Upper limb anatomy Flashcards
Which root is sensory and which is motor
Dorsal = sensory Ventral = motor
Root vs ramus
Root = 1-way (input OR output) Ramus = contains both sensory input + motor output
Except for T2-T12, all ____ branch and make lateral connections just outside the spinal cord =
Ventral rami
Make NERVE PLEXUSES
What is the important of a plexus?
Each muscle receives nerve supply from >1 spinal nerve –> damage to one doesn’t completely paralyze it
Brachial plexus nerves + spinal levels
C5-C8 + T1 Axillary Musculocutaneous Median Ulnar Radial
Socket of shoulder joint =
What helps make it deeper?
Glenoid cavity
Labrum
a rounded protuberance at the end of some bones, forming an articulation with another bone
condyle
What part of the ulna posteriorly fits into a fossa of the humerus?
Olecranon (fits into olecranon fossa between medial and lateral epicondyles of the humerus)
ulna and radius each have a ___ process distally
styloid
Name the carpal bones (2 rows lateral –> medial starting with proximal row)
Some Lovers Try Positions That They Cannot Handle
Scaphoid Lunate Triquetrum Pisiform
Trapezium Trapezoid Capitate Hamate
Which carpal bones articulate with the radius?
Scaphoid + lunate
Which 3 nerves of the brachial plexus go all the way into the hand?
Radial, median, ulnar
5 branches (peripheral nerves) of the brachial plexus. Name the spinal levels and their targets: Axillary
C5-C6
Teres minor, deltoid
5 branches (peripheral nerves) of the brachial plexus. Name the spinal levels and their targets: Radial
C5-T1
Posterior compartments
5 branches (peripheral nerves) of the brachial plexus. Name the spinal levels and their targets: Musculocutaneous
C5-C7
Arm flexors
5 branches (peripheral nerves) of the brachial plexus. Name the spinal levels and their targets: Median
C5-T1
Forearm flexors
5 branches (peripheral nerves) of the brachial plexus. Name the spinal levels and their targets: Ulnar
C8-T1
Forearm flexors
Extensor compartment nerves of upper limb
Axillary nerve + radial nerve
WHAT ARE THE BRANCHES OF THE MF AORTA
Brachiocephalic (–> R subclavian + R common carotid)
L common carotid
L subclavian
Vasculature of the R arm
Brachiocephalic –> Subclavian artery –> axillary –> brachial –> radial + ulnar –> palmar arches (deep goes R –> U, superficial goes U–>R)
Blood samples often taken from what vein?
Median cubital vein
veins of the arm empty into which main vein?
Subclavian (–> brachiocephalic –> SVC)
Muscles acting on the shoulder: superficial layer (extrinsic back) (4)
Trapezius
Latissimus dorsi
Rhomboids (+/-)
Teres major
Muscles acting on the shoulder:deep layer (4)
Supraspinatus Infraspinatus Teres minor Subscapularis "SITS"
Muscles acting on the shoulder: pectoral (3)
Serratus anterior
Pectoralis major
Pectoralis minor
Muscles acting on the shoulder: brachium
Deltoid
Long head of biceps
Long head of triceps
What back muscle extends, adducts, and medially rotates the humerus?
Latissimus dorsi
What muscle elevates/depresses/retracts the scapula?
Trapezius
Teres major does what movements of humerus?
Adduction + medial rotation (inserts on the lesser tubercle = anterior)
Which rotator cuff muscle inserts at the lesser tubercle of the humerus?
Subscapularis
Rotator cuff: teres minor and infraspinatus insert at the ___ and therefore rotate the humerus ___
Greater tubercle of the humerus
laterally
Pectoralis minor moves the ____
Pectoralis major moves the _____
Minor –> scapula (protraction)
Major –> humerus (arm flexion/adduction
Winged scapula = lesion of ____ resulting in what?
