VIVA: Anatomy - Upper limb Flashcards
Describe the superficial lymphatics of the upper limb
- Originate from lymphatic plexuses and ascend mostly with superficial cephalic and basilic veins*
- Some accompanying the basilic veins enter the cubital lymph nodes
- Efferent vessels from here drain to axillary lymph nodes*
- Lymphatics accompanying the cephalic veins enter the axillary lymph nodes with some entering deltopectoral lymph nodes earlier
*needed to pass
Describe the boundaries of the cubital fossa
Triangular fossa with boundaries (3/4 to pass):
- Superiorly: imaginary line between epicondyles
- Medially: lateral border pronator teres
- Laterally: medial border of brachioradialis
- Floor: brachialis and supinator
- Roof: deep fascia reinforced by bicipital aponeurosis, subcutaneous tissue and skin
In this photo, identify the contents of the cubital fossa
- Radial nerve* with superficial terminal branch (16)
- Biceps and tendon (3)
- Brachial artery* (4)
- Ulnar (17) and radial (13) arteries
- Median nerve* (12)
- Brachialis (5)
Describe the course of the ulnar nerve around the elbow
Passes through the elbow posterior to the medial epicondyle of the humerus
What clinical findings would you expect if the ulnar nerve is injured at the elbow?
Loss of sensation to*:
- Medial half of palm (palmar cutaneous branch)
- Medial one and a half fingers, and associated dorsal hand area (dorsal cutaneous branch)
- Palmar surface of the medial one and a half fingers (superficial ulnar branch)
Motor, unable to*:
- Flex and adduct hand at wrist (FCU)
- Flex DIPJ 4th and 5th digits (FDP III and IV)
- Flex and abduct 5th MCPJ (hypothenar muscles: abductor digiti minimi, opponens digiti minimi, flexor digiti minimi)
- Adduct thumb (adductor pollicis, half of flexor pollicis brevis)
- Abduct and adduct 4th and 5th fingers (interosseous muscles, 3rd and 4th lumbricals)
*sensory + 2/5 motor to pass
How would you differentiate an ulnar nerve lesion at the elbow from one at the wrist?
More pronounced claw hand if lesion is more distal, as FCU and FDP preserved
Identify the components of the brachial plexus
6 to pass:
- Axillary nerve (1)
- Lateral cord (6)
- Lateral root of median nerve (8)
- Medial cord (12)
- Medial cutaneous nerve of arm (13)
- Medial cutaneous nerve of forearm (14)
- Medial root of median nerve (16)
- Musculocutaneous nerve (18)
- Posterior cord (20)
- Ulnar nerve (26)
What are the nerve roots that make up the posterior cord of the brachial plexus?
C5-8, T1
What are the terminal branches of the posterior cord and what do they supply?
Axillary nerve (C5,6)*:
- Glenohumeral joint
- Deltoid, teres minor
- Skin over inferior aspect of deltoid
Radial nerve (C5-T1)*:
- All muscles in posterior compartment of arm and forearm
- Skin over posteroinferolateral arm, posterior forearm and dorsum of hand lateral to ring finger
Other branches:
- Upper scapular nerve (C5): supplies subscapularis
- Lower subscapular nerve (C6): supplies inferior part of subscapularis and teres major
- Thoracodorsal nerve (C6-8): supplies latissimus dorsi
*needed to pass + example of supply
What does the musculocutaneous nerve supply?
Motor:
- Muscles of anterior arm (biceps brachii, brachialis, coracobrachialis)
Sensory:
- Skin over lateral forearm (becomes the lateral cutaneous nerve of the forearm after giving off its motor supply)
Apart from wrist extensor weakness, what other functions may be lost with a radial nerve lesion in the axilla?
1 to pass:
- Finger extension
- Sensory loss over radial side of dorsum of hand
A 60 year old alcoholic man is brought to ED after being found slumped in a chair. He is noted to have a wrist drop. Identify the nerve most likely injured.
Radial nerve (21)
Identify the main features of this bone
- Glenoid cavity*
- Spine*
- Supra and infraspinous fossae*
- Subscapular fossa*
- Acromion*
- Coracoid process*
- Neck
- Facet for clavicle
- Suprascapular notch
- Supra and infraglenoid tubercles
- Deltoid tubercle
- Inferior angle
- Medial border
- Lateral border
- needed to pass
Demonstrate on this bone the attachments of the scapulohumeral muscles
- Deltoid: acromion and spine of scapula*
- Supraspinatus: supraspinous*
- Infraspinatus: infraspinous fossa*
- Teres minor: middle part of lateral border
- Teres major: posterior surface of inferior angle
- Subscapularis: subscapular fossa*
*needed to pass
What are the actions of the individual rotator cuff muscles?
