Anatomy of Upper extremity

Anatomy of upper extremity

1. Upper extremities Dr. Sunil Pahari , 3 rd year resident , department of orthopaedic surgery, yangtze university , hubei , China

2. Boundaries of upperlimbs Superior clavical—acrimoin—spinous process of C7 Anterior anterior border of the deltoid—anterior axillary fold Posterior posterior border of the deltoid—posterior axillary fold

3. Bony structures of upperlimbs Clavical Scapula Humerus Radius Ulna Carpal bones Matacarpal bones Phalanges

4. Clavicle Only one bone that lie horizontally ,subcutaneous through out , first bone to start ossify , 2 primary center of ossification , membranous ossification, S- shaped , 1 shaft and 2 end ,, medial part articulates with sternum and lateral part with acromian process of scapula … m/c fracture site - junction between middle and outer -third . Most common fracture bone in body also called Collar bone or beauty bone ..

5. scapula 2nd to 7th rib Flat and triangular Anterior surface(costal surface) & dorsal or posterior surface(spine of scapula). Superior, medial and lateral border. Superior, inferior angle. Acromian articulates with clavicle . glenoid cavity articulates with head of humerus . Coracoid process projects upward provides attachment for muscles and ligaments.

6. humerus Longest and largest bone of upper limb Body and two ends Head, greater and lesser tubercle/ intertubecular sulcus or bicipital groove. Anatomical neck Surgical neck=head meets the shaft Lower end is flat and two articular surfaces Capitulum for head of radius Trochlea for articulation with trochlear notch of ulna. Lateral and medial epicondyles for muscles and ligament attachment Radial fossa for radial head when elbow is flexed Coronoid fossa for coronoid process of ulna during same movement. Olecranon fossa posteriorly for olecranon process of ulna during extension.

7. Humerus fractures and nerve injury surgical neck fracture - axillary nerve injury . shaft #- radial nerve injury supracondylar # - median nerve injury . Supracondylar fracture

8. Radius and ulna

9. Radius Fracture of the distal end ( Colle’s fracture): It is due to a fall on the outstretched hand in patients over (50) years. The distal fragment of the radius is pulled posteriorly and superiorly The distal articular surface is directed posteriorly . The posterior displacement produces a posterior bump. The deformity is referred to as, ‘dinner-fork deformity’ because the forearm and wrist resemble the shape of a dinner fork. Smith’s fracture is a reversed Cole’s as the distal segment is displaced anteriorly

10. Carpal bones 8 in numbers proximal row ( lateral to medial ) Scaphoid ( boat shaped ) Lunate( half –moon ) Triquetrum ( three cornered Pisiform ( pea Shaped ) Distal row Trapezium ( four sided ) Trapezoid ( babys shoes shaped ) Capitate ( head ,,, biggest ) Hamate ( hook) Scaphoid fracture is most common .

11. Fracture of the Scaphoid Bone Common in young adults Fracture line passes through the narrowest part of the bone If the fragments will not unite properly, there will be permanent pain and weakness at the wrist Deep tenderness in the anatomical snuff box after a fall on an outstretched hand in a young adult is an indication of fracture of scaphoid bone

12. Elbow Joint Dislocations are common and most are posterior. Are more common in children, due to a fall on outstretched hand. The distal end of humerus is pushed anteriorly through weak part of the capsule Pulled Elbow : occurs in children, when the child is lifted by the upper limb. The radial head is pulled out of the annular ligament

13. Tennis Elbow Caused by partial tear or degeneration of the origin of superficial extensor muscles attached to the lateral epicondyle It results due to excessive use of these muscles as in tennis, violinists and housewives. Results in pain and tenderness over the lateral epicondyle that radiates to the lateral side of the forearm

14. Golfer’s Elbow (Medial Epicondylitis ) Caused by partial tear or degeneration of the origin of superficial flexor muscles attached to the medial epicondyle It results due to excessive use of these muscles as in playing golf Results in pain and tenderness over the medial epicondyle that radiates to the medial side of the forearm

15. Bones of Hand Carpal bones Metacarpals Phalanges From lateral to medial : 1- the proximal row : scaphoid , lunate , triquetral & pisiform . 2- the distal row : trapezium , trapezoid , capitate & hamate

