Upper Limb Flashcards
anterior interosseous nerve classically innervates 2.5 muscles
Flexor pollicis longus o Pronator quadratus o The radial half of flexor digitorum profundus (the lateral two out of the four tendons).
Extensor loss without sensory
Posterior interosseous – extensor loss without sensory, radial entrapped in the arcade of Frohse
Extensor retinaculum - how many tunnels
Extensor retinaculum - 6 tunnels
Klumpke’s Palsy
C8, T1
· Axillary nerve – C5,C6, - through quadrangular space and then…
o lower border of subscapularis
o Posterior to the axillary artery
o With the posterior circumflex humeral vessels
Erb’s palsy
C5/C6 Arm is hanging loose on the side, pronated and medially rotated
Lac next to pisiform
ulnar artery
interossei – how many of which and supplied by
3 Palmar + 4 dorsal interossei
ulnar nerve
Lumbricals nerve supplied
1+2 Median Nerve, 3+4 Deep branch ulnar
Subscapularis inserts onto
lesser tuberosity
FDP – deepest + closest to
hamate
PAD/DAP
Palmar interossei adduct / Dorsal Abduct (Deep Ulnar Nerve)
Cephalic vein – superficial to most
most facia and tendons
Separates ulnar artery from median nerve
Pronator teres
Abductor pollicus longus supplied by the..
posterior interosseous branch of the radial nerve
Superficial radial branch relative to wrist
midline of wrist.
Suprascapular nerve supplies…
supra + infraspinatus
C5,C6
Only nerve trunk
cannot initiate shoulder abduction
Kumpke’s supply and appearance
Kumpke – C8/T1:
Medial forearm sensation,
wrist extension,
Horner’s + Claw hand,
MCP extended, IP flexed
recurrent ant shoulder dislocation
Bankart lesion – anterior inferior glenoid lambrum defect
winging of the scapula
C5,6,7 Serratus anterior
Wings to heaven
Supinator
Radial nerve
Superior joint capsule inserts into
anatomical neck of humerus
Branches that arise from the lateral cord
LLM
Lateral pectoral nerve: innervates pectoralis major
Lateral root of the median nerve: innervates forearm flexors (except FCU and ulnar half of FDP) and ‘LOAF’ muscles in the hand
Musculocutaneous nerve: innervates biceps brachii, brachialis and coracobrachialis. It continues as the lateral cutaneous nerve of the forearm
Branches that arise from the medial cord:
MMMU
Medial pectoral nerve: Innervates pectoralis minor and part of pectoralis major
•Medial cutaneous nerve of the arm: Supplies skin on medial side of arm
•Medial cutaneous nerve of the forearm: Supplies skin on medial side of forearm
•Medial root of the median nerve: Innervates forearm flexors (except FCU and ulnar half of FDP) and ‘LOAF’ muscles in the hand
•Ulnar nerve: Innervates FCU, ulnar half of FDP, intrinsic muscles in hand except ‘LOAF’
Name the muscles which attach to the coracoid process.
CPS
Coracobrachialis
Pectoralis minor
Short head of biceps
Name the muscles that make up the rotator cuff and their innervation.
SITS
- Supraspinatus:Suprascapular nerve (C5, C6)
- Infraspinatus: Suprascapular nerve (C5, C6)
- Teres minor: Axillary nerve (C5, C6)
- Subscapularis : Upper and Lower Subscapular nerves (C5, C6)
Name the muscles responsible for abduction at the shoulder.
Supraspinatus initiates abduction from 0 -15 degrees.
The lateral fibres of deltoid abduct the shoulder from 15 —100 degrees.
Further rotation of the shoulder is by rotation of the scapula on the thoracic wall aided by trapezius and levator scapulae.
Posterior Cord (ULNAR)
- Upper subscapular nerve
- Lower subscapular nerve
- Nerve to latissmus dorsi (thoracodorsal)
- Axillary nerve
- Radial nerve
Name the muscles innervated by branches from the posterio cord
- Subscapularis: Innervated by the upper and lower subscapular nerves
- Latissimus dorsi: Innervated by the thoracodorsal nerve
- Teres major: Innervated by the lower scapular nerve
- Deltoid and teres minor: Innervated by the axillary nerve
- Triceps and all extensors of the forearm: Innervated by the radial nerve
What the four nerves pass between
- Median nerve: Passes between the two heads of pronator teres.
- Ulnar nerve: Enters the forearm between the two heads of flexor carpi ulnaris.
- Musculocutaneous nerve: Initially pierces the coracobrachialis and then lies between the biceps and brachialis in the distal arm.
- Radial nerve: Lies between the two heads of supinator.
What are the boundaries of the axilla?
- Apex: Cervicoaxillary canal (where clavicle, scapula and 1st rib converge)
- Anterior: Pectoralis major and minor, subclavius
- Base/Posterior: Superiorly to inferiorly: subscapularis, teres major, latissimus dorsi
- Medial: Serratus anterior, upper three ribs, intercostal spaces
- Lateral: Intertubercular groove of the humerus, short head of biceps, coracobrachialis tendon
Lymph drainage of axilla
- *Lateral (humeral) group:** • Located posteromedial to axillary vein
- *Receives drainage from upper limb**
- *Anterior (pectoral) group:** • Located inferior to pectoralis minor along the course of lateral thoracic vessels. •
- *Receives drainage from abdominal wall, chest and breast**
- *Posterior (subscapular) group:** • Located in the posterior axillary wall along with subscapular vessels
- *• Receives lymph from back, shoulder and neck**
- *Central group:** • Located in the axillary fat
- *• Receives drainage from lateral, posterior and anterior group of nodes**
Apical group: • Most superior group of nodes • Receives drainage from all groups of nodes in addition to lymphatic vessels that accompany the cephalic vein and the vessels that drain the superior region of the breast.
Basilic vein pierces
brachial fascia
Axillary nerve winds around
surgical neck of humerus
Radial nerve
under Teres Major as it enters axilla
What are the boundaries of the quadrangular space?
- Lateral: humerus
- Medial: long head of triceps
- Superior: teres minor
- Inferior: teres major
Name the structures that pass through the quadrangular space
•Axillary nerve
•Posterior circumflex humeral artery
Three heads of triceps…
The long head - infraglenoid tubercle of the scapula. It extends distally anterior to the teres minor and posterior to the teres major.[1]
The medial head arises proximally in the humerus, just inferior to the groove of the radial nerve; from the dorsal (back) surface of the humerus; from the medial intermuscular septum; and its distal part also arises from the lateral intermuscular septum.
The lateral head - dorsal surface of the humerus, lateral and proximal to the groove of the radial nerve, from the greater tubercle down to the region of the lateral intermuscular septum.
Fibres converge to a single tendon to insert onto the olecranon process of the ulna
Radial nerve relation to condyles
Radial nerve – anterolateral in supracondylar area
Scaphoid blood supples
dorsal carpal branch of radial artery
Lattimus dorsi blood supply
thoracodorsal artery
ß post branch of subscapular
ß 3rd axillary branch
Boundaries and significance of triangular interval
Superior: teres major
Medial: long head of triceps
Lateral: humerus
Note: the triangular interval is also referred to as the lateral triangular space, lower triangular space, and triceps hiatus.
The radial nerve and profunda brachii artery pass through the triangular interval, on their way to the posterior compartment of the arm.
Structures that pierce the clavipectoral fascia:
- Cephalic vein
- Lymphatics (from the infraclavicular nodes to the apical nodes of the axilla)
- Lateral pectoral nerve
- Thoraco-acromial artery and vein
What is ‘painful arc’ syndrome?
Inflammation of supraspinatus (supraspinatus tendinitis) and of the subacromial bursa results in painful abduction between 60 and 120 degrees when the inflamed tendon is compressed against the acromion.
Frozen Shoulder
The following muscles arise from the common extensor origin at the lateral epicondyle of the humerus except:
A. Extensor carpi radialis brevis (ECRB)
B. Extensor indicis proprius (EIP)
C. Extensor digitorum communis (EDC)
D. Extensor digiti minimi (EDM)
E. Extensor carpi ulnaris (ECU)
B. Extensor indicis proprius (EIP)
These do arise from the common extensor origin at the lateral epicondyle of the humerus
Extensor carpi radialis brevis (ECRB)
Extensor digitorum communis (EDC)
Extensor digiti minimi (EDM)
Extensor carpi ulnaris (ECU)
Name the nerves which can be injured after a fracture of the humerus.
- Axillary nerve: # Surgical neck of the humerus
- Radial nerve: # Shaft of humerus at the junction between the proximal 2/3rd and distal 1/3rd (at the level of spiral grove)
- Ulnar nerve: Medial epicondyle, Galeazzi #
- Median nerve and AIN: Supracondylar #, Galeazzi #
- PIN: Radial head, proximal third of radius, Monteggia #
Muscles supplied by PIN
4 Common extensors
ECRB •
Extensor digitorum communis (EDC)
Extensor digiti minimi (EDM)
Extensor carpi ulnaris (ECU)
5 Deep extensors
Supinator
Abductor pollicis longus (APL)
Extensor pollicus longus and brevis (EPL/EPB)
Extensor indicis proprius (EIP)
(sensory fibres to dorsal wrist capsule but no cutaneous innervation)
Anterior interosseous Syndrome
PIN Syndrome
Jersey Finger
Boutonniere
RA
Nodes
Pisform can compress
Ulnar Nerve - which is medial to ulnar artery
Dermatomes of upper limb
C4- Shoulder tip
CS- Lateral aspect of arm
C6- Lateral aspect of forearm, thumb and index finger
C7- Middle finger
C8- Ring, little fingers and medial aspect of hand and forearm
T1- Medial aspect of upper arm and axilla
Borders of anatomical snuff box
Ulnar (medial) border: Tendon of the extensor pollicis longus.
Radial (lateral) border: Tendons of the extensor pollicis brevis and abductor pollicis longus.
Proximal border: Styloid process of the radius.
Floor: Carpal bones; scaphoid and trapezium.
Roof: Skin
Non-traumatic EPL Rupture
Rheumatoid arthritis and
Previous Colle’s And Smith’s fracture
Ulnar nerve path
Ulnar nerve between heads of FCU, medial to FDP, muscles except for LOAF
Axillary vein
Lies at the apex of the axilla, it is the continuation of the basilic vein. Becomes the subclavian vein at the outer border of the first rib.
Musculocutaneous nerve supplies
Musculocutaneous nerve supplies BBC
Brachioradialis, biceps brachii and coracobrachialis
Hill Sach’s Lesions
Hill Sach’s Lesions – Glenohumeral dislocation
Nerve APL
PIN
Radial and PIN supplies
supplies all the muscles on the radial side and dorsal surface of the forearm, except the anconaeus, brachioradialis, extensor carpi radialis longus.
Deep branch becomes PIN after exiting supinator
Deep - ECRB + Supinator
Radial - Anconeus, Brachioradialis + ECRL
PIN - the rest - INCLUDING APL
