The Upper Extremity

1. The Upper Extremity Bones, Muscles, Vessels, pg 608

2. 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!!! Bones pg 612

3. Joints of Upper Extremity pg 626-7 • Sternoclavicular • Synovial-saddle • Diarthrosis • Acromioclavicular • Synovial-plane • Diarthrosis • Glenohumeral joint • Synovial-ball&socket • 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. If the origin is on the scapula – moves the arm Subscapularis Supraspinatus Infraspinatus Teres Minor Teres Major Latissimus Dorsi (partial attachment) Coracobrachialis Scapula Muscles pg 614 Rotator Cuff

9. If the insertion is on the scapula – moves the scapula Rhomboids Trapezius Pectoralis Minor Serratus Ventralis Levator Scapulae Scapula Muscles pg 614 Use location of Insertion to determine movement!!

10. Innervation of Muscles Moving Arm

11. Cross elbow, move forearm 2 compartments Anterior Flexors of forearm Posterior Extensors of forearm Arm Muscles pg 667

12. Anterior compartment Brachialis Biceps brachii Coracobrachialis Arm Muscles pg 651 pg 671

13. Posterior compartment Triceps brachii Arm Muscles pg 636

14. Muscles of Arm

15. Arm Muscle Innervation • Anterior compartment • Musculocutaneous nerve • Coracobrachialis • Brachialis • Biceps brachii • Posterior compartment • Radial nerve • Triceps brachii

16. 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 Forearm Muscles pg 694

17. 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 Forearm Muscles pg 688

18. MusclesNerves 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 profundusUlnar (med 1/2) Median (lat 1/2) Anterior Compartment of Forearm pg 696

19. Posterior Compartment of Forearm pg 702 MusclesNerves • 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. Carpus (8) “True” wrist Distal to radius/ulna Metacarpus (5) Distal to carpus Phalanges (14) Distal to metacarpus Hand Bones pg 711

21. Intrinsic Muscles of the Hand MuscleNerve • 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. 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 Blood Supply - Veins pg 677

24. Subclavian (neck) Axillary (armpit) Subscapular Circumflex humeral arteries Brachial (arm) Deep brachial Radial (forearm) Ulnar (forearm) Common Interosseous Superficial & Deep Palmar arches Digital Blood Supply - Arteries pg 675

25. 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 Axilla pg 688

26. Cephalic Vein Biceps brachii Triceps brachii Olecrenon Process Medial Epicondyle Lateral Epicondyle Surface Anatomy of Arm pg 688

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. Carpal Tunnel Carpals concave anteriorly Carpal ligament covers it Contains: long tendons, Mediannerve 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) Surface Anatomy of Hand pg 715

29. 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 Brachial Plexus pg 618 pg 21

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 RamiTrunks • C5 Upper Trunk • C6 • C7Middle Trunk • C8 • T1 Lower Trunk

32. Trunks Split to form Divisions! (in neck) TrunksDivisions • UpperAnteriorPosterior • MiddleAnteriorPosterior • LowerAnterior Posterior

33. Divisions Join to form Cords! (in axilla) TrunksDivisionCords 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 (thoracodorsal) (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. 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 Nerve Damage pg 737-8