16. Deltoid origin – from lateral 1/3 rd of clavicle , acromion process and spine of scapula. insertion – into the deltoid tuberosity of humerus . Action - act as main muscle for abduction of shoulder joint . Its anterior part is flexor and medial rotator of humerus while posterior part is extensior and lateral roatatior of humerus . supraspinatus- deep to trapezius, arises from supraspinatus fossa of scapula. Fibers crosses above the shoulder joint and is inserted into greater tubercle of humerus . Stabilizes shoulder joint and abducts the humerus . Muscles that abduct the upper arm

17. Muscles origin Insertion Actions Nerve supply Deltiod Scapula and clavical Humerus Abduct the upper arm Axillary nerve Supra spinatous Scapula Humerus Abduct the upper arm Suprascapularnerve

18. Muscles that adduct the upper arm 1) pectoralis major 2) lattissimus dorsi 3) teres major 4) subscapularis

19. Latissimus dorsi : very broad, flat and triangular muscle in lower back. It is overlapped by lower part of trapezius. It originates from lumbar fascia, spines of lower six thoracic vertebrae, lower three or four ribs and inferior angle of scapula. .

20. Muscles origin Insertion Actions Nerve supply Pectoralis major Clavical and sternum Humerus Adduct the upper arm Medial and lateral pectoral nerves from brachial plexus Lattissimus dorsi Thoracic-lumber vertebrae Humerus Adduct the upper arm Thoracodorsal nerve Teres major Scapula Humerus Adduct the upper arm Lower subscapular nerve Subcapsularis scapula Humerus Rotate the upper arm medially Upper and lower subscapular nerves Infraspinatus scapula Humerus Rotate the upper arm laterally Suprascapular nerve

21. Rotator cuff muscles The name given to the tendons of the subscapularis , the supraspinatus , the infraspinatus , and the teres minor muscles , which are fused to the underlying capsule of the shoulder joint. The cuff is important in stabilizing the shoulder joint.

22. Mucles that move forearm Anterior flexor muscles 1) bicep brachii 2) brachilais 3) coracobrachialis

23. coracobrachialis elongated muscle in superiomedial aspect of arm. Originates from coracoid process of scapula and inserts into medial aspect of shaft of humerus . It flexes the arm musculocutaneous nerve.

24. Muscles origin Insertion Actions Nerve supply Baicep brachii Scapula Radius Flexes the forearm and supinates the hand Musculocutaneous nerve Coracobrachialis scapula humerus Flex the forearm Musculocutaneous nerve Barchialis Humerus Ulna Flex the forearm Musculocutaneous nerve

25. Posterior extenser muscle of arm Triceps Brachii : Arises by three heads, from which it takes its name. Origin of each of the three heads is Long Head : originates from infraglenoid tubercle of scapula Lateral Head : upper half of posterior surface of shaft of humerus Medial Head : Lower half of posterior surface of shaft of humerus All the fibers inserts into olecranon process of ulna. It is an extensor of elbow joint nerve supply - radial nerve

26. Muscles that move the hand Anterior flexor pronator group Flexor carpi radialis (flexes and abduct the hand ) Palmaris longus (flexes the hand) Flexor carpi ulnaris (flexes and adduct the hand) Proneter teres (pronates the hand) Brachioradialis Flexor digitorium superficialis Flexor pollicis longus Pronator quadratus

27. Posterior extensor group muscles :- Extensor carpi radialis - Extends and abduct the hand 2) Extensor carpi ulnaris - Extends and adduct the hand 3) Extensor digitorium - Extends the phalanges

28. Volkmann’s Ischaemic Contracture It is the contractures of the muscles of the forearm that follows fractures of the distal end of the humerus or fractures of the radius and ulna. Spasm of a localized segment of the brachial artery reduces the blood flow to the flexors and extensor muscles so that they under go ischemic necrosis. The flexor muscles are mostly affected

29. Intrinsic muscles of the hand 1) palmer flexors :- thernar group hypothernar intermidiate group 2) dorsal extensor :- thenar extensor hypothernar extensor intermidiate extensor

30. Dupuytren’s Contracture It is a localized thickening and contracture of the palmar aponeurosis . It commonly starts near the root of the ring finger pulling it to the palm and flexing it at the metacarpo-phalngeal joint. Later the little finger is involved. Dupuytren's disease is familial, and may be associated with cigarette smoking, vascular disease, epilepsy, and diabetes.

31. Pulp-Space Infection (Felon) This is the commonest hand infection. Pus more often gathers in the finger tips than anywhere else in the hand. It is more common in the thumb and index fingers.

32. ARTERIES OF THE UPPER LIMB: THE AXILLARY ARTERY :It begins at the outer border of the 1 st rib as a continuation of the Subclavian A. & ends at the lower border of the teres major M. by becoming the Brachial A.