Long thoracic nerve
Inactive serratus anterior (so pec minor pulls scapula forward)
Deltoid is innervated by ___ nerve and responsible for what movements?
Axillary nerve
Flexion, extension, abduction
Abduction of shoulder involves what 4 muscles in what order to get from 0 –> 180 degrees?
(note - supplied by 4 diff nerves!)
Supraspinatus –> deltoid –> trapezius –> serratus anterior
Up to 30o arm abduction, what joint? a
After 30o, what joint?
First just glenohumeral
then glenohumeral + scapulothoracic
Which arm flexor is also innervated by the radial nerve?
Brachialis
3 arm flexors
Biceps (supination)
Coracobrachialis (shoulder flexion)
Brachialis (elbox flexion)
Popeye sign =
Rupture of biceps tendon (long-head)
*generally not surgically repaired, brachialis does most of the work
Which heads of the triceps extend the arm? Which extend the forearm?
All extend forarm (insert in ulna via triceps brachii tendon)
Only long head extends arm because it originates on scapula, medial/lateral originate on humerus)
common origin of the flexor compartment (forearm)
Medial epicondyle
Common origin of the extensor compartment (forearm)
Lateral epicondyle
Forearm flexor innervated by radial nerve
Brachioradialis
Name 5 SUPERFICIAL forearm flexors from lat to med
Brachioradialis then Pass Fail Pass Fail
Pronator teres (pronation)
Flexor carpi radialis (abduction +flexion of hand)
Palmis longus (flexion at wrist, weak elbow flexion)
Flexor carpi ulnaris (adduction/flexion of hand)
Middle + Deep forearm flexors (3)
Flexor digitorum superficialis
Flexor digitorum profundus
Pronator quadratus
Thick fibrous band across base of wrist (anterior) to protect/hold tendons =
Flexor retinaculum
Flexor digitorum superficialis does what? Innervation?
Flexes phalanges @ PIP
Medial nerve
Flexor digitorum profundus does what? Innervation?
Flexes wrist, metacarpophalangeal, PIP and DIP joints of 2nd-5th digits
Median + ulnar nerve
Holding tendons in place at back of wrist =
Extensor retinaculum
Forearm extensors (lateral –> medial)
Extensor carpi radialis (longus + brevis) - abduct hand
Extensor digitorum
Extensor digiti minimi
Extensor carpi ulnaris
Deep lateral forearm extensor that supinates arm
Supinator
2 types of epicondylitis
Medial collateral ligament (flexors) = golfer’s elbow (overuse flexion)
Lateral collateral ligament (extensors) = tennis elbow (overuse extension)
Outcropping muscles of forearm (4)
Abductor pollicus longus Extensor pollicus longus Extensor pollicus brevis Extensor indicis (2nd digit)
What is the action of the 4 lumbricals of the hand?
Flex the metacarpophalangeal joints
Extend the PIP & DIP joints
(N= median for 1-2, ulnar for 3-4)
intrinsic muscle sets of the hand (5)
Lumbricals (1-4) Dorsal interossei (1-4) Palmar interossei (1-3) Thenar group Hypothenar group
What do the dorsal interossei do?
Abduct digits from axial line
N = ulnar
What do the palmar interossei do? N =
Adduct digits toward axial line
N = ulnar
What muscle does all the fancy thumb motions (flexion, extension, opposition, adduction, abduction)
Thenar muscles (N = median & ulnar)
4 joints of the pectoral girdle
Glenohumeral
Sternoclavicular
Acromioclavicular
Scapulothoracic (not a true joint)
Important prominences of the scapula
Spine (posterior)
Acromion (lateral)
Coracoid (anterolateral)
Ligaments of the AC joint
Acromioclavicular ligament
Coracoclavicular ligaments
“shoulder dislocation” occurs at what joint?
Glenohumeral joint
“shoulder separation” occurs at what joints?
