The Upper Extremity

1
The Upper Extremity

• Bones, Muscles, Vessels,

pg 608
2
Bones
pg 612

• 30 bones!!!!
• Appendicular skeleton
• Pectoral girdle
• Glenoid cavity
• Allows for mobility
• Attachments
• Upper extremity
• Arm
• humerus
• Forearm
• Radius, ulna (interosseous membrane)
• Hand
• Carpals, metacarpals, phalanges
• Review bones and landmarks studied in lab!!!

3
Joints of Upper Extremity
pg 626-7

• Sternoclavicular
• Synovial-saddle
• Diarthrosis
• Acromioclavicular
• Synovial-plane
• Diarthrosis
• Glenohumeral joint
• Synovial-ballsocket
• Diarthrosis
• Many ligaments
• Muscle reinforcement
• Great Mobility

4
Joints of the Upper Extremity
pg 681-2

• Elbow Joint
• Synovial hinge
• Diarthrosis
• Articulations
• Humerus Ulna
• Humerus Radius
• Many Ligaments

5
Joints of Upper Extremity
pg 691

• Proximal Radioulnar joint
• Synovial - pivot
• Diarthrosis
• Distal Radioulnar joint
• Synovial pivot
• Diarthrosis
• Allows pronation and supination of forearm

6
Joints of the Upper Extremity
Pg 711

• Radiocarpal joint
• Synovial-condyloid
• Distal radius with proximal row of carpals
• Intercarpal joints
• Synovial-plane
• Carpal-metacarpal (2-5)
• Synovial-plane
• Trapezium-metacarpal 1
• Synovial-saddle
• Metacarpal-phalangeal
• Synovial-condyloid
• Interphalangeal
• Synovial-hinge
• ALL DIARTHROSES

7
Review of Naming..

• What do the following names TELL you about the
  muscle?
• Naming
• Flexor carpi ulnaris
• Flexor digitorum superficialis
• Flexor pollicis longus
• Pronator quadratus
• Extensor carpi radialis brevis

8
Scapula Muscles
pg 614

• If the origin is on the scapula moves the arm
• Subscapularis
• Supraspinatus
• Infraspinatus
• Teres Minor
• Teres Major
• Latissimus Dorsi (partial attachment)
• Coracobrachialis

Rotator Cuff
9
Scapula Muscles
pg 614

• If the insertion is on the scapula moves the
  scapula
• Rhomboids
• Trapezius
• Pectoralis Minor
• Serratus Ventralis
• Levator Scapulae

Use location of Insertion to determine movement!!
10
Innervation of Muscles Moving Arm
Muscle Innervation
Subscapularis Teres Major Subscapular N.

Infraspinatus Supraspinatus Suprascapular N.

Teres Minor Axillary N.

Coracobrachialis Musculocutaneous N.
11
Arm Muscles
pg 667

• Cross elbow, move forearm
• 2 compartments
• Anterior
• Flexors of forearm
• Posterior
• Extensors of forearm

12
Arm Muscles
pg 651
pg 671

• Anterior compartment
• Brachialis
• Biceps brachii
• Coracobrachialis

13
Arm Muscles
pg 636

• Posterior compartment
• Triceps brachii

14
Muscles of Arm
Muscle Origin Insertion Action
Anterior
Brachialis Ant shaft , distal humerus Coronoid proc/tuberosity (ulna) Flex forearm
Biceps Brachii Long supraglenoid tubercle (scapula) Short coracoid proc (scapula) Radial Tuberosity (radius) Flex forearm, Supination
Coracobrachialis Coracoid proc (scapula) Medial surface midshaft (humerus) Flex arm
Posterior
Triceps Brachii Long Infraglenoid tubercle Short Posterior shaft (middle humerus) Lateral Posterior Shaft (proximal humerus) Common tendon to olecranon (ulna) Extend forearm
15
Arm Muscle Innervation

• Anterior compartment
• Musculocutaneous nerve
• Coracobrachialis
• Brachialis
• Biceps brachii
• Posterior compartment
• Radial nerve
• Triceps brachii

16
Forearm Muscles
pg 694

• Cross elbow, wrist and finger joints
• Movement of hand and fingers
• Cross Wrist
• flex, extend, abduct, adduct hand
• Cross Fingers
• flex, extend fingers
• Proximally are fleshy
• Distally have long tendons
• Flexor and extensor retinacula
• wristbands
• Keep tendons from jumping outwards when tensed