33. ARTERIES OF THE UPPER LIMB: The pectoralis minor M . divided it to 3 parts The 1 st part : lies above the pectoralis minor & give one branch ( superior thoracic A .) . It lies very deeply with the axillary vein on its medial side .

34. The 2 nd part : lies behind the pectoralis minor M. & gives 2 branches ( acromio thoracic A.& lateral thoracic A. ). The 3 rd part : lies below the pectoralis minor M. & gives 3 branches :( subscapular A., post. circumflex humeral A. & ant . Circumflex humeral A.).

35. Anastamosis around the scapula The branches of the third part of axillary A. * the sub scapular A . which go down along the lateral border of the scapula. *the circumflex scapular A . which arise from the sub scapular A.& go to the infraspinous fossa .

36. THE BRACHIAL ARTERY : It begins at the lower border of the Teres major M. as a continuation of the Axillary A. & ends at the level of the neck of the Radius by dividing to Radial & Ulnar Aa . It is a superficial A. lies immediately below the deep fascia. The basilic vein lies on its medial side.

37. The branches of the brachial A.: It supplies all the Mm. of the arm & gives 3 branches 1- the profunda brachii A. 2- the superior ulnar collateral A. 3- the inferior ulnar collateral A .

38. Anastamosis around The Elbow Joint : It is a rich anastamosis between small branches of brachial ,ulnar & radial Aa.:

39. Anastamosis around medial epicondyle : The two branches of the brachial A . (the superior ulnar collateral A. & the inferior ulnar collateral A.) with the branches of ulnar A. (the ant. & post. Ulnar recurrent Aa .) .i.e. the brachial & the ulnar Aa . only . Anastamosis around lateral epicondyle : The 2 terminal branches of the profuda brachii a. with recurrent branches of ulnar & radial Aa .

40. Radial artery Begins: in the cubital fossa at the neck of the radius . Course : passes downward and laterally end with deep palmer arch Branches Radial recurrent a. Superfical and deep palmar branch Principal artery of thumb At the lower end of the radius , it leaves the front of the forearm & turns backward round the lateral border of the wrist , below the styloid process of the radius& enter the anatomical snuff-box where the pulsation can be felt then pass to the palm .

41. Ulnar artery Begins in the cubital fossa at the opposite neck of the radius. Course : passes downward and medially . Branches Ulnar recurrent a. Common interosseous artery Anterior interossous a. Posterior interosseous a . Deep palmar branch

42. THE SUPERFICIAL PALMER ARCH : It is superficial because it lies immediately next to the palmer aponeurosis . It is formed mainly by the ulnar A. with the superficial palmer branch of the radial A. It gives 4 digital Aa . to supply the 4 medial fingers.

43. THE DEEP PALMER ARCH : It is formed mainly by the radial A. with the deep palmer branch of the ulnar A . It gives 3 palmer – metacarpal Aa . To pass to the clefts of the fingers.

44. Review The subclavian artery  becomes the axillary artery after crossing the 1st rib The axillary artery  becomes the brachial artery after crossing the posterior axillary fold The brachial artery  divides just distal to the elbow into the radial and ulnar arteries. The ulnar artery  gives rise to the common interosseous artery, which divides into anterior and posterior interosseous arteries. The hand is supplied on the palmar aspect by variable anastomoses between branches of the radial and ulnar arteries .

45. THE VEINS OF THE UPPER LIMB There are superficial & deep veins in the upper limb . The deep veins are the veins which accompany the main Aa . ( way & name ). The superficial Vv. : start as superficial venous network on the back of the hand. this network drains in 2 directions laterally into Cephalic V & medially to the basilic V.

46. Blood vessels of upper limbs Superficial veins  Dorsal venous network Cephalic vein Basilic vein   Axillary vein( basilic + brachial vein)   Median cubital vein  Median vein of forearm Deep veins  Named according to companian arteries Radial vein   Ulnar vein Brachial vein   Axillary vein

47. Clinical importance of median cubital vein Often used for clinical procedures Blood sampling Blood transfusion Intravenous injection Introduction of cardiac catheters to secure blood samples from chambers of heart and great vessels Cardio-angiography

48. Brachial plexus

49. THE BRACHIAL PLEXUS A plexus: it is a complex arrangement of the anterior primary rami of certain spinal Nn . Which gives branches to supply the Mm. & skin of a certain part of a body.

