type

A

Synovial hinge joint between lower end of humerus and upper ends of radius and ulna, communicates with proximal radioulnar joint

35
Q

Elbow capsule attachments

A

Medial and lateral margins of trochlea of humerus
Above coronoid and radial fossa
Above the olecranon fossa
Fisally to margins of trochlear notch of ulna and annular ligament of proximal radioulnar joint.

NOT ATTACHED TO RADIUS

Capsule and lower annular ligament lined by synovial membrane which is attached to articular margins of all 3 bones.

36
Q

What prevents downward herniation of elbow synovial membrane

A

Quadrate ligament on lower margin of radial notch of ulnar and neck of radius

37
Q

Ulnar collateral ligament of elbow anatomy

A

3 bands, triangular
Anterior=strongest, from medial epicondyle of humerus to tubercle on medial border of coronoid process (sublime tubercle)
Posterior= joins sublime tubercle and medial border of olecranon
Middle= thin, connects two others and is grooved for ulnar nerve

38
Q

Radial (lateral) collateral ligament anatomy

A

Triangular band
Apex attached to lateral epicondyle and base fuses with annular ligament of radial head.

39
Q

Annular ligament anatomy

A

Attached to anterior and posterior margins of radial notch of ulna
Clasps head and neck of radius in proximal radioulnar joint
NO attachment to radius, free to rotate in annular ligament

40
Q

Wrist/radiocarpal Joint type?

A

Biaxial synovial joint
Concave ellipsoid distal surface of radius and attached articular disc with convex prox surface of scaphoid, lunate and triquetral bones.

41
Q

What seperates the radiocarpal and distal radioulnar joint?

A

Fibrocartilaginous disc holding lower ends of radius and ulnar together.

42
Q

Radiocarpal articulations

A

Styloid process with scaphoid and lunate

Triquetral with capsule reinforced by ulnar collateral ligament

43
Q

Radiocarpal joint capsule attachments

A

Surrounds joint and thickened to form palmar, dorsal and collateral ligaments

44
Q

What does palmar aponeurosis communicate with

A

Reinforced by SF layer continuous with palmaris longus tendon

Continuous proximally with flexor retinaculum and thenar/hypothenar fascia.

Longitudinal fibres continue distally to skin of distal palm and central fibres of digital strips to base of each digit, NOT thumb.

This then diverges to insert into deep transverse metacarpal ligament, bases of proximal phalanx and fibrous flexor sheath.

45
Q

What is superficial transverse metacarpal ligament (natatory ligament)

A

Thickening of transverse directed fibres at level of heads of metacarpal bones. If thickened=Dupuytren’s contracture

46
Q

What is flexor retinaculum and attachments

A

Strong fibrous band 2-3cm transverse and longitudinally in front of carpus in proximal hand.

Attachments- Prox limit is dominant wrist crease.
Hook of hamate, pisiform medially and tubercle of scaphoid and ridge of trapezium laterally

47
Q

What are fibrous flexor sheaths?

A

From metacarpal heads to distal phalanges of all 5 digits are strong fibrous sheath attached to margins of phalanges where flexor tendons lie in fibro-osseus tunnel.

Thumb- Fibrous sheath only has tendon of FPL

Fingers- tendons or superficial and deep flexors (superficial split around deep). Proximal ends receive insertions of digital slips of palmar aponeurosis.

Fibrous flexor sheaths of fingers reinforced by annular pulleys.
Anterior to MCP=A1
middle 1/3 PP= A2 PIP= A3 middle 1/3 MP=A4. In between are cruciform pulleys (C1,C2,C3).

In thumb A1 pulley anterior to MCPJ and A1 prox to IPJ.

Oblique pulley over middle 1/3 prox phalanx

48
Q

What are the carpal joints

A

Mid-carpal joint= continuous synovial sheath between two rows of carpal bones. Extends proximal and distal between adjacent carpal bones continuous with intercarpal joints.

Carpo-metacarpal joints-
Communicated with intercarpal joints and articulates with base of metacarpals.

Hook of hamate and 5th metacarpal is most mobile

First MCP seperate synovial cavity between trapezium and 1st metacarpal.

Metacarpal joints are synovial joints.
Palmar ligaments limit extension of joint.
Index to middle finger are joined by transverse bands which make deep transverse metacarpal ligament. Joining the digital palmar aponeurosis slips on palmar surface. Flanked by collateral ligaments.

Interphalangeal joints are pure hinge joints, NO abduction is possible. extension limited by palmar and collateral ligaments.

49
Q
A

Part 1 MCQ (5 decks)

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