17
Forearm Muscles
pg 688

• Anterior flexor compartment
• Superficial and Deep
• Most flexors have common tendon on medial
  epicondyle
• Contains 2 pronators
• Posterior extensor compartment
• Superficial and Deep
• Most extensors in superficial layer have common
  origin on lateral epicondyle

18
Anterior Compartment of Forearm
pg 696

• Muscles Nerves
• Superficial
• Flexor digitorum superficialis brevis Median
• Flexor carpi radialis Median
• Pronator teres Median
• Palmaris longus Median
• Flexor carpi ulnaris Ulnar
• Deep
• Pronator quadratus Median
• Flexor pollicis longus Median
• Flexor digitorum profundus Ulnar (med 1/2)
  Median (lat 1/2)

19
Posterior Compartment of Forearm
pg 702

• Muscles Nerves
• Superficial
• Brachioradialis Radial
• Anconeus Radial
• Extensor carpi radialis longus brevis Radial
• Extensor digitorum Radial
• Extensor carpi ulnaris Radial
• Extensor digiti minimi Radial
• Deep
• Supinator Radial
• Abductor pollicis longus Radial
• Extensor pollicis longus brevis Radial
• Extensor indicus Radial

20
Hand Bones
pg 711

• Carpus (8)
• True wrist
• Distal to radius/ulna
• Metacarpus (5)
• Distal to carpus
• Phalanges (14)
• Distal to metacarpus

21
Intrinsic Muscles of the Hand

• Muscle Nerve
• Pinky (little finger)
• All digiti minimi Ulnar (Flexor, Abductor,
  Opponens)
• Thumb
• Abductor pollicis brevis Median
• Flexor pollicis brevis Median
• Opponens pollicis Median
• Adductor pollicis Ulnar
• Other Intrinsic Muscles
• Palmar Dorsal Interossei Ulnar
• Lumbricals Median, Ulnar

22
Intrinsic Muscles of the Hand
pg 718
pg 723
Dorsal
Palmar
Lumbrical Muscles
Interossei Muscles
23
Blood Supply - Veins
pg 677

• Deep veins
• Deep palmar venous arches
• Radial - forearm
• Ulnar - forearm
• Brachial arm/elbow
• Axillary axilla
• Subclavian - neck
• Superficial Veins
• Digital
• Superficial palmar venous arches
• Median forearm
• Median cubital elbow
• Blood draws!!
• Cephalic arm/forearm
• Basilic arm/forearm

24
Blood Supply - Arteries
pg 675

• Subclavian (neck)
• Axillary (armpit)
• Subscapular
• Circumflex humeral arteries
• Brachial (arm)
• Deep brachial
• Radial (forearm)
• Ulnar (forearm)
• Common Interosseous
• Superficial Deep Palmar arches
• Digital

25
Axilla
pg 688

• Armpit!!
• Where axillary hairs grow
• Boundaries
• Ventral
• Pectoral muscles
• Dorsal
• Latissimus dorsi, teres major, subscapularis
• Medial
• Serratus ventralis
• Lateral
• Inetrtubercular (Bicipital) groove of humerus
• Contents
• axillary lymph nodes, axillary vessels, brachial
  plexus

26
Surface Anatomy of Arm
pg 688

• Cephalic Vein
• Biceps brachii
• Triceps brachii
• Olecrenon Process
• Medial Epicondyle
• Lateral Epicondyle

27
Surface Anatomy of Elbow
pg 686

• Cubital Fossa
• Anterior surface elbow
• Contents
• Median Cubital Vein
• Brachial Artery
• Median Nerve
• Boundaries
• Medial Pronator teres
• Lateral Brachioradialis
• Superior Line between epicondyles

28
Surface Anatomy of Hand
pg 715

• Carpal Tunnel
• Carpals concave anteriorly
• Carpal ligament covers it
• Contains long tendons, Median nerve
• Inflammation of tendons compression of Median
  nerve
• Anatomical Snuffbox
• Lateral E.pollicis brevis
• Medial E. pollicis longus
• Floor scaphoid, styloid of radius
• Contains Radial Artery (pulse)

29
Brachial Plexus
pg 618
pg 21

• Nerve plexus
• Network of nerves formed by ventral rami
• Lies partly in neck and partly in axilla
• Gives rise to almost all nerves that supply upper
  limb
• Formed by intermixing of ventral rami of spinal
  nerves C5-C8 and T1
• Small contributions from C4 and T2

30
Brachial Plexus
pg 660

• Really Tired? Drink Coffee Buddy!
• R RAMI (ventral) (5)
• T TRUNKS (3)
• D DIVISIONS (2)
• C CORDS (3)
• B BRANCHES (Many!!)