50. It is formed by the anterior primary rami of C5,C6,C7,C8 &T1 Nn . these are called ROOTS of the plexus. It lies in the lower part of the neck behind the clavicle & in the axilla & formed of 4 main parts : Roots , Trunks , Divisions & cords.

51. The root of C7 alone form the middle trunk . The roots of C8 & T1 unite to form the lower trunk. Then each trunk divides into anterior & posterior division . Then the 3 posterior divisions unite to form the posterior cord . The anterior divisions of the upper & middle trunks form the lateral cord . The anterior division of the lower trunk alone forms the medial cord . THE TRUNKS formed by The roots of C5 & C6 unite to form the upper trunk

52. So we have :5 roots , 3 trunks , 6 division , 3 cords & 5 terminal branches . No branches arise from the trunks nor from the divisions ( except the suprascapular N. which come from the erbs point=at beginning of the upper trunk). . The brachial plexus gives 16 branches , 11 small branches & 5 big branches : radial , ulnar , median , circumflex ( axillary ) & musclocutaneous Nn .

53. Each cord gives rise to 2 branches one is big & consider the continuation of the cord & one is small SO The posterior cord continues as the radial N. The medial cord continues as the ulnar N. The lateral cord continues as the median N. The 3 cords named according to their position to 2 nd part of the axillary A. (post. , medial & lateral.) while the name of the main N. according to position in the forearm( ulnar , median & radial ).

54. The 5 main Nn . Arise opposite the lower border of the pectoralis minor M. near the coracoid process . 1- The circumflex ( axillary ) N. supplies the deltoid & teres minor Mm. then become the lateral cutaneous N. of the arm. 2- The musculocutaneous N. supplies the biceps , coracobrachialis & brachialis Mm. then become the lateral cutaneous N. of the forearm . 3- The median N ( with its branch =ant. Interosseous N.) supplies most of the Mm. of front of the forearm with sensation of lateral 3 & ½ fingers anteriorly .

55. 4- The radial N .( with its branch=post. Interosseous N.) supplies most of the mm. of the back of the forearm. With sensation of lateral 3 & ½ fingers posteriorly . 5- The ulnar N. supplies Mm. on the medial side of the forearm with sensation of medial 1 & ½ fingers anteriorly & posteriorly .

56. Median nerve Origin : arises from the medial and lateral cord of the brachial plexus. Course : Descends on the lateral side of brachial artery. Halfway down the arm, it crosses the brachial artery to reach its medial side.

57. he median nerve travels through a tunnel within the wrist called the  Carpal Tunnel . The median nerve gives sensation to the palm sides of the thumb, index finger, long finger, and half of the ring finger. It also sends a nerve branch to control the  thenar muscles  of the thumb. The thenar muscles help move the thumb and let you touch the pad of the thumb to the tips each of each finger on the same hand, a motion called  opposition .

58. Ulnar nerve Origin : arises from the medial cord of the brachial plexus. Course : Descends on the medial side of brachial artery. At the middle of the arm, it pierces the medial intermuscular septum and passes down behind the medial epicondyle of the humerus .

59. THE DERMATOMES OF THE UPPER LIMB It is the cutaneous sensation of the upper limb. C4 supplies the skin over the tip of the shoulder . C5 supplies the lateral side of the arm &the upper lateral part of the forearm . C6 supplies the lateral side of the lower part of the forearm & the lateral aspect of the hand C7 supplies the middle aspect of the hand (ant.& post.) . C8 supplies the medial side of the hand & the medial lower part of the forearm. T1 supplies the medial part of the upper part of the forearm & the medial lower part of the arm. T2 supplies the medial side of the upper part of the arm & the floor of the axilla .

60. Cubital fossa Boundaries Superior : an imaginary line drawn between the two epicondyles of the humerus. Lateral : brachioradialis; Medial : pronator teres; General introduction Body wall Head and neck Limbs Thoracic cavity Abdominal cavity Pelvic cavity

61. Cubital fossa Contents: The median N. The brachial A., radial A., ulnar A. The superficial and deep branches of the radial N. Radial artery Ulnar artery Median nerve Brachial artery Radial nerve General introduction Body wall Head and neck Limbs Thoracic cavity Abdominal cavity Pelvic cavity

62. The blood pressure is universally recorded by auscultating the brachial artery in medial side of the biceps’ tendon in the cubital fossa. Applying Cubital fossa Brachial artery Biceps General introduction Body wall Head and neck Limbs Thoracic cavity Abdominal cavity Pelvic cavity

63. Thank you !!!