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
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
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