31
Rami join to form Trunks! (in neck)

• Ventral Rami Trunks
• C5 Upper Trunk
• C6
• C7 Middle Trunk
• C8
• T1 Lower Trunk

32
Trunks Split to form Divisions! (in neck)

• Trunks Divisions
• Upper Anterior Posterior
• Middle Anterior Posterior
• Lower Anterior Posterior

33
Divisions Join to form Cords! (in axilla)

• Trunks Division Cords
• U A Lateral
• P
• M A Medial
• P
• L A Posterior
• P

34
Cords Give off Branches!! (in axilla)

• Lateral Musculocutaneous
• Median
• Medial Ulnar
• Posterior Radial Axillary (thoraco
  dorsal) (subscapular)

35
Brachial Plexus Cords and Branches

• Lateral
• Musculocutaneous n.
• Median n.
• Medial
• Ulnar n.
• Posterior
• Radial n.
• Axillary n.
• Thoracodorsal n.
• Subscapular n.

36
Lateral Cord

• Musculocutaneous nerve
• Off lateral cord
• Course
• Anterior arm
• Becomes cutaneous and gives skin sensation to
  lateral forearm
• Innervates
• Corocobrachialis (motor)
• Biceps brachii (motor)
• Brachialis (motor)
• Skin distal to the elbow (sensory)
• Suprascapular (not part of lateral cord)
• Runs with suprascapular artery and vein C5, C6
• Innervates
• Supraspinatus
• Infraspinatus

37
Medial Cord

• Ulnar nerve
• Course
• Comes off medial cord
• Descends along medial side of arm
• Passes posterior to medial epicondyle
• Follows the ulna
• Superficial to carpal tunnel into hand
• Branches to supply intrinsics and skin
• Innervates
• Flexor carpi ulnaris (motor)
• Flexor digitorum profundus (motor)
• Most intrinsic hand muscles (motor)
• Dorsal branch supplies skin of medial 2/3 of hand
  (sensory)

38
Both Medial and Lateral Cords

• Median nerve
• Course
• Middle of brachial plexus (from lateral and
  medial cords)
• Does not branch in arm
• Distal to elbow provides many branches to most
  forearm flexors
• Passes through carpal tunnel to hand to lateral
  palmar intrinsics
• Innervates
• Anterior forearm (motor)
• Most flexors, some intrinsics (thumb)
• 2/3 Lateral palm (sensory)
• Dorsum of fingers 2 and 3 (sensory)

39
Posterior Cord

• Radial nerve
• Largest branch of brachial plexus
• Comes from posterior cord
• Course
• Through arm
• Around humerus
• Around lateral epicondyle (then divides)
• Innervates
• Posterior muscles of arm and forearm
• Triceps brachii, anconeus, supinator,
  brachioradialis
• Divides in forearm
• Superficial
• Skin of arm and dorsolateral surface of hand
• Deep
• Extensor muscles of forearm (eg ext. carpi
  radialis L B)

40
Posterior Cord (continued)

• Axillary nerve
• Branches off posterior cord
• Course
• Runs posterior to humerus
• Runs with caudal humeral circumflex artery
• Innervates
• Deltoid and teres minor (motor)
• Capsule of shoulder, skin of shoulder (sensory)
• Subscapular nerve
• Innervates
• Subscapularis, Teres major
• Thoracodorsal nerve
• Course
• Runs with thoracodorsal artery and nerve
• Innervates
• Latissimus dorsi

41
Cutaneous Innervation to Hand
pg 620, 727, 729
42
Nerve Damage
pg 737-8

• Ulnar nerve
• Claw hand
• Inability to extend fingers at interphalangeal
  joints, results in permanent flexion claw
• Median nerve
• Ape hand
• Inability to oppose thumb
• Radial nerve
• Wrist drop
• Inability to extend the hand, inability to fully
  extend forearm