3/4 to pass:
- Supraspinatus: abduction
- Infraspinatus: lateral rotation
- Teres minor: lateral rotation
- Subscapularis: medial rotation
What are the articulating surfaces in the shoulder joint?
Ball-and-socket synovial joint with:
- Rounded head of humerus*
- Shallow glenoid cavity of scapula* (deepened by labrum)
*needed to pass
What structures stabilise the shoulder joint?
- Rotator cuff muscles (supraspinatus, infraspinatus, teres minor, subscapularis)*
- Fibrocartilaginous glenoid labrum (deepens the joint)
- Coraco-acromial arch (formed by coraco-acromial ligament, resists superior displacement of humerus)
- Anterior glenohumeral ligaments (stabilise the joint anteriorly)
- Coraco-humeral ligament (supports superior joint capsule)
- Transverse humeral ligament (between two tubercles of humerus; holds tendon of long head of biceps in place)
*3/4 rotator cuff muscles + 2 others to pass (need to show understanding that there are different elements that contribute to stability)
What muscles are responsible for abduction and adduction of the shoulder?
Abduction:
- Supraspinatus* (initiates)
- Deltoid* (especially acromial part)
- With upward movement of scapula
Adduction:
- Pectoralis major* and latissimus dorsi* acting in concert
- Teres major* and long head of triceps* (synergists)
*2/4 to pass
What muscles are responsible for other movements of the shoulder (besides abduction and adduction)?
Flexion:
- Pectoralis major (clavicular head)
- Deltoid (clavicular and anterior acromial parts)
- Coracobrachialis (synergist)
Extension:
- Deltoid (spinal part)
- Latissimus dorsi
- Teres major
- Long head of triceps (synergists)
Medial rotation:
- Subscapularis
- Pectoralis major
- Latissimus dorsi
- Teres major
- Deltoid (clavicular part; synergist)
Lateral rotation:
- Infraspinatus
- Teres minor
- Deltoid (spinal part; synergist)
Circumduction
Outline the bursae of the shoulder joint
- Subscapular bursa:
- Between neck of scapula and subscapularis tendon
- Protects tendon - Subacromial (subdeltoid) bursa:
- Between acromion, coraco-acromial ligament and deltoid superiorly, and supraspinatus tendon and joint capsule inferiorly
- Facilitates movement of supraspinatus tendon
Identify the features on this model of a shoulder
Bones:
- Humerus * (with humeral head)
- Scapula * (with coracoid process *, acromion *, spine and body)
- Clavicle *
Joints:
- Glenohumeral *
- Acromioclavicular *
Ligaments:
- Coracoclavicular * (with conoid and trapezoid parts; most important for stability of ACJ)
- Acromioclavicular * (from top of clavicle to acromion)
- Glenohumeral ligament (reinforce anterior part of capsule from glenoid labrum to humerus)
Tendons:
- Long head of biceps tendon *
*needed to pass
What anatomical structures confer stability to the shoulder joint?
3/5 to pass:
- Joint capsule with fusion of the tendons of scapular/rotator cuff muscles
- Ligamentous: glenohumeral and coracohumeral ligaments
- Coracoacromial arch superiorly created by coracoacromial ligament
- Deepening of glenoid cavity by glenoid labrum
- Tendons of long head of biceps and triceps
What structures can be damaged by shoulder dislocation?
