Upper limbs Flashcards
regions of upper limb
Label the surface anatomy of the upper limb
label the elbow joint
Describe how flexion at the elbow joint occurs
Three flexors work together : BBC
Biceps brachii
Brachialis
Brachioradialis
Define pronation and supination
Produced at the radioulnar joints not at the elbow joint
Attachments/function/nerve supply of biceps brachii
Two heads
Short head - Apex of the Coracoid process of the scapula
Long head - Supraglenoid tubercle of the scapula
The two heads merge to form a single tendon that inserts on the radial tuberosity
Innervation - musculocutaneous
Function - long head (abduction) and (inward rotation) whereas the short head (adduction). When both heads contract flexion/supination of forearm
surface Anatomy of posterior axioappendicular and scapulohumeral muscles
Identify the structures in the shoulder bones
Idenitfy the labelled structures in this hand x-ray
Can Toms Todger Please Leslie The Huge Slut
Capitate, Trapezium, Triquetral, Pisiform, Lunate, Trapezoid, Hook of Hamate, Scaphoid
what does the musculocutaneous nerve supply
desribe its course
muscles in the anterior compartment of the arm (coracobrachialis, biceps brachii and the brachialis). gives rise to the lateral cutaneous nerve of forearm, which innervates the lateral aspect of the forearm.
derived from lateral chord; then pierces coracobrachialis and runs between Brachialis and biceps
Boundaries and contents of cubital fossa
Boundaries : superiorly - imaginary line connecting the lateral and medial epicondyles
Medially - pronator teres
Laterally - brachioradialis
Contents - median cubital vein, end of brachial artery, medial nerve, start of radial and ulnar arteries
Clinical significance - blood is removed from median cubital vein for blood test
Snuffbox boundaries and contents
Does the ulna articulate with the carpal bones directly
No
Muscles that are attached in the region of the bicipital groove
Pec major - lateral lip
Latissimus dorsi - floor of groove
Teres major - medial lip
mnemonic - Lady between the two Majors
The tendon of the biceps passes directly through the groove
Identify the fucntion/innervation/relative positioning of muscles in the anterior compartment of the forearm
superficially - (all originating from the medial epicondyle)
flexor carpi ulnaris (flexion and adduction of wrist), palmaris longus(wrist flexion/median nerve),
flexor carpi radialis (wrist flexion and abduction/median nerve)
pronator teres(pronation/median nerve).
intermediate -
flexor digitorum superficialis (median nerve and ulnar artery pass between its two heads, and then travel posteriorly)
deep -
flexor digitorum profundus(originates from ulna, splits into 4 tendon and attaches to the distal phalanges of the 4 fingers via the carpal tunnel. flexes the DIP/PIP/wrist; median and ulnar),
flexor pollicis longus(attaches from radius to phalanx of thumb; flexes IP/MP of thumb),
pronator quadratus(covers anterior surfaces of ulna and radius; pronates forearm; median nerve).
Identify the extensor/superficial muscles of the posterior forearm
Brachioradialis ; flexion elbow joint
extensor carpi radialis longus (ECRL) ; wrist muscle - extends and abducts wrist
extensor carpi radialis brevis (ECRB) ; wrist muscle - extends and abducts wrist
extensor digitorum - Extends medial four fingers at the MCP and IP joints.
extensor digiti minimi - orginates from extensor digitorum ; Extends the little finger and wrist
extensor carpi ulnaris - extension and adduction of wrist
anconeus - Extends and stablises the elbow joint. Abducts the ulna during pronation of the forearm.
Describe the common attachments at the epicondyles and the clinical relevance
Extensors and supinations originate from the lateral epicondyle
flexors and pronators originate from the medial epicondyle
overuse of each muscle groups can cause tenderness and pain at their respective epicondyle the attach to
Flexor muscles of the forearm
First Layer:
Pronator teres
Flexor carpi radialis
Palmaris longus
Flexor carpi ulnaris
Intermediate (Second ) Layer:
*Flexor digitorum superficialis
Deep (third layer):
*Flexor digitorum Profundus
*Flexor pollicis longus
Pronator quadratus
*: flexion of the digits.
Idendify the muscles
Identify each type of hand bones and how many of each
5 distal phalanges
4 intermediate phalanges
5 proximal phalanges
5 meta carpal bones
8 carpal bones
Extrinsic vs intrinsic muscles of the hand
Extrinsic muscles are found both posteriorly and anteriorly ; control basic movements and produce strong grip
intrinsic muscles are found deep within the hand ; allow fine motor functions like writing
Identify the extensors of the posterior hand
Extrinsic:
Extensor digitorum (medial 4 digits)
Extensor indicis
Extensor digiti minimi
(adjacent tendons are linked by 3 oblique intertendinous connections that restrict independent extension of the fingers)
Thenar muscles: (outcrop muscles that make the anatomical snuff box)
Abductor policis longus
Extensor policis brevis
Extensor pollicis longus
Medial nerve innervates the …
-
Motor functions: Innervates the flexor and pronator muscles in the anterior compartment of the forearm (except the flexor carpi ulnaris and part of the flexor digitorum profundus, innervated by the ulnar nerve). Also supplies innervation to the thenar muscles and lateral two lumbricals in the hand.
- Sensory functions: innervates the lateral aspect of the palm, and the lateral three and a half fingers on the anterior (palmar) surface of the hand.
Identify the tendons, nerves, vessels in this cross section of the hand
Describe the spread of infection in the hand
the ulnar and radial bursa are able to communicate
this can lead to horse-shoe tenosynovitis - v-like spread of infection
Identify the muscles responsible for finger extension
Extensor digitorum (attaches to extensor attachment of medial 4 digits)
Extensor indicis (additional to forefinger)
Extensor digiti minimi (extensor attachment of 5th)
identify the muscles responsible for extension of the thumb
extensor pollicis longus dorsal III
extensor pollicis brevis dorsal I
abductor pollicis longus dorsal I
Describe the wrist movements
dorsiflexion - moving hand up to the sky
palmarflexion - moving hand down to the ground
radial deviation - moving had toward the left
ulnar deviation - moving hand towards the right
Blood vessels of wrist and hand (Anterior view)
What muscles does the ulnar nerve supply
Cutaneous - anterior and posterior ⅓ of hand
- Flexor carpi ulnaris – flexes and adducts the hand at the wrist.
- Flexor digitorum profundus (medial half) – flexes the ring and little fingers at the distal interphalangeal joint
- Hypothenar muscles (flexor digiti minimi brevis, abductor digiti minimi, opponens digiti minimi)
- Medial two lumbricals
- Adductor pollicis brevis
- Palmar and dorsal interossei of the hand
What muscles does the radial nerve supply
most of posterior forearm = extensors and supinators
triceps brachii, brachialis, anconeus, extensor carpi radialis longus/brevis, extensor carpi ulnaris, extensor Digitorum , extensor digiti minimi, extensor indicis, supinator
cutaneous supply to dorsal hand and fingers, lateral upper arm, posterior forearm
Describe the extrinsic muscles of the shoulder
attachment
functions
innervations
Extrinsic muscles originate from the torso and attach to the clavice, scapula or humerus ; also located in the back so maybe called superficial back muscles
trapezius - elevate the scapula and rotate it during abduction of the arm
latissiumus dorsi ; arises from spinous processes T7-12 and converges into a tendon that attaches to the intertubercular sulcus of the humerus ; acts to extend addict and medially rotate the upper limb
3 deep muscles:
levator scapulae - being in in transverse processes of C1-4 and attaches to medial border of scapula ; acts to elevate scapula
rhomboids - major and minor; originate from spinous processes of C7-T1 and attach to medial border of scapula; act to retract and rotate the scapula
Describe the path of the ulnar nerve through the upper limb
as it descends the upper arm, it travels medially ; brachial artery located laterally