Acromioclavicular and sternoclavicular
3 joints of elbow
Radiocapitellar (capitulum of humerus)
Ulnotrochlear
- radiocapitellar + ulnotrochlear –> hinge joint of elbow
Proximal radioulnar (pronation/supination)
3 important ligaments of elbow
Ulnar collateral ligament
Radial collateral ligament
Annular ligament of radius
Name the 6 main forearm flexors
Brachioradialis Pronator teres Flexor carpi radialis Palmaris longus Flexor carpi ulnaris Flexor digitorum superficialis
Name the 5 main forearm extensors
Supinator Extensor carpi radialis (longus + brevis) Extensor digitorum Extensor digiti minimi Extensor carpi radialis
Which carpal one is only visible on palmar aspect of hand
Pisiform (p = palm)
Which carpal bones form the anatomical snuff box of the hand? Tendons of which muscles?
Scaphoid + trapezium
EPB/APL + EPL
Which carpal bone is most commonly fractured
Scaphoid
Each interphalangeal joint of hand is a ___ joint with it’s own ___ and _____
Synovial
Capsule
Lateral/collateral ligaments
The thumb is a ___ joint
Saddle
___ joint is what we typically think of as the “wrist”. Important ligaments? (4)
Radiocarpal joint Ulnar carpal collateral ligament Radial carpal collateral ligament Dorsal/palmar radiocarpal ligaments Dorsa/palmar radioulnar ligament Palmar ulnocarpal ligament
What is a colle’s fracture? What usually causes it? Sign on x-ray?
Fracture of radius where styloid process pushed posteriorly
usually FOOSH
Dinnerfork deformity
What is thoracic outlet syndrome? What 3 areas can this occur?
Compression of brachial plexus/subclavian vessels
3 areas: interscalene triangle, costoclavicular space, pectoralis minor space
What is the test for thoracic outlet syndrome?
Wright’s test (hyperabduction)
Arm into external rotation + abduction –> check for radial pulse ablation
What nerve goes through the carpal tunnel? What bounds it? How many tendons go through?
Median nerve
Floor = carpal bones
Root = flexor retinaculum
9 (2 per digit + one for thumb)
Implications of carpal tunnel syndrome?
Thenar muscle weakness + skin paresthesia
Shoulder is most prone to dislocation ____
Infero-anteriorly (least stabilizing structures/ligaments)
What is the most common site of bursitis in the rotator cuff?
Subacromial bursa (between acromion and supraspinatus)
What is subacromial impingement syndrome?
inflammation and irritation of the rotator cuff tendons as they pass through the subacromial space, resulting in pain, weakness, and reduced range of motion within the shoulder
2 possible pathologies that can cause SIS?
Rotator cuff tendinosis
Subacromial bursitis
(chicken & egg situation)
THe proximal radioulnar joint is what kind of joint?
Pivot joint (facilitates supination/ pronation, annular ligament of radius loops around)
The main large bursa of the elbow
Olecranon bursa
What nerve can become entrapped in the cubital tunnel?
Ulnar nerve
Where can the ulnar nerve be found on elbow palpation?
Medial para-olecranon groove just behind medial epicondyle
What is the carrying angle?
Valgus physiological deviation of upper limb (up to 10 degrees in men, 20 in women); allows us to swing arms and carry stuff without abducting shoulders
Difference between smith fracture and colle’s fracture?
Smith = distal radius anteriorly displaced Colles = posteriorly displaced (dinner fork sign)
How do you differentiate between Dupuytren’s contracture (thickened palmar fascia) vs torn tendon?
Name 4 conditions DC is associated with
Passive movement. DC will be rigid
Diabetes, epilepsy, alcoholism, liver disease/cirrhosis
What are osteophytes? Most common cause
Bone spurs caused by joint damage
Osteoarthritis
What are bouchard’s nodes and heberden’s nodes? What else might you see in the same disease?