- Joint capsule and glenoid labrum damage (results in recurrent dislocation)
- Axillary nerve * lies below joint capsule (results in axillary nerve palsy: regimental badge sensory loss and inability to abduct shoulder past 15 degrees)
- Associated fracture of greater tubercle
*needed to pass
Name the ligaments of the shoulder and describe how they stabilise the joint
2/4 to pass:
1. Glenohumeral ligaments (superior, middle and inferior):
- Consists of three bands, which runs with joint capsule from glenoid fossa to anatomical neck of humerus
- Acts to stabilise the anterior aspect of the joint
2. Coracohumeral ligament:
- Attaches base of coracoid process to the greater tubercle of the humerus
- Supports the superior part of the joint capsule
3. Transverse humeral ligament:
- Spans distance between two tubercles of humerus
- Holds the tendon of long head of biceps in the intertubecular groove
4. Coracoacromial ligament:
- Runs between the acromion and coracoid process of the scapula, forming the coracoacromial arch
- This overlies the shoulder joint, preventing superior displacement of the humeral head
Identify the numbered bony features depicted on this photo of a humerus
6/10 to pass:
1. Anatomical neck
2. Deltoid tuberosity
3. Greater tubercle
4. Groove for radial nerve
5. Head
6. Intertubercular groove
7. Lateral lip of intertubercular groove
8. Lesser tubercle
9. Medial lip of intertubercular groove
10. Surgical neck
Name the muscles of the arm, describe their action, and name the peripheral nerve which innervates them
Anterior compartment* (innervated by musculocutaneous nerve):
- Biceps brachii: forearm supination, forearm flexion when supine, short head resists dislocation of shoulder
- Brachialis (also innervated by radial nerve): forearm flexion in all positions
- Coracobrachialis: aids in arm flexion and adduction, resists dislocation of shoulder
Posterior compartment* (innervated by radial nerve):
- Triceps brachii: chief extensor of forearm, long head resists dislocation of humerus (especially important during adduction)
*3 muscles to be at standard with the correct innervation and muscle action for them
Describe the main visible features of this bone
- Correct side*
- Head*
- Anatomical and surgical neck*
- Greater and lesser tuberosities* (major attachment areas for rotator cuff and deltoid)
- Intertubercular groove (for long head of biceps)
- Shaft
- Radial groove (for radial nerve and profunda brachii artery)
- Deltoid tuberosity
- Lateral (extensor origin) and medial (flexor origin) epicondyles* (ulnar nerve inferior to medial)
- Coronoid
- Radial and olecranon fossa
- Capitulum*
- Trochlea*
*needed to pass + 2 others
On this picture, identify the medial and lateral borders of the cubital fossa
- Medial border: pronator teres (4)
- Lateral border: brachioradialis (6)
Identify the contents of the cubital fossa
3 to pass:
- Brachial vein (1)
- Median nerve (2)
- Brachial artery (bifurcates into radial and ulnar arteries at the apex, and has accompanying veins; 3)
- Biceps tendon (7)
- Radial nerve also in the cubital fossa but not visible here
- Bicipital aponeurosis (forms roof; 5)
Describe the superficial lymphatics of the upper limb
- Originate from lymphatic plexuses in the hand and ascend mostly with superficial cephalic and basilic veins*
- Some accompanying the basilic veins enter the cubital lymph nodes: efferent vessels from here drain to axillary lymph nodes
- Lymphatics accompanying the cephalic veins enter the axillary lymph nodes with some entering deltopectoral lymph nodes earlier
*needed to pass
Name the structures of the cubital fossa in this picture
5 to pass:
- Biceps/biceps tendon (3)
- Brachial artery (4)
- Brachialis (5)
- Brachioradialis (6)
- Pronator teres (cut; 9)
- Median nerve (12)
- Radial artery (13)
- Ulnar artery (17)
Name the branches of the brachial artery that contribute to the peri-articular anastomosis surrounding the elbow
1 to pass:
- Profunda brachii
- Superior ulna collateral artery
- Inferior ulna collateral artery
Identify the superficial veins
- Basilic vein* (2)
- Cephalic vein* (6)
- Median cubital vein (11)
- Median forearm vein (12)
- needed to pass + one other
Identify other neurovascular structures in the cubital fossa
(McMinns cubital fossa)
- Median nerve* (15)
- Brachial artery* (4)
- Ulnar artery (22)
- Radial artery (21)
- needed to pass + one other
Identify the tendons at the wrist
4/6 to pass:
- FCU (9)
- FDS (10)
- Palmaris longus (18)
- FCR (8)
- FPL (11)
- Brachioradialis (5)
What structures lie deep to the flexor retinaculum at the wrist?
3/4 to pass:
- FDS
- FDP
- FPL
- Median nerve
(+/- FCR, debatable)
Which is the larger terminal branch of the brachial artery: ulnar or radial?
Ulnar
Identify the brachial artery and its branches in the forearm
- Brachial (2 on R)
- Radial (9 on R)
- Ulnar (13 on R)
- Common interosseous (7 on L)
- Posterior interosseous
- Median (6 on R)
Identify and name the muscles of the forearm
4 to pass:
- Pronator teres (20)
- Brachioradialis (5)
- Biceps tendon (2) and aponeurosis (3)
- FCU (9)
- FCR (8)
- Palmaris longus (18)
- FDS (10)
Identify the bony features on this XR
6 to pass:
- Medial/lateral epicondyles
- Capitulum
- Olecranon
- Radius (with head and neck)
- Olecranon fossa
- Coronoid fossa
- Trochlea
- Proximal radio-ulnar joint
- Coronoid process of ulna
What factors determine the stability of the elbow joint?
Bony factors:
- Shape of trochlea and olecranon fossa*
Joint capsule:
- Weak fibrous joint capsule
Ligaments:
- Radial collateral ligament* (from lateral epicondyle, blends with annular ligament)
- Annular ligament* of radius (holds radial head in radial notch of ulna)
- Medial ulnar collateral ligament* (from medial epicondyle to coronoid process and olecranon of ulna; three bands with anterior strongest, posterior weakest, and oblique deepening the trochlear notch)
Muscles:
- Biceps brachii
- Brachialis
- Brachioradialis
- Triceps
*3/4 to pass
Identify this bone and describe its anatomical features
Radius* (with correct side and why)
Features (5/7 to pass):
- Head: articulates with capitulum of humerus
- Neck
- Radial tuberosity: demarcates the head/neck from the shaft, provides attachment for biceps brachii
- Shaft: triangular in cross-section, with anterior and posterior oblique lines
- Distal end with styloid process, ulnar notch, and dorsal tubercle
Which carpal bones articulate with the distal end of the radius?
Scaphoid
Lunate
Describe the normal relative relationship between the radial and ulnar styloid processes
Radial styloid projects further (i.e. more distal) than ulnar styloid
Demonstrate the movement of the radius during supination
- The axis of supination passes through the centre of the head of the radius proximally and the ulnar styloid distally
- The head of the radius rotates within the collar formed by the annular ligament and the ulnar radial notch
- Supination rotates the radial head laterally around its axis (pronation rotates it medially)
Describe the venous drainage of the hand and forearm
Superficial:
- Dorsal venous network and superficial venous palmar arch drains to either the basilic vein (ulnar side) or cephalic vein (radial side)
- Highly variable distribution
Deep:
- Deep venous palmar arch drains to paired radial veins and paired ulnar veins which accompany the arteries of the same name (venae comitantes)
- Interosseous veins unite with radial and ulnar veins
- All terminate into the brachial veins as they leave the forearm
Name and identify the carpal bones on this model
6 to pass:
- Scaphoid
- Lunate
- Triquetrum
- Pisiform
- Hamate
- Capitate
- Trapezoid
- Trapezium
What movements occur at the wrist joint (demonstrate them) and which muscles produce them?
Flexion:
- FCR *, FCU *, flexors of fingers and thumb, palmaris longus, AbPL
Extension:
- ECRL *, ECRB *, ECU *, extensors of fingers and thumb
Abduction (limited to 15 degrees due to radial styloid):
- FCR, ECRL, ECRB, AbPL
Adduction:
- ECU, FCU
Circumduction (combined movements)
*needed to pass
Identify the attachments of the flexor retinaculum
2/4 to pass:
- Scaphoid tubercle
- Hook of hamate
- Trapezium
- Pisiform
What structures pass through the carpal tunnel?
- FCR
- FPL
- FDS
- FDP
- Median nerve
Which muscles flex the wrist?
5/7 to pass:
- FCR
- FCU
- FDP
- FDS
- FDM
- FPL
- Palmaris longus
On this model identify ligaments of the wrist
4 to pass:
- Ulnar collateral ligament
- Interosseous membrane
- Radial collateral ligament
- Dorsal radiocarpal ligament
- Dorsal radioulnar ligament
- Intercarpal ligaments
- Palmar carpometacarpal ligaments
- Palmar radiocarpal ligament
- Palmar radioulnar ligament
Describe the arterial supply of the hand
Ulnar and radial arteries supply all of the blood supply to the hand*
- Radial artery
- Forms deep palmar arch *
- Lies deep to long flexor tendons and sits across the metacarpals just distal to their bases
- Branches include 3x palmar metacarpal arteries, princeps pollicis artery, radialis indicis artery - Ulnar artery:
- Two terminal branches
- Deep palmar branch anastomoses with radial artery via deep palmar arch
- Main terminal branch is superficial palmar arch, which gives off 3x common palmar digital arteries (which then divide into a pair of proper palmar digital arteries that run along adjacent sides of 2nd to 4th digits)
*needed to pass + 1 branch of each arch
Can you identify the ulnar artery on this picture?