Passes posterior to the elbow via the ulnar tunnel
Travels lateral to ulnar bone in forearm
enters hand via ulnar canal (between pisiform and hook of hamate)
Describe the path of the radial nerve through the upper limb
originates from post chord
found next to axillary artery
passes through radial groove
Enters forearm anterior to lateral epicondyle and passes through the cubital fossa
teminates at deep/superficial branches (does not enter hand)
describe the path of the median nerve through the upper limb
Lateral to the brachial artery as it passes anterior to the humerus
passes over the brachial artery at the cubital fossa and becomes situated medially as it passes over the forearm (still anterior)
enters the hand via the carpal tunnel
describe the tests for the nerve damage of the radial, median, and ulnar nerves
Radial - wrist drop
median - oppose thumbs, ask patients to dorm ring and try to break the ring
ulnar - pull paper from finger, ask patient to spread fingers and you try to press fingers together
Identify A, B, C and D
A - long head of triceps
B - lateral head of triceps
C - medial head of triceps
D - radial nerve and deep brachial artery
anatomical landmarks for injection onto the shoulder joint capsule
palpate the head of the humerus, the coracoid process, and the acromion.
Describe the thenar muscles
Three short muscles in the base of the thumb ; allow fine movements of thumb (intrinsic muscles)
all 3 innervated by median nerve
opposes policis - largest and lies under the other two ; allows opposition of thumb by medically rotating and flexing the metacarpal on the trapezium
abductior pollicis brevis - anterior to the OP and next to the FCB ; abducts the thumb
flexor pollicis brevis - the most anterior ; flexes the metacarpophalangeal joint of the thumb
Identify the joints of the hand
Describe the hypothenar muscles
Produce the hypothenar eminence - muscular protrusion on the medial side of the palm, below the little finger
Innervated by ulnar nerve
opponents digiti minimi - deepest of the 3 muscles; rotates the metacarpal of the little finger towards the palm = opposition
abductor digiti minimi - most superficial ; abduction of the little finger
flexor digiti minimi - lateral the ADM; flexes the MCP joint of little finger
Describe the lumbricals
4 , each associated with a finger ; they link the extensor tendons to the flexor tendons
each initiate from a tendon of the flexor digitorum profundus and wrap around the fingers , ending posteriorly
actions: flexion at MCP and extension at the interphalangeal joints of each finger
Describe the interossei muscles
Located between the metacarpals
ulnar innervated
dorsal interossei - most superficial ; consists of 4 muscles ; abduct the fingers at the MCP joint
palmar interossei - anteriorly located ; consist of 3 muscles ; addict the finger at the MCP joint
Describe the palmaris brevis and addoctor pollicis
Both ulnar innervated
Palmaris brevis ; wrinkles skin of hypothenar eminence , curving hand = stronger grip
adductor pollicis - large triangular muscle with two heads - radial artery passes anteriorly through them; adductor of thumb
Rotator cuff muscles
Originate from the scapula and attach to the Humeral head ; they pull the Humeral head into the glenoid fossa
uses the acronym SITS
Supraspinatus - abducts the arm the first 15 degrees , assist deltoid from 15-90 degrees
Infraspinatus - laterally rotates the arm
Teres minor - laterally rotates arm
Subscapularis - medially rotates the arm
Describe ulnar claw
Ulnar claw is caused by ulnar nerve damage - hyperflexion at IP/ hyperextension at MCP of 4/5th digits; also wasting of hypothenar eminence
seen at rest as well
draw a diagram depicting the arterial supply to the upper limbs
Route of axillary nerve
In the axilla, its posterior to the axillary artery and anterior to the subscapularis muscle. It exits the axilla via the quadrangular space.
The axillary nerve then passes medially to the surgical neck of the humerus
Triceps attachment
Long head - proximal to infraglenoid tubercule of glenoid cavity
lateral head - attaches above the radial groove of the humerus
medial head - attaches below the radial groove of humerus
all 3 head join to form the tricep aponeuroisis which attaches to the olecranon of ulna
Label the extensory compartment of the upper Limb
Tennis elbow (lateral epicondylitis)
Due to repetitive use of superficial extensor muscles, and hence strain of the common extensor tendon
Inflammation forms
Pain is at lateral epicondyle and can extend down to posterior aspect of forearm
Lunate dislocation
Lunate separates from capitate and radius
Occurs when a great force is applied to a hyperextended wrist – e.g FOOSH.
describe the attachment/innervation/function of the flexor digitorum superficialis
- It has two heads – one originates from the medial epicondyle of the humerus, the other from the radius. The muscle splits into four tendons at the wrist, which travel through the carpal tunnel, and attaches to the middle phalanges of the four fingers.
- Actions: Flexes the metacarpophalangeal joints and proximal interphalangeal joints at the 4 fingers, and flexes at the wrist.
- Innervation: Median nerve.
finger movements - metacarpophalangeal joints
clinical relevance of quadrangular space
gap in the muscles in posterior scapular region;
pathway for axillary nerve and the posterior humeral circumflex artery to pass from the axilla to the posterior arm and shoulder ;
these can be compressed as a result of trauma, hypertrophy (athletes who complete overhead activities) = weakness of delts and teres minor
deep muscles of posterior forearm
the supinator (floor of cubita fossa; radial nerve passes between its 2 heads;
abductor pollicis longus (abducts thumb),
extensor pollicis brevis(Extends at the metacarpophalangeal and carpometacarpal joints of the thumb.),
extensor pollicis longus(Extends all joints of the thumb: carpometacarpal, metacarpophalangeal and interphalangeal.)
and extensor indicis(Extends the index finger, allowing it to be independent of the other fingers).
wrist drop clinical relevance
Wrist drop is a sign of radial nerve injury that has occurred proximal to the elbow.
There are two common characteristic sites of damage:
- Axilla – injured via humeral dislocations or fractures of the proximal humerus.
- Radial groove of the humerus – injured via a humeral shaft fracture.
Describe colles fracture
appearance
cause
treatment
Cause - FOOSH
most Common wrist fracture
posterior angulation
intra-articulation (fracture occurs within joint) = shortening of joint = muscle atrophy
treatment - plaster
EPL(extensor pollicis longus) tendon rupture
symptoms, causes and treatment
Symptoms - inability to lay hand flat and lift thumb, inability to straighten the thumb
causes - wrist fracture or rheumatoid arthritis (inflammation of the tendon )
treatment - tendon graft, tendon transfer from one of the extensor tendons to the index
Describe carpal tunnel decompression
what is it used for
describe the procedure
Some fractures can cause compression of the median nerve that pass through the carpal tunnel - this causes pain, numbness and parenthesis in the 3 and ½ digits (thumb, index, middle and half of ring)
the procedure involves cutting through the flexor retinaculum
clinical significance of palmaris longus
Absent in most people as not an essential muscle
can be used as a graft for other damaged arm tendons
surface anatomy of cubical fossa
Winged scapula - clinical relevance
Paralysis of serrations anterior due to injury to the long thoracic nerve 9often in a knife fight where limbs are elevated)
arm cannot be lifted above horizontal either
innervations of musculocutaneous nerve
cutaneous branch - lateral forearm ; motor branch- coracobrachialis, brachialis, biceps brachii
the medial pec nerve branches off the …
medial chord
the long thoracic nerve branches off from which roots of the brachial plexus?
roots of C5/6/7
quadrangular space - boundaries and contents
- uperior – inferior aspect of teres minor
- Inferior – superior aspect of teres major
- Lateral – surgical neck of humerus.
- Medial – long head of triceps brachii
- Anterior – subscapularis
contents - axillary nerve and posterior circumflex humeral artery and vein. These structures can be compressed as a result of trauma, muscle hypertrophy or space occupying lesion; resulting in weakness of the deltoid and teres minor.
label the nerves innervating the dermatomes of the upper limb
Label the extensor expansor of 1 digit
A retired labourer visited his doctor because of a lump he could feel in his neck. He pointed to the omoclavicular triangle of his neck and complained of pain round about the tumour.
What are the most important structures are found in the omoclavicular triangle?
Trunks of brachial plexus, Scalenus anterior m; subclavian artery; 1st rib
How does the radial artery arise?
Subclavian → axillary → brachial → radial
Neurological examination showed paralysis of supraspinatusand infraspinatus muscles and reduced function in the following nerves: median, musculocutaneous, radial, axillary, lateral pectoral and subscapular.
Q Do these muscles and nerves have a root value in common?
Yes C5 and C6
Descirbe subacromial impingement and the symptoms/causes e
inflammation of rotator cuff tendons as they pass through the subacromial space Symptoms- pain, weakness and reduced range of motion of shoulder caused by overuse from sport involving overhead motion, wear and tear with age, or the shape of your acromion being unaccommodating, bony growths on acromion due to age
Describe supraspinatus tendinopathy - symptoms, causes, treatment
common source of pain in athletes performing overhead sports such as tennis ; tendon of the supraspinatus degenerates from repeated use = inflammation; Patient will present with deltoid pain that is aggravated by abduction and flexion of arm; pain may radiate to lateral upper arm ; injection may be given but now practice is to avoid injections as can actually cause more inflammation to tendon; instead physical rehab exercises should be focused on instead - muscle needs lots of stimulation to heal
Where should injection of corticosteroids be given to treat supraspinatus tendinopathy
Acromioclavicular joint ; patient should be supine or seated; to identify the AC joint palpate the clavicle until it terminates at the shoulder at which you should feel a depression; needles is inserted above and in front but directed from the back
Subacromial decompression - what is it? When is it provided?
surgery to to treat shoulder impingement often done using arthroscopy (keyhole surgery); general anaesthetic given ; the aim is to make more space under the acromion by removing some bone and tissue; evidence emerging to show that surgery doesn’t help that much long term; NSAIDs, therapy and reposition of humerus and scapula via strengthening of serratous interior (involved in moving the lower scapula) are more effective
Possible causes of shoulder pain
Acromioclavicular joint disease Glenohumeral joint disease - frozen shoulder or arthritis ; characterised by pain all over and restriction of all active and passive movements of shoulder Rotator cuff disorders - pain on abduction with thumb pointing down
Primary flexors of MCP joint
what other muscles are also involved ?
Lumbricals
Flexor digitorum profundis and superficialis also involved
extension of the IP joint relies on the synergistic action of which 3 muscles?
Interossei, lumbricals and extensor digitorum
Describe ape hand and sign of benediction
sign of benediction is cause by damage to the median nerve just above the condyles of the humerus - patients able to flex all fingers except for the index and middle(they will stay pointing as supplied by ulnar nerve) ; they will be unable to make a fist ; also wasting of anterior forearm and thenar eminence
Ape hand - thumb usually in front of digits at rest ; damage to median nerve causes thumb to be in the same plane as the other fingers ; prominence at base of thumb too
Carpal tunnel syndrome
describe
symptoms
cause
treatment
caused by compression of the median nerve due to swelling of tissue inside carpal tunnel
- an ache or pain in your fingers, hand or arm
- numb hands
- tingling or pins and needles
- a weak thumb or difficulty gripping
- atropy of thenar muscles
- symptoms are intermittent and worsen at night
causes - repetitive hand movements or prolonged hyperextension or hyperflexion
Treatment - wrist splin to keep wrist straight and relieve pressure on median nerve ; steroid injection to reduce inflammation ; worst case scenario surgery ; avoid activities that put excessive strain on wrist such as playing instrument or using vibrating tools
identify the strongest flexor of elbow
Brachialis