Osteophytes formed at PIPs and DIPS respectively in osteoarthritis
Also see squaring of the wrist due to osteophytes at the first CMC joint
“sausage digits”
Dactylitis (can be seen in psoriatic arthritis)
What are you looking for if you get the pt to do the “Prayer Sign”?
Swan neck deformities (extend PIP, flex DIP)
Boutonnier’s deformities (PIP flex, extend DIP - like pushing button)
^signs of RA
In RA the ___ are typically spared from swelling
DIP
What 2 hand bumps do you easily feel (right beside the wrist)
Pisiform (medial by pinky)
Scaphoid (lateral by thumb)
Shoulder Physical Exam: Inspection
Asymmetrical height of shoulders could indicate what?
Scoliosis
Sprengel’s deformity (high-riding scapula)
Test to check for internal rotation of the scapula
Apley scratch test
Main pathologies you’re looking for in shoulder special tests (5)
1) Supraspinatus tear
2) Subacromial impingement syndrome
3) Bicipital tendinitis
4) Acromioclavicular joint pathology (e.g. OA)
5) Instability
Special test for supraspinatus tear
Drop arm test
Special tests for SIS (4)
1) Painful arc (abduction)
2) Neer’s test (passive full flexion)
3) Hawkins-Kennedy Test (hold hawk, push down)
4) Empty can test (push down)
Special tests for bicipital tendinitis (2)
1) Speed’s test (push down)
2) Yergason’s test (thumbs up, you try to pronate them, they resist)
Special tests for acromioclavicular joint pathology (2)
Scarf test (wrap hand like scarf, push while stabilizing ipsilateral shoulder) AC Joint distraction test (adduction behind back)
Test for inferior shoulder instability
Pull down on arm –> SULCUS sign
Test for recurrent anterior subluxation/anterior shoulder instability)?
Apprehension test
Relocation test
Anterior release sign
Name 6 special tests for the elbow
MCL/LCL stability (vagus/varus with arm at 30 degrees)
Anterio-posterior stability (arm at 90, try to move humerus)
Tennis elbow (start with arm out wrist extended)
Golfer’s elbow (same but wrist flexed)
Tinel’s sign (tap ulnar nerve) - cubital tunnel syndrome
Elbow flexion test (60 seconds CTS)
What is quervain’s tenosynovitis
inflammation of tendons of lateral snuffbox (extensor pollicis brevus/abductor pollicis longus)
Tests for carpal tunnel syndrome
Tinel’s sign (same as cubital but in this case tap median nerve)
Phalen’s sign (hold dorsal hands together 60 seconds)
How can you test for DeQuervain’s tenosynovitis?
Finkelstein’s test (thumb in fist, ulnar deviation)
Name 4 stability tests in the hand exam
1) Wrist stability (sublux up & down)
2) Piano key sign (push down in ulnar head) - distal radioulnar ligament stability, RA can impact
3) MCP stability (flexed!) - like ant-post drawer test, also valgus/varus
4) IP stability (varus/valgus)
Median nerve motor and sensory testing
Motor = "okay" sign Sensory = palmar pad of index finger
Radial nerve motor and sensory testing
Motor = thumbs up Sensory = dorsal 1st web space
Ulnar nerve motor and sensory testing
Motor = finger abduction Sensory = palmar pad of pinky finger
Heads of humerus, radius, ulna (proximal vs distal)
Humerus = proximal Radius = proximal Ulna = distal (by styloid)
Subacromial bursitis =
Supraspinatus tendonitis (chicken and egg, they come together)
4 compartments of the forearm
Superficial volar (flexor carpi U/R, pronator teres, flexor digitorum superficialis) Deep volar (FDP, FPL) Dorsal (supinator, extensors) Lateral Mobile Wad of Henry (brachioradialis, extensor carpi radialis longus, extensor carpi radialis brevis)
Compartments of the arm
Anterior: biceps brachii, brachialis, coracobrachialis
Posterior: triceps brachii
Deltoid