23
Describe the sensory innervation to the index and middle fingers
Median nerve to palmar aspect and nailbed / dorsal tip
Radial nerve to dorsal aspect, proximal to DIPJ
Identify on the picture muscles in the hand and forearm that are innervated by the median nerve
Hand:
- 1st (7) * and 2nd (22) lumbricals *
- Muscles of the thenar eminence: opponens pollicis, AbPB (2) *, FPB (13) *
Forearm:
- FCR (8) *
- Palmaris longus
- FDS (12) *
- Radial half of FDP (2nd and 3rd digits; 11) *
- FPL (14) *
- Pronator quadratus
*4/8 to pass
Demonstrate where the dorsal and palmar interossei muscles attach
Dorsal:
- From adjacent sides of two metacarpals (bipennate) to bases of proximal phalanges (plus extensor expansions of 2nd to 4th digits)
Palmar:
- From palmar surfaces of 2nd, 4th and 5th metacarpals (unipennate) to bases of proximal phalanges (plus extensor expansions of digits 2nd, 4th and 5th)
What do interosseous muscles do?
Palmar interossei adduct digits around axial line
Dorsal interrossei abduct digits around axial line
Flex MCPJ and extend IPJ
Describe the sensory and motor nerve supply of the hand
- Ulnar nerve*:
- Motor: innervates majority of intrinsic muscles of hand (hypothenar, interosseous, adductor pollicis, deep head of FPB, ulnar lumbricals for digits 4 and 5)
- Sensory: innervates skin of 5th digit and ulnar half of 4th digit and adjacent hand - Median nerve*:
- Motor: supplies innervation to thenar muscles (except adductor pollicis and deep head of FPB) and radial two lumbricals
- Sensory: sensation to skin of palmar and distal dorsal aspects of radial three and a half digits - Radial nerve:
- Sensory: sensation to dorsum of radial side of the hand excluding distal fingers
- needed to pass
Identify the structures seen in this image
- Median nerve* (16) and branches (17, 18, 19)
- Ulnar nerve* (25) and branches (24, 26, 27, 28)
- Ulnar artery (23)
- Thenar muscles: APB (2), FPB (13)
- Adductor pollicis (4), lumbricals (7, 22)
- FCR (8)
- FCU (9)
- BR (5)
- FDS (12)
- FDP (11)
*needed to pass + 6/10 others
Describe the median nerve supply in the hand
Motor*:
- LOAF: 1st and 2nd lumbricals, OP, APB, FPB (superficial head)
Sensory:
- Palmar surface of lateral three and a half digits, and dorsum of distal halves of these digits
*2/4 needed to pass + sensory
How would you clinically test the median nerve function in the hand?
Motor:
- Thumb opposition or abduction (thumb flexion not reliable as deep head of FPB supplied by ulnar nerve)
Sensory:
- Sensation over volar aspect of lateral three and a half digits (sensation over thenar eminence preserved as supplied by palmar cutaneous branch of median nerve)
Describe the course of the ulnar nerve in the upper limb
- Arises from brachial plexus as a continuation of medial cord, contains fibres from spinal roots C8 and T1
- Descends in a plane between axillary artery (lateral) and vein (medial) down the medial aspect of the arm, with brachial artery located lateral
- At mid-point of arm, penetrates medial fascial septum to enter posterior compartment of the arm
- Passes posterior to elbow through ulnar tunnel (small space between medial epicondyle and olecranon) and gives rise to articular branch supplying the elbow joint
- In the forearm, pierces the two heads of FCU and travels deep to the muscle, alongside the ulna
- Three main branches in the forearm: muscular (innervates FCU and FDP 3-4), palmar cutaneous (innervates medial palm), and dorsal cutaneous branch (innervates dorsal medial one and a half fingers and associated dorsal hand)
- At the wrist, travels superficial to flexor retinaculum and medial to ulnar artery
- Enters hand via ulnar canal
- In the hand, terminates by giving rise to superficial (innervates palmar medial one and a half fingers) and deep (innervates most intrinsic muscles of hand) branches
