Upper Limb Anatomy Flashcards
Where are the roots of the brachial plexus found
Between scalenus anterior and medius
Where are the trunks of the brachial plexus found
Base of the posterior triangle of the neck behind 3rd part of subclavian artery
Where are the divisions of the brachial plexus found
Behind the middle 1/3 of the clavicle
Where are the cords of the brachial plexus found
Related to the 2nd part of axillary artery
What is Erb’s palsy
Damage to roots C5 and C6
Waiters tip deformity - arm adduction, arm internal rotation, forearm extension and pronation, wrist flexion.
Loss of sensation of the radial side of arm and forearm
What is Klumpe’s palsy
Injury to lower cords - C8 and T1
Claw hand deformity - muscle wasting and loss of fine finger movements, weak wrist and finger flexion, hyperextension of MCPJ, flexion of PIPJ
Loss of sensation over ulnar aspect of forearm and hand
In Erb’s palsy which reflexes are impacted
Biceps and brachioradialis reflexes
Show the roots of the brachial plexus
What is the action of brachioradialis
Relatively weak flexion of the forearm which is maximal when forearm is in midpronated position
What muscles are supplied by the musculocutaneous nerve
Biceps, brachialis and coracobrachialis
What is the sensory supply of the musculocutaneous nerve
Lateral border of forearm
Sensory supply of radial nerve
Lateral cutaneous nerve of arm
Posterior cutaneous nerve of arm
Posterior cutaneous nerve of forearm
Superficial branch - terminal division - dorsal surface of lateral 3 and 1/2 digits and dorsum of hand
Number 1, 3, 6, 11, 13,14,16,17,18,19,20,21,25,26,27
1: Axillary nerve
3: Coracobrachialis
6: Lateral cord of brachial plexus
11: Lower sub scapular nerves
13: Medial cutaneous nerve of arm
14: Medial cutaneous nerve of forearm
16: Medial root of median nerve
17: Median nerve
18: Musculocutaneous nerve
19: Pec minor and lateral pectoral nerve
20: Posterior cord
21: Radial nerve
25: Thoracodorsal nerve
26: Ulnar nerve
27: Upper sub scapular nerves
A - anterior view
B - posterior view
C - medial view
D - lateral view
1- anatomical neck
2- deltoid tuberosity
3- greater tubercle
4- groove for radial nerve
5- head
6- inter tubercular groove
7- lateral lip of inter tubercular groove
8- lesser tubercle
9- medial lip of intertubercular groove
10- surgical neck
2, 3, 5, 6,7,8,10,12,13
A - anterior
B - posterior
2- capitulum
3- coronoid fossa
5-lateral epicondyle
6-lateral supracondylar ridge
7-medial epicondyle
8-medial supracondylar ridge
10-olecranon fossa
12- radial fossa
13-trochlea
2,4,5,7,8,11
A - anterior
B- posterior
C-medial
D- lateral
2- Anterior oblique line
4- head
5- interosseous border
7- neck
8- posterior border
11- tuberosity
How do you articulate the elbow joint
Capitulum of humerus + radial head
Trochlea of humerus + trochlear notch of ulna
Olecranon of ulna + olecranon fossa of humerus
What is the bony prominence that EPL tendon wraps around
Lister tubercle
6, 11, 12
A - anterior
B- posterior
C- medial
D- lateral
6- olecranon
11 - trochlear notch
12 - tuberosity
3, 7
E - anterior
F - posterior
G- medial
H- lateral
3- head
7- styloid process
Identify the carpal bones
What is the blood supply of the scaphoid artery and what is its clinical significance
Receives blood supply from the palmar and dorsal branches of the radial artery. The proximal portion relies on retrograde flow from the distal portion which can result in avascular necrosis
16,25 and 23
16 - median nerve
25 - ulnar nerve
23 - ulnar artery (moved laterally to allow visualisation of ulnar nerve)
Sensory supply of median nerve
Lateral 2/3 of palm of hand - palmar cutaneous branch
Palmar digital branch:
Lateral 3 and 1/2 digits on palmar side
Dorsum of tips of index and middle fingers and thumb
Motor action of median nerve in hand
Lateral 2 lumbricals
Opponens Pollicis
Abductor pollicis brevis
Flexor policis brevis
What sits in the inter tubercular groove of the humerus
Tendon of long head of biceps
What sits in the spiral groove of radius
Radial nerve
How to orientate the lower end of the humerus
Medial epicondyle ismost prominent, Olecranon fossa is posterior
How to orientate the radius
Upper part - radial head
Radial tuberosity is anteromedial
What notches are there in the ulna
Radial notch and trochlear notch
Ulnar nerve injury at wrist features
Complete clawing of hand - hyperextension of MCPJ and flexion of PIPJ - paralysis of the medial lumbricals and interossei
Loss of sensation medial 1/3 of palmar aspect of hand and medial 1 and 1/2 fingers
Ulnar paradox
In proximal ulnar nerve injuries, FCU and ulnar part of FDP also affected, causing decreased flexion of DIPJs and clawing is thus only partial
Attachments of flexor retinaculum
Proximal
Medial - pisiform
Lateral - tubercle of scaphoid
Distal
Medial - hook of hamate
Lateral - tubercle of trapezium
Structures passing through carpal tunnel
4 tendons of FDS
4 tendons of FDP
1 tendon of FPL
1 tendon of FCR
Median nerve
31, 30, 27, 29
27 - radial artery
31 - ulnar artery
30 - superficial branch of radial artery
29 - superficial palmar arch
Flexion of the thumb muscles and innervation
Flexor pollicis longus - AIN
Flexor pollicis brevis - recurrent branch of median
Extension of the thumb and innervation
Extensor pollicis longs and brevis - PIN
Abduction of thumb and innervation
Abductor longus - PIN
Abductor brevis - recurrent branch median nerve
Adduction of thumb and innervation
adductor pollicis - deep branch of ulnar nerve
Opposition of thumb and innervation
Opponens policis, flexor pollicis brevis - recurrent branch of median nerve
Where does the tendon of FDS insert
Splits and inserts on either side of middle phalanx
Where does the tendon of FDP insert
Goes through split FDS tendon to insert to base of terminal phalanx
How to test FDP
Fix the PIPJ to eliminate action of FDS
How to test FDS
Fix the adjacent fingers in extension to eliminate action of FDP on adjacent fingers
How to test ulnar artery
Allens test
Elevate the hand and make a fist for 30 seconds
Occlude the ulnar and radial arteries
Open the hand - it will be blanched
Open the ulnar artery - it should reperfuse the hand
On doing a power grip of the hand, what is the role of the radial nerve
It supplies wrist extensors which give a mechanical advantage to power grip by synergistic activity causing more efficient flexion of the digits
Why is hand grip more powerful in extension than in flexion
The flexor muscles in an extended position are in a state of tension so contraction in this position is more powerful
Identify all
1- Extensor digitorum tendon
2- Extensor indices tendon
3- intertendinous connections
4- 1st dorsal interosseus
5- radial styloid process
6- ulnar styloid process
7- extensor carpi ulnaris
8- abductor digiti minimi
9-extensor carpi radialis longus tendon
10- extensor carpi radialis brevis tendon
What is the origin, insertion and action of the 1st dorsal interosseous muscle
Origin - 1st MC bone
Insertion - lateral side of extensor expansion of index finger
Action - abduction of index finger, flexion of MCPJ and extension of PIPJ and DIPJ
Which tendon is attached to the pisiform bone
flexor carpi ulnaris
What attaches extensor tendons to the phalanges
Extensor expansion
Which structure prevents subluxation of extensor tendons on metacarpal bones
Extensor retinaculum
What are the functions of intertendinous connections
- Co-ordinating movement between tendons
- Transmitting tension between muscles
- Providing mechanical support to the tendons
- Reducing friction between the tendons
- Maintaining alignment of the tendons
Anatomical snuff box boundaries and contents
Anterolateral - tendon of abductor policis longus and extensor policis brevis
Posteromedial - extensor policis longus tendon
Contents - radial artery, superficial branch radial nerve, cephalic vein
How many compartments are below the extensor retinaculum
6
What is the content of compartment 3
EPL tendon
1,2,5,6,7,8,9,10,11,12,14,15,16,17,19
1- Abductor digiti minimi
2 - abductor pollicis longus
5- ECR brevis
6 - ECR longus
7-ECU
8- extensor digiti minimi
9- extensor digitorum
10- extensor indicis
11- extensor pollicis brevis
12- extensor pollicis longus
14- first dorsal interosseous
15- fourth dorsal interosseous
16- second dorsal interosseous
17- styloid process of ulna
19 - third dorsal interosseous
What is in each extensor compartment of the hand
1 - tendons of APL and EPB
2 - ECRL and ECRB
3- EPL
4- ED and EI
5- EDM
6- ECU
Guyon’s canal borders
Medial - pisiform, FCU tendon, ADM muscle
Lateral - hook of hamate
Roof - palmar carpal ligament
Floor - flexor retinaculum
Contents of guyon’s canal
Ulnar nerve, ulnar artery, venae comitantes of ulnar artery, lymphatics
Ulnar nerve bifurcates in the canal into superficial and deep branches
Boundaries of the cubital fossa
Superolateral - brachioradialis muscle
Medial - pronator teres
Floor - brachialis
Contents of cubital fossa from medial to lateral
Median nerve
Brachial artery
Biceps tendon
What structures pass in the spiral groove
Radial nerve, profunda brachii vessels
What are the symptoms of radial nerve injury at the spiral groove
Paralysis of wrist extensors - wrist drop
Paralysis of finger extensors - finger drop
Loss of sensation in 1st web space
Median nerve injury at elbow findings
Loss of flexion of index and middle fingers - unable to make a fist - paralysis of FDS and lateral half of FDP
Flexion of the MCPJs of index and middle fingers can still be done - interosseous muscles are not affected
Loss of flexion of distal phalanx of thumb - paralysis of FPL
Median nerve injury at the elbow or at the wrist
Ape like hand - flattening of thenar eminemce
Thumb is adducted
Opposition and abduction of thumb not possible - loss of pincer action
Cause - paralysis and wasting of muscles of the thenar eminence. Adductor pollicis is unopposed
What complications can occur from supracondylar fracture of humerus
Brachial artery injury
Median and AIN injury
Ulnar nerve injury (less likely)
Radial nerve injury (less likely)
4 - brachial artery
12 - median nerve
2 - AIN
What are the muscles of the rotator cuff
Supraspinatus
Infraspinatus
Teres minor
Subscapularis
What is the origin and insertion of supraspinatus
Supraspinatus fossa to greater tuberosity
What is the origin and insertion of infraspinatus
Infraspinatus fossa to greater tuberosity
Origin and insertion of teres minor
Upper 2/3 of lateral border of scapula on dorsal aspect to greater tuberosity
Origin and insertion of subscapularis
Ventral aspect of scapula/ subscapular fossa to lesser tuberosity
Nerve supply to supra and infra spinatus
Where does this nerve originate from
Suprascapular nerve
From the upper trunks of the brachial plexus
Nerve supply of teres minor
Axillary nerve - posterior cord of the brachial plexus
Subscapularis nerve supply
Upper and lower subscapular nerves which are branches of the posterior cord
Which muscles are involved in abduction of shoulder joint
Supraspinatus - 0-15 deg
Deltoid - 15-90 deg
Trapezius and serrates anterior - >90 deg
What skeletal change accommodates abduction over 90 deg
Upward rotation of the scapula with external rotation of the humerus
Which factors decrease the stability of the shoulder joint
Shallow glenoid fossa with large humeral head
Lax capsule with few ligaments
Inferior aspect is not supported due to the presence of the quadrangular space
What is the main stabiliser of the shoulder joint
Rotator cuff muscles
Borders of the quadrangular space
Superior - teres minor
Inferior - teres major
Lateral - surgical neck of humerus
Medial - long head of triceps
Contents of quadrangular space
Axillary nerve
Posterior circumflex humeral vessels
Name 11,10, 14, 10, 12, 1 and 6
11 - teres minor
10 - teres major
14- long head of triceps
12 - surgical neck of humerus
1 - axillary nerve
6- posterior circumflex numeral vessels
Motor functions of the axillary nerve
Deltoid and teres minor
Sensory function of axillary nerve
Regimental patch area - skin of lower half of deltoid
Injury of axillary nerve
Inability to abduct the shoulder over 15 deg and loss of sensation over regimental patch area
Which muscle divides the axillary artery into 3 parts
Pectoralis minor muscle
What are the branches of 1st part of axillary artery
Superior thoracic artery
What are the branches of 2nd part of axillary artery
Thoraco acromial artery
Lateral thoracic artery
Branches of 3rd part of axillary artery
Subscapular artery
Anterior circumflex humeral
Posterior circumflex humeral
Where does axillary artery continue as brachial artery
lower border of teres major muscle
Which muscles insert into bicipital groove
Lady between 2 majors
Latissimus dorsi - between
Teres major - medial lip
Pectoralis major - lateral lip
Identify 1, 4, 6 and 5
1 - acromion
4- clavicle
5- deltoid
6- glenoid cavity
Origin and insertion of biceps
Origin
Long head - supraglenoid tubercle
Short head - coracoid process
Insertion - radial tuberosity
nerve supply of biceps
Musculocutaneous nerve - lateral cord of brachial plexus
Origin and insertion of triceps
Origin
Long head - infraglenoid tubercle
Lateral head - Area of humerus above spiral groove
Medial head - area below the spiral groove
Insertion - olecranon process of ulna
Nerve supply of triceps
Radial nerve
What are the roots of the biceps reflex and how to test it
c5/6
Tap over finger over the biceps tendon
How to test the triceps reflex and what are the roots
Rest the forearm at 90 degrees and tap over the olecranon process
c7
Supinator reflex
c6
4 inches proximal to base of the thumb with forearm supinated
Name 2, 10, 15 and 5
2 - acromion process
10 - spine of scapula
15 - supraspinus fossa
5 - infraspinus fossa
3, 11
3 - coracoid process
11- subscapular fossa
1,9,3,5
1- acromion
9- supraglenoid tubercle
3- glenoid fossa
5- infraglenoid tubercle
1,2,3,4,5
1 - acromial head
2 - conoid process
3- groove for subclavius muscle
4- impression for costoclavicular ligament
5- sternal head
How to orientate the clavicle
Rounded head - sternal head
Flat head - acromial head
Lower surface has a groove for origin of subclavius muscle, conoid process and costoclavicular ligament impression
What is the surface marking of the coracoid process
1cm below the point between the medial 3/4 and lateral 1/4 of the clavicle
Which structures attach to the coracoid process
Ligaments
coracoacromial ligament
coracoclavicular ligament
Muscles
2 originate - coracobrachialis, short head of biceps
1 inserts - pectoralis minor
Origin and insertion of pec major
Origin -
Clavicular head - medial half of anterior surface of clavicle
Sternocostal head - sternum, upper 6 costal cartilages, external oblique aponeurosis
Insertion - lateral lip of the bicipital groove
Nerve supply (and roots) of pec major
Medial and lateral pectoral nerves
Medial - c8-t1
Lateral - c5-c7
Action of pec major
Adduction and medial rotation of arm
Clavicular head - flexion of arm
Sternocostal head - extend the flexed arm
Accessory respiratory muscle
Trapezius origin and insertion
Origin - external occipital protuberance, superior nuchal line and spinous process of c7 - t12
Insetion - lateral surface of clavicle, medial acromion, spine of the scapula
Nerve supply of trapezius
Spinal accessory nerve
Serratus anterior origin and insertion
Origin - 9 slips to ribs 1-8
Insertion - medial border of scapula
Nerve supply of serratus anterior
Long thoracic